European Journal of Pediatric Surgery最新文献

Recent studies show that at least three-quarters of surgeons who perform minimally invasive surgery suffer from musculoskeletal pain and discomfort. This problem may compromise surgical performance, patient outcomes, and career longevity. Because of small patient dimensions, pediatric surgery is associated with a different set of ergonomic challenges than adult surgery.A 59-item questionnaire was sent to all practicing pediatric surgeons in Germany. It contained a general assessment of demographics, practice setting, operative volume, types of operations performed, and compensatory interventions, followed by the validated Nordic Questionnaires for the analysis of musculoskeletal symptoms (NMQ). Responses were collected and statistically evaluated to identify risk factors for musculoskeletal complications.A total of 152 pediatric surgeons participated in the survey. Among the participants, 21% were trainees, 58% attendings, and 21% chiefs of service. The median time in practice was 18 years (range: 0 to 38 years). Musculoskeletal pain was reported by 75%, and was most prevalent in the neck/cervical (80%), shoulder (56%), and lower back/lumbar region (71%). Footrests or steps were used by 88%, intraoperative breaks were employed by 49%, and 96% of respondents sometimes operated in a sitting position. The only significant factor for musculoskeletal pain was number of years in practice.Musculoskeletal pain among pediatric surgeons is common and increases with years in practice. Although many pediatric surgeons incorporate ergonomic measures in their daily activities, these are far from being implemented universally. More awareness and research on the prevention of long-term musculoskeletal sequelae in pediatric surgery is necessary.

Introduction:  In this report we present a new anatomical stratification for vaginal obstruction (hydrocolpos) based on MRI findings while referring the level of obstruction to a fixed bony landmark (the pubic symphysis). This new approach can overcome the limitations of current classifications, which are prone to approximation errors during measurement and fail to account for variations in body mass across different age groups.

Methods:  Data of cases diagnosed with vaginal obstruction were retrospectively analyzed. Cases of cloaca with vaginal obstruction were excluded. MRI confirmed the diagnosis and enabled classification of the level of vaginal obstruction relative to the pubic symphysis in the mid-sagittal plane as low, intermediate, or high-opposite the lower, mid, or upper end of the pubic symphysis, respectively.

Results:  A total of 13 girls presented with vaginal obstruction during the period 2010 through 2024. Their age ranged between 1 month and 14 years (mean: 54 months; median: 18 months). Three cases presented in the neonatal period with antenatal diagnosis of hydrocolpos, while six cases were referred later during infancy/childhood from other centers. Another group of adolescent girls (four cases) presented with a clinical picture of cryptomenorrhea. The cause of vaginal obstruction was imperforate hymen in one, vaginal atresia in six, persistent urogenital sinus (five cases), and one case of obstructed hemi-vagina. In this series, six cases (46%) had features related to genetic syndromes (Bardet Biedl/ McKusick-Kaufman spectrum). Chronic parenchymatous renal disease was present in three cases among other syndromic features of Bardet Biedl syndrome, in addition to another case with obstructed left hemi-vagina that had absent left kidney (Herlyn-Werner-Wunderlich syndrome). Surgical techniques included simple excision of distal obstructing membrane (four cases), abdominal assisted vaginoplasty (two cases), vaginal pull-through (four cases), simple introitoplasty (one case), urogenital sinus mobilization (one case), and division of longitudinal vaginal septum for a case of obstructed hemi-vagina. Vaginal stenosis or retraction occurred in three cases with intermediate to high-level obstruction-two following abdominal assisted vaginoplasty and one after vaginal pull-through.

Conclusion:  MRI-based stratification of vaginal obstruction using the pubic symphysis as a reference provides a practical and reproducible approach for surgical planning.

Type of study and level of evidence:  This is a case series (level IV evidence).

Thoracoscopic esophageal atresia (EA) repair is a demanding procedure. It provides long-term benefits for patients including better cosmesis and less musculoskeletal sequelae compared with open surgery. Besides technical challenges, there is concern that thoracoscopy increases treatment costs. However, surgical treatment of EA in Germany is not centralized with more than 90 pediatric surgical units offering treatment for 200 expected EA patients yearly. Our aim was to evaluate the rate of thoracoscopic EA repair regarding characteristics of treating hospitals, surgical approach and treatment costs in Germany.Insurance claims data (January 2020 to June 2024) from six health insurance companies representing about one-third (28.5 million) of the German population were analyzed. The database was queried for specific ICD-10-GM (International Statistical Classification of Diseases and Related Health Problems, 10th revision, German Modification) and OPS (Operationen- und Prozedurenschlüssel) coding. Characteristics of treating hospitals, length of hospital stay and medical treatment costs were assessed.A total of 149 reconstructive procedures for EA were analyzed. Eleven esophageal anastomoses were performed thoracoscopically (7%). All thoracoscopic procedures were performed in a specialized center. Mean length of hospital stay for open and thoracoscopic surgery was 76 versus 79 days, respectively (p > 0.05). Mean treatment costs were 142,741 € versus 150,238 €, respectively (p > 0.05).Thoracoscopic EA repair remains the exception in Germany. Thoracoscopy is exclusively performed in specialized hospitals. Length of hospital stay and treatment costs are comparable to open surgery, assumingly due to only uncomplicated patients without comorbidities being considered for thoracoscopy. We recommend surgical treatment in specialized centers to enable surgical advantages to all patients with EA.

The aim of this study is to explore the protective effects and mechanisms of Eupatilin, a peroxisome proliferator-activated receptor α (PPARα) agonist, on cholestatic liver disease induced by common bile duct ligation (BDL) in mice.We selected Balb/c mice (both male and female) aged 6 to 8 weeks for the common BDL procedure (ethical approval number: MUST-FDCT-20241114001). The groups include the BDL group and the BDL+ Eupatilin group, with three mice in each group. Once the mice developed jaundice postsurgery (5 days), they were treated with Eupatilin via gavage at a dosage of 20 mg/kg daily for a period of 8 days. On day 13, ocular blood was collected, and liver tissues were extracted for histopathological examination with H&E staining, Sirius Red staining, and subsequent RNA sequencing. Statistical differences among the parameters were evaluated using a t-test.Eupatilin reduces the liver weight/body weight ratio by 41% and ameliorates liver necrosis and fibrosis in Balb/c mice. It could decrease alanine transaminase ( p = 0.0498), aspartate aminotransferase (p = 0.0077), while maintaining ALB (Albumin) and γ-GT (gamma-glutamyl transferase) within normal ranges. RNA sequencing analysis revealed that antioxidant genes (acetaldehyde dehydrogenase 2 [Aldh2] and superoxide dismutase 1 [Sod1]) might be the targets of Eupatilin action.We found that Eupatilin can upregulate antioxidant genes (Aldh2; p = 0.0107) and Sod1 (p = 0.0208) of Balb/c mice, thereby ameliorating BDL damage in mice with cholestatic liver disease.

Ex vivo fluorescence confocal microscopy (FCM) is an emerging technology that enables real-time, high-resolution digital imaging of freshly excised tissues without requiring standard histological preparation. This study aims to evaluate the diagnostic performance of FCM compared with conventional histology in a pediatric population with suspected oncological pathology.A total of 18 tissue samples from pediatric patients with suspected oncological lesions were analyzed using FCM. The results were compared with the definitive diagnoses obtained via conventional histology, serving as the gold standard. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated to assess the diagnostic accuracy. Cohen's kappa coefficient (Κ), 95% confidence interval (95% CI), and p-value were computed to evaluate the interobserver agreement and the concordance between FCM and histology.FCM correctly identified 10 positive cases (true positives) and 7 negative cases (true negatives), with 1 false positive and no false negatives. Interobserver agreement was perfect, with a Cohen's kappa coefficient of 1.00 (95% CI: 0.81-1.00, p < 0.001). Sensitivity was 100% (95% CI: 72.2-100%), specificity 87.5% (95% CI: 52.9-97.8%), PPV 90.9% (95% CI: 62.3-98.4%), and NPV 100% (95% CI: 64.6-100%). The Cohen's kappa coefficient was 0.89, indicating excellent agreement between FCM and histology (95% CI: 0.67-1.10, p < 0.001). FCM provided rapid diagnostic results, significantly reducing turnaround time compared with conventional methods.FCM demonstrates exceptional diagnostic accuracy, with excellent sensitivity and specificity in evaluating pediatric specimens. Its ability to deliver reliable intraoperative results highlights its potential as a valuable adjunct to conventional histopathology in pediatric surgery. Larger studies are warranted to confirm these findings and establish their role in clinical practice.

Surgical management of necrotizing enterocolitis (NEC) can result in significant morbidity and mortality. Surgical management varies in the absence of international evidence-based guidelines. We aimed to gain insight into practice variation between expert centers in the Netherlands and Finland.Bicentric retrospective cohort study including all infants treated surgically for NEC (Bell's stage ≥IIA) in two centers in the Netherlands and Finland between 2000 and 2021. Main outcomes were preoperative, intraoperative, and 3-month postoperative characteristics.We included 191 patients (122 Dutch and 69 Finnish). Median gestational age and birth weight were lower in Finnish patients (median [min.-max.]: 25 + 4/7 [23 + 0/7-39 + 0/7] vs. 28 + 2/7 [23 + 6/7-41 + 6/7], p < 0.001, and 795 g [545-4,000] vs. 1,103 g [420-3,065], p < 0.001). Indication for surgery was mostly pneumoperitoneum in Finnish patients (56.5% vs. 37.7%; p = 0.02) versus clinical deterioration on conservative treatment in Dutch patients (51.6% vs. 23.2%; p < 0.001). A fixed-bowel loop was also more often an indication in Finland (20.3% vs. 3.3%; p < 0.001. Ostomy creation was more common in Finnish patients (92.8% vs. 53.3%; p < 0.001) and primary anastomosis in Dutch patients (29.5% vs. 4.4%; p < 0.001). Open-close procedures occurred in 13.9% of Dutch cases, versus 1.4% of Finnish cases (p = 0.004). Mortality at 3 months was comparable when excluding open-close procedures (24.8% vs. 19.1%; p = 0.46).We observed varying populations, indications for surgery, and surgical approaches in NEC between the Netherlands and Finland. The occurrence of open-close procedures is 10-fold higher (13.9% vs. 1.4%) in the Netherlands compared to Finland. Long-term outcomes remain to be studied. These results point toward significant practice variation and strengthen the need for European management guidelines.

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.

Objective:  The pyeloureteral anastomosis remains the most challenging part of pyeloplasty. A purpose-built anastomotic device could simplify this step and potentially improve outcomes. The concept of a pyeloureteral magnetic anastomosis device (PUMA) was proven in minipigs, but only in short term. Our aim was to test the PUMA in domestic pigs and achieve a prolonged follow-up period.

Methods:  Five female domestic pigs underwent laparoscopy and ligation of the left ureter. Four weeks later, laparoscopic implantation of the PUMA was planned. Removal of the device and a retrograde contrast study were scheduled after another 4 weeks. The experiment was terminated when the animals could no longer be properly cared for due to their weight.

Results:  Due to unexpected smaller ureteric diameters, a modified PUMA could only be successfully inserted in pig number 3 (49 kg). Four weeks later, the device was found to be dislocated, but the anastomosis remained patent. After modifying the study protocol, the PUMA was successfully implanted in pigs number 4 (96 kg) and 5 (68 kg) 8 weeks after ureteric ligation. Pig 4 developed malignant hyperthermia and died. In pig 5, the magnets were removed 4 weeks later. After an additional 8 weeks, the animal reached 135 kg and was terminated. The anastomosis remained patent and preserved its diameter.

Conclusion:  Despite limitations, our study successfully demonstrated that the PUMA can achieve a patent ureteric anastomosis in domestic pigs. This suggests a potential for minimally invasive ureteric anastomosis in clinical settings. Further research is needed to optimize the technique and validate its effectiveness in humans.

This study aimed to evaluate the diagnostic accuracy of uroflowmetry in detecting pediatric urethral strictures following tubularized incised plate (TIP) and non-TIP urethroplasty.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.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 (Q_max) exhibited a higher area under the curve (AUC) than the average urinary flow rate (Q_ave) in both the TIP and non-TIP groups. The Q_max in the non-TIP group demonstrated a higher AUC than in the TIP group (non-TIP: AUC = 0.94, cutoff = 6.65 ml/s, sensitivity = 100%, specificity = 81.0%; TIP: AUC = 0.80, cutoff = 5.75 ml/s, sensitivity = 100%, specificity = 58.1%). A significant quadratic correlation was found between Q_max and urethral calibration (non-TIP: C ² = 14.72 * Q_max, R ² = 0.96; TIP: C ² = 14.76 * Q_max, R ² = 0.88). The Q_max nomogram interval ≤ -3 standard deviation was a significant predictor for non-TIP urethral strictures (kappa = 0.70).Uroflowmetry, particularly Q_max, shows promise as a noninvasive screening tool for detecting urethral strictures after hypospadias repair. It has high diagnostic accuracy in non-TIP cases but limited utility in TIP cases.

Necrotizing enterocolitis (NEC) is a leading cause of death in very preterm born infants. The most severe variant is NEC totalis (NEC-T), where necrosis of the small intestines is so extensive that curative care is often withdrawn. Mortality and NEC-T are difficult to predict before surgery, complicating counseling and decision-making. This study's aim was to identify preoperative risk factors for overall 30-day mortality and NEC-T in preterm born infants with surgical NEC.This multicenter retrospective cohort study included preterm born infants (<35 weeks) surgically treated for NEC between 2008 and 2022. NEC-T was defined as necrosis of the majority of small intestine, leading to a surgical open-close procedure without curative treatment. Preoperative risk factors for 30-day postoperative mortality, NEC-T, and mortality without NEC-T were assessed using multivariable logistic regression analyses.Among the 401 patients included, the 30-day mortality rate was 34.2% (137/401), of which 18.7% (75/401) involved NEC-T. Significant risk factors for mortality were male sex (odds ratio [OR]: 2.53; 95% confidence interval [CI]: 1.54-4.16), lower birthweight (OR: 0.91; 95% CI: 0.86-0.96/100 g), portal venous gas (PVG) on abdominal radiograph (OR: 1.89; 95% CI: 1.11-3.20), need for cardiovascular support between NEC diagnosis and surgery (OR: 3.26; 95% CI: 2.02-5.24), and shorter time between diagnosis and surgery (OR: 0.74; 95% CI: 0.65-0.84). Similar risk factors were found for NEC-T. In patients without NEC-T, the need for cardiovascular support (OR: 2.33; 95% CI: 1.33-4.09) and time between diagnosis and surgery (OR: 0.77; 95% CI: 0.64-0.91) were significant.Male sex, lower birthweight, PVG, cardiovascular support, and a short interval between NEC diagnosis and surgery are preoperative risk factors for 30-day mortality and NEC-T. Preoperative cardiovascular support and a shorter time interval between diagnosis and surgery are also risk factors for mortality without NEC-T.II.