European Journal of Pediatric Surgery最新文献

Contrast enema (CE) is widely used in the evaluation of suspected Hirschsprung disease (HD). Deep learning is a promising tool to standardize image assessment and support clinical decision-making. This study assesses the diagnostic performance of a deep neural network (DNN), with and without clinical data, and compares its interpretation with that of pediatric surgeons and radiologists.In this retrospective study, 1,471 CE images from patients <15 years were analyzed, with 218 images used for testing. A DNN, pediatric radiologists, and surgeons independently reviewed the testing set, with and without clinical data. Diagnostic performance was assessed using ROC and PR curves, and interobserver agreement was evaluated using Fleiss' kappa. Rectal biopsy served as the reference standard.The DNN achieved high diagnostic accuracy (area under the receiver operating characteristic curve [AUC-ROC] = 0.87) in CE interpretation, with improved performance when combining anteroposterior and lateral images (AUC-ROC = 0.92). Clinical data integration further enhanced model sensitivity and negative predictive value. The super-surgeon (majority voting of colorectal surgeons) outperformed most individual clinicians (sensitivity 81.8%, specificity 79.1%), while the super-radiologist (majority voting of radiologists) showed moderate accuracy. Interobserver analysis revealed strong agreement between the model and surgeons (Cohen's kappa = 0.73), and overall consistency among experts and the model (Fleiss' kappa = 0.62).Artificial intelligence-assisted CE interpretation achieved higher specificity and comparable sensitivity to that of the clinicians. Its consistent performance and substantial agreement with experts support its potential role in improving CE assessment in HD.

Fenestrated laparoscopic-assisted internal ring-rrhaphy (FLAIR) is a refined percutaneous technique for pediatric inguinal hernia repair. Although its outcomes have been reported in boys, its application in girls, particularly in relation to round ligament management, remains underexplored. Whether to include or exclude the ligament during internal ring closure is still debated.This study evaluated the impact of round ligament management on surgical outcomes in girls undergoing FLAIR. A retrospective cohort of 69 hernias, operated on between July 2016 and December 2023, was reviewed. Patients were divided into two groups: those in whom the round ligament was included in the closure (Inclusion group) and those in whom it was deliberately spared (Exclusion group). Recurrence rates and postoperative complications were compared.All four recurrences (11%) occurred in the Inclusion group, while no recurrences were observed in the Exclusion group (p = 0.048). All recurrences occurred within 3 months postoperatively and were successfully reoperated using the exclusion technique, with no further recurrence during follow-up. No significant differences in other postoperative complications were identified between groups.FLAIR appears to be a safe and effective approach in girls, particularly when the round ligament is excluded from the closure. Exclusion was associated with zero recurrences and no increase in complications. These findings, observed over intermediate-term follow-up, suggest that sparing the round ligament may enhance repair integrity and potentially protect the ligament from entrapment, thereby preserving its anatomical function. Larger, multicenter studies with extended follow-up are needed to validate these results and guide pediatric hernia repair strategies.

We aimed to describe long-term outcome, treatment success, and complications of antegrade continence enema (ACE) procedures considering underlying etiologies and associated disorders.Overall, 180 patients undergoing ACE procedure at our institution during 1997-2019 were included in this retrospective study. Treatment success was defined as patient staying clean.The main underlying etiologies included spina bifida (n = 65, 36%), anorectal malformations (n = 58, 32%), Hirschsprung disease (n = 25, 14%), and functional constipation (n = 7, 4%). The most common complications were stomal leakage (n = 39, 22%), stenosis (n = 38, 21%), infection (n = 35, 19%), and granuloma/mucosal prolapse of the stoma (n = 34, 19%), and 29% (n = 52) of the patients reported functional problems. Overall, 48% of the patients (n = 87) experienced at least one ACE-related complication. At the latest follow-up, 61% of the patients were using ACE (n = 110), of whom 86% stayed clean (n = 95). Overall, ACE treatment was successful in 81% of patients (n = 144), defined as being clean with ACE in current use or after discontinuing ACE treatment as unnecessary. In total, 31% of the patients had stopped using ACE as unnecessary (n = 45). Spina bifida patients were least likely to discontinue ACE usage (n = 9, 14%), followed by anorectal malformation patients (n = 17, 29%), while 32% of Hirschsprung patients (n = 8) and 71% of constipation patients (n = 5) discontinued ACE as unnecessary.As previous studies have also shown, we demonstrated that ACE treatment can be successfully utilized in majority of children with impaired fecal control. Two-thirds of patients continued ACE treatment over 5 years of whom 86% patients were staying clean.

Small bowel volvulus is a clinical condition that causes intestinal ischemia-reperfusion (I/R) injury, leading to severe tissue damage and high mortality rates. Polydatin, a natural stilbenoid polyphenol, has demonstrated anti-inflammatory and antioxidant properties. This study aimed to evaluate the protective effects of polydatin on I/R injury using an experimental small bowel volvulus model.A total of 24 healthy female Wistar albino rats were divided into four groups: Sham (Group 1), Polydatin (Group 2), I/R (Group 3), and Treatment (Group 4). In Group 1, no I/R procedure was applied, and intraperitoneal saline was administered. Group 2 received 20 mg/kg intraperitoneal polydatin without I/R. In Group 3, a 5-cm segment of the small intestine was twisted 360 degrees clockwise, leading to 2 hours of ischemia and 2 hours of reperfusion. Group 4 received 20 mg/kg intraperitoneal polydatin before reperfusion. Blood and intestinal tissue samples were collected for biochemical and histopathological analysis.Serum total antioxidant status (TAS) levels were significantly higher in the treatment group compared with the I/R group (p = 0.004). Serum total oxidant status (TOS) levels were significantly elevated in the I/R group compared with all other groups (p < 0.001) but were significantly reduced in the treatment group (p < 0.001). Tissue oxidative stress index (OSI) values were significantly lower in the treatment group compared with the I/R group (p = 0.004). Although serum OSI levels and tissue TAS and TOS values showed a favorable trend, they were not statistically significant. Histopathological evaluations revealed a marked reduction in tissue damage in the treatment group compared with the I/R group.Polydatin exerts protective effects against I/R injury in an experimental small bowel volvulus model by reducing oxidative stress and histopathological damage. These findings highlight its therapeutic potential and warrant further clinical research.

This study aimed to assess if the position of the duodenal-jejunal junction in the anteroposterior view can reliably diagnose malrotation and if atypical position of the duodenal-jejunal junction (medial to the left pedicle to midline) is associated with a low risk of narrow mesenteric root.Children diagnosed with intestinal rotational abnormalities (2007-2023) through upper gastrointestinal fluoroscopy (UGI) studies who underwent surgery were reviewed independently by two pediatric radiologists. Key observations included the duodenal-jejunal junction location in the anteroposterior view, duodenal position in the lateral view, jejunal loop position, and colon anatomy.Radiologists independently reviewed the UGI studies and disagreements between radiologists were resolved by consensus readings. Chi-square tests were used to compare the anatomical variables and the presence of surgically confirmed narrow mesenteric roots.Of the examined 79 children (mean age, 2 years), 60 (75.9%) underwent Ladd's procedure after confirming a narrow mesenteric root.According to the consensus, 77.1% of children with atypical duodenal-jejunal junction in the anteroposterior view had narrow mesenteric roots, and one had midgut volvulus. The likelihood of missing a surgically confirmed narrow mesenteric root was significantly lower (p = 0.0167) when considering the position of the duodenum in the lateral view, along with the jejunal loops and colonic position (0/3), compared with relying solely on duodenal-jejunal junction position in the anteroposterior view (29/37).The anteroposterior view alone is insufficient for diagnosing malrotation. Reviewing the lateral view of the duodenum, and when necessary, the colonic anatomy, reduces the risk of missing cases with surgically confirmed narrow mesenteric roots.

Background:  Necrotizing enterocolitis (NEC) is one of the main causes of acute abdomen in neonates. Surgical treatment entails important morbidity and mortality and conservative management, when possible, offers better outcomes. Post-NEC intestinal strictures are one of the main complications.

Methods: Retrospective analysis from June 2011 to November 2022 of post-NEC strictures (PNS) after conservative management of neonates diagnosed with NEC (modified Bell stage IIA or higher) at a tertiary neonatal surgery center.

Results:  Out of 219 NEC, 126 received initial conservative management (57.5%), 24 (19%) of which eventually underwent surgery for PNS. Average gestational age and weight at birth of our cohort were 31.3 ± 4.9 weeks and 1,694 ± 1,009 g.PNS diagnosis was made 38.4 ± 16.5 days after the NEC episode. 6/24 (25%) were asymptomatic and diagnosed by screening enema, 11 (46%) presented signs of intestinal obstruction before the enema could be performed and 7 (29%) after a normal previous protocol study.Median age at PNS surgery was 56 ± 17.9 days. A total of 2/3 strictures were found in cecum, ascendent, and transverse colon. Primary resection and anastomosis were performed in all cases. Feeds were restarted on postoperative day 4.3 ± 2.9. Two cases presented anastomotic complications (1 dehiscence and 1 stenosis), and no deaths were recorded.

Conclusions:  PNS is a frequent complication after conservative management. Deffered surgical treatment after the acute NEC episode is resolved allows for safer surgeries (since patients have reached hemodynamical stability and overcome septic shock), shorter resections, and favorable postoperative outcomes.

Introduction:  Pectus excavatum patients frequently experience psychosocial distress, yet the relationship with morphological features of the deformity remains unexplored. We hypothesize that certain morphological features analyzed by 3D optical surface imaging contribute more prominently to the distress experienced by pectus excavatum patients as they impact the visible severity of the deformity.

Materials and methods:  Consecutive pectus excavatum patients who received three-dimensional optical surface imaging between August 2019 and November 2022 were included. Logistic regression analysis assessed the association between morphological features and psychosocial distress in which the distress was scored as a binary variable, based on a self-reported assessment.

Results:  Among 215 patients, 55% reported psychosocial distress with multivariable analyses revealing greater depth and length of the deformity being significantly correlated with psychosocial distress. However, this prediction model demonstrated a moderate discriminative ability with an area under the receiver operating characteristic curve of 0.66 (95% confidence interval [CI], 0.59-0.73) for pectus depth and 0.58 (95% CI, 0.51-0.66) for pectus length.

Conclusions:  The morphological features of length and depth of the deformity are correlated with psychosocial distress. Nonetheless, these individual features are weak predictors due to their moderate discriminative ability. This underscores that other patient-related factors, such as personality traits, neuropsychological conditions, and other psychosocial influences, are likely to play a role in the occurrence of psychosocial distress. Future studies should investigate these variables alongside the incorporation of standardized instruments for measuring psychosocial distress to better understand and address the distress in this population.

Introduction:  This study aimed to evaluate the non-neoplastic renal parenchyma in Wilms tumor (WT) and investigate its impact on nephron-sparing surgery (NSS).

Materials and methods:  The non-neoplastic renal parenchyma of WT patients was prospectively collected for pathological examination. The histology of non-neoplastic renal parenchyma was assessed from two perspectives: nephrogenic rests (NRs) and nephrons.

Results:  A total of 46 non-neoplastic renal parenchyma specimens were collected from 42 WT patients. The surgeons assessed the median proportion of non-neoplastic renal parenchyma as 30%, whereas using ellipsoid volume, it was calculated to be 27%. The Youden index of surgeons' assessment peaked at a 15% proportion of non-neoplastic renal parenchyma. The bilateral WT (BWT) group and NSS group exhibited significant differences compared with the unilateral WT group and radical nephrectomy group, respectively, with the BWT group showing a tendency toward thickened basement membrane.

Conclusion:  The presence of NRs and endogenous nephron alternations should be given due attention in WT. The probability of abnormalities is low when the proportion of non-neoplastic renal parenchyma exceeds 15%, providing pathological support for expanding the adaptation of NSS.

Introduction:  The T-fasteners gastrostomy (T-PEG) has become increasingly popular over recent years as an alternative to the "pull-technique" gastrostomy (P-PEG). This study aimed to compare P-PEG and T-PEG complications.

Materials and methods:  A retrospective observational study of pediatric patients who underwent percutaneous endoscopic gastrostomy (PEG) placement. P-PEG was performed using the standard Ponsky technique and was replaced after 6 months by a balloon gastrostomy under sedation. T-PEG was performed using three percutaneous T-fasteners (that allow a primary insertion of a balloon gastrostomy). The balloon was replaced by a new one after 6 months without sedation. Complications were recorded.

Results:  In total, 146 patients underwent PEG placement, 70 P-PEG and 76 T-PEG. The mean follow-up was 3.9 years (standard deviation = 9.6). Age, weight, and associated comorbidities were comparable (p > 0.05). The overall complications were 17 (24.2%) in the P-PEG group and 16 (21.0%) in the T-PEG group (p > 0.05). P-PEG was associated with more sedation for button replacement (97 vs. 2.6% [p < 0.05]). P-PEG was associated with more early tube dislodgement during the first replacement (7.2 vs. 1.4% [p = 0.092]). Two of the five dislodged gastrostomies in the P-PEG group underwent laparotomy due to peritonitis, whereas the only dislodged gastrostomy in the T-PEG group was solved endoscopically. Altogether, P-PEG was associated with more complications that required urgent endoscopy, laparotomy, or laparoscopy (18.6 vs. 6.6% [p < 0.05]).

Conclusions:  P-PEG was associated with more sedation, complications during first button replacement, and complications requiring urgent endoscopy, laparotomy, or laparoscopy compared with T-PEG.

Introduction:  Previous assumptions suggested that the technique of approximation without osteotomy in primary exstrophy repair (PER) could only be applied in newborns and anticipated poorer outcomes. Recent studies indicated that this technique can be successfully executed not only in immediate PER but also yields favorable long-term results. Therefore, we evaluated and compared the orthopaedic and radiological long-term outcomes after pubic symphysis approximation without osteotomy in immediate and delayed PER.

Methods:  From March 2018 to December 2020, individuals with PER and approximation of the symphysis without osteotomy were recruited. Patients <12 years and with a history of orthopaedic surgery of the bony pelvis were excluded. Orthopaedic examinations and magnetic resonance imaging (MRI) of the bony pelvis including the hip joints were performed and pubic diastasis, the acetabulum angle (ACA), and the center-edge angle (CEA) were evaluated.

Results:  Twenty-nine patients were included, 11 of them had an immediate and 18 had a delayed PER. Between the two groups, no significant differences could be observed concerning hip pain (p = 0.419), mobility impairment (p = 0.543), sports impairment (p = 0.543), hip impingement (p = 1.000), leg length discrepancy (p = 0.505), and width of the pubic diastasis as measured by MRI (p = 0.401). There were also no significant differences with regard to CEA right (median 30 degrees, p = 0.976), CEA left (median 31.5 degrees, p = 0.420), ACA right (median 19 degrees, p = 0.382), and ACA left (median 17 degrees, p = 0.880).

Conclusion:  There were no significant differences in clinical orthopaedic or radiological long-term outcomes between bladder exstrophy patients after immediate and delayed bladder closure with symphysis approximation without osteotomy. Establishing core outcome sets is essential to get robust and comparable results, further advancing and substantiating our initial insights.