European Journal of Pediatric Surgery最新文献

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.

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 of PFPT and outcomes following PFPT.We performed a single-institution, retrospective chart review of patients with HD referred to PFPT between 2020 and 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; symptoms were also compared. A p-value of 0.05 was considered significant.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 the 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).Although 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:  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.

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.A retrospective review of pediatric patients between 2012 and 2022 with symptomatic diaphragm paralysis treated with phrenic nerve reconstruction. Nine patients with a median age of 10 years were offered surgical treatment. The etiology of their paralysis included: 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.One hundred percent of 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 in 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. One of four patients with bilateral paralysis and chronic ventilator dependency did not improve. There were no postoperative complications defined as hematoma, wound infection, pleural effusion, pneumonia, sepsis, nerve injury, or hardware malfunction seen during follow-up.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.

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 (CSFs) are very rare in the growing-age population, despite that multiple classification schemes exist.The aim of this study was to assess the inter- and intrarater reliability of the four most commonly used CSF classifications and their role in guiding treatment decisions in everyday clinical practice.Fifty-one patients with CSFs were retrospectively analyzed in a multicenter study. Of these, X-rays in two planes of 20 randomly selected CSFs were given to eight independent raters for classification according to Dubberley, Bryan and Morgan, Murthy, and AO. Cohen's kappa statistic was used to assess interrater agreement and intrarater consistency. Intraclass correlation coefficient (ICC) estimates and 95% confidence intervals (CIs) 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).All patients received x-rays in two planes initially. Cross-sectional imaging was added in 76.5% of cases (CT 58.8%, MRI 11.7%, both 5.9%). Interrater reliabilities were classified as fair for Dubberley (ICC 0.354; 95% CI 0.198, 0.573) and Bryan and 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). The intrarater agreement was moderate to substantial for most of the eight raters and did not differ between the four classification systems. The rate of surgical treatment was 49/51 patients.The most commonly used classification schemes for CSFs 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:  Diagnosing appendicitis in children remains a challenge, and the role of urine dipstick is controversial. This study aimed to evaluate the association between abnormal urine dipstick results and appendicitis, particularly appendicitis severity and appendix position.

Methods:  A prospective cohort study was conducted from 2017 to 2021 at a tertiary hospital in Sweden. Children aged ≤ 15 years with suspected appendicitis were included. Logistic regression was used to assess associations between abnormal urine dipstick results and sex, age, peritonitis, body temperature, C-reactive protein, complicated appendicitis, and appendix position.

Results:  A total of 311 children with suspected appendicitis were included, with 193 (62%) diagnosed with appendicitis. Among these, 80 (41%) had complicated appendicitis. There was no difference in appendicitis rate between children with positive and normal urine dipstick results. Among children with appendicitis, 119 (62%) had positive urine dipstick results: 49% ketones, 29% erythrocytes, 23% protein, 19% leukocytes, and 2% nitrite. Multivariable analysis revealed that female sex (adjusted odds ratio: 2.41 [95% confidence interval, CI: 1.21-4.80], p = 0.013), retrocecal appendicitis (aOR: 2.39 [95% CI: 1.18-4.84], p = 0.015), and complicated appendicitis (aOR: 2.27 [1.01-5.13], p = 0.015) were significantly associated with abnormal urine dipstick results. Sensitivity and specificity of positive urine dipstick for complicated appendicitis was 56% (95% CI: 45-67%) and 64% (95% CI: 54-73%), respectively, with an area under the curve of 0.62 (95% CI: 0.54-0.70). Limitations in this study include potential unmeasured confounders such as hydration status and urinary tract infections.

Conclusion:  Abnormal urine dipstick results are common in children with appendicitis. Urine dipstick might help identify cases of complicated and retrocecal appendicitis.

Despite an awareness of the transformative potential of artificial intelligence (AI) in health care, its development in pediatric surgery seems slow. One major reason may be a lack of formal AI training. This study assesses the basic AI knowledge and the effectiveness of AI workshops (AI-WS).Four AI-WS were held at the International Academy of Pediatric Surgery 2024. Topics included AI principles, real-time algorithm training, and potential AI applications in pediatric surgery. Self-developed surveys consisting of eight pre-WS and nine post-WS questions were conducted, focusing on participants' AI competencies, usage, educational needs, barriers, and future perspectives.Out of 57 pediatric surgeons, 53 completed both surveys. None had formal AI training. Although 90% were familiar with AI in diagnostic imaging, most had only basic knowledge of AI technology. After the workshop, participants reported a significant increase in the general understanding of AI/machine learning (ML) (p < 0.001). 96% stated that they were better informed about AI/ML applications for clinical practice; 83% expressed interest in further AI training; 91% believed that AI will be more integrated into clinical practice; and over 80% anticipated that AI will improve patient outcomes.The AI-WS effectively enhanced pediatric surgeons' AI knowledge and their readiness to adopt AI technologies. Even though our study is limited by the relatively low sample size and a potential selection bias, our results still highlight the importance of targeted education in preparing health care professionals for AI integration. The long-term sustainability of knowledge gains, however, has to be examined in further studies.