European Journal of Pediatric Surgery最新文献

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.

Introduction:  The aim of the study was to investigate the prevalence of esophageal atresia (EA), frequency of associated anomalies, and mortality from 2004 to 2017 in the Finnish population. We hypothesized the Spitz classification and the presence of other congenital malformations would predict mortality in patients with EA as well as assumed the survival to be high among patients with EA.

Materials and methods:  This retrospective, population-based study was based on the registries maintained by THL Finnish Institute for Health and Welfare and Statistics Finland. The cases were identified and classified according to the World Health Organization's International Classification of Diseases and Health Related Problems (ICD) revisions 9 and 10 (ICD-9 and ICD-10) codes and accompanying written diagnoses. Associated anomalies were classified based on the EUROCAT criteria, and minor anomalies were excluded. All statistical tests were performed as a two-sided significance level set at p < 0.05. The chi-square or Fisher's exact test was utilized for categorical variables. The change in prevalence rates during the study period was evaluated with linear regression.

Results:  In total, 337 cases with EA were identified including 295 (87.5%) live births, 17 (5.0%) stillbirths, and 25 (7.4%) terminations of pregnancy. The total prevalence for EA in Finland was 4.17/10,000 births with no significant change during the study period, p = 0.35. Neonatal mortality was 5% (n = 15) and 1-year survival was 91.5%. Mortality was associated with syndromic cases (p = 0.002). The Spitz classification predicted neonatal mortality better than cardiac anomalies alone (p < 0.001 and p = 0.6, respectively). Type C was the most common atresia type (65.9%) followed by type A (14.8%) and B (6.8%). The most common group of associated malformations were heart defects (35.0%) followed by other gastrointestinal tract malformations (15.3%) and limb anomalies (12.2%). Syndromic cases (12.2%) were associated with type A and B atresias (p = 0.001). VACTERL association was observed in 16.6% of the cases.

Conclusion:  The overall prevalence of EA remains stable and relatively high in Finland. Despite the high prevalence of co-occurring malformations, the overall survival rate is high. Spitz classification predicted neonatal survival well.

Background:  Visual examination is crucial for assessing pectus carinatum (PC) severity and treatment results. This cross-sectional study evaluates the inter- and intraobserver agreement of PC deformities before and after treatment.

Methods:  Observers examined medical photographs of patients before and after treatment. Primary outcome was inter- and intraobserver agreement on esthetic results after treatment. Secondary outcomes included inter- and intraobserver agreement on severity and symmetry before treatment, differences in esthetic results after Ravitch surgery and dynamic compression bracing (DCS bracing), and the impact of scars, age, and treatment duration on esthetic results.

Results:  Medical photographs of 201 patients (aged 4-18) were evaluated by five surgeons and five peers. Surgeons and peers demonstrated inadequate (κ < 0.61) interobserver agreement on esthetic results (κ = 0.26, κ = 0.22), severity of PC (κ = 0.43, κ = 0.38), and symmetry (κ = 0.37, surgeons only). Agreement between surgeons and peers on esthetic results (κ = 0.37) and severity before treatment (κ = 0.54) was similarly inadequate. Surgeons and peers demonstrated inadequate intraobserver agreement on esthetic results (κ = 0.49, κ = 0.34), severity of PC (κ = 0.54, κ = 0.48), and symmetry (κ = 0.60, surgeons only). Deformities treated with Ravitch surgery were perceived as more severe but yielded better results. Peers, unlike surgeons, viewed scars as negatively impacting results. No relationship was found between results after treatment and treatment duration (p = 0.682, p = .062) or age (p = 0.205, p = .527).

Conclusions:  Subjective assessment of PC severity and esthetic results is inconsistent. Three-dimensional scanning could help standardize treatment completion and aid patients and surgeons in determining treatment completion. The psychosocial effects of scars should be addressed when discussing treatment options.

Objective:  To evaluate the outcomes of jejunal turnover and bowel plication (JTBP) in high jejunal atresia of neonates.

Materials and methods:  The clinical data of neonates that met the criteria were retrospectively analyzed from January 2012 to December 2021. The neonates were divided into the JTBP group and control group according to the surgical procedure. Demographics, postoperative morphology of the duodenum and proximal jejunum, intestinal recovery time, and complications were compared.

Results:  A total of 75 patients were allocated to the JTBP (n = 30) and control (n = 45) groups, respectively. There was no significant difference between the two groups in terms of gestational age, birth weight, age at surgery, the pathological classification, and concomitant disease. Upper gastrointestinal contrast study showed that the diameter of the proximal bowel of the anastomotic stoma was normal and the duodenum and proximal jejunum were in streamline shape in the JTBP group. While the duodenum was dilated, the shape of Trojan angle was classified into sharp angle and blunt round angle in the control group. The duration of total parenteral nutrition, postoperative oral feeding time, and oral feeding time of 40 mL/3 h were significantly different between the JTBP group and control group (sharp and blunt round type): 9.0 ± 3.5, 7.0 ± 2.1, and 11.0 ± 6.0 versus 16.9 ± 4.2, 14.0 ± 5.0, and 19.0 ± 7.4 versus 11.9 ± 8.3, 8.2 ± 3.9, and 15.8 ± 3.6 days (p < 0.05).

Conclusions:  JTBP for neonatal high jejunal atresia can significantly change the diameter of the proximal bowel and the course of duodenum jejunum flexure. Postoperative bowel movement was more in line with fluid dynamics, which was conducive to the recovery of the intestinal function and resulted in fewer complications.

Introduction:  Erector spinae plane (ESP) blocks, thoracic epidural, and patient-controlled analgesia (PCA) have all been used for perioperative pain management in the Nuss procedure without a consensus on what modality produces the best outcomes. Intercostal nerve cryoablation (INC) is a relatively new modality that involves freezing the nerves to prevent pain during recovery. Our hypothesis is that using INC for the Nuss procedure will decrease opioid use, pain scores, and length of stay (LOS) but will increase cost compared with ESP block, thoracic epidural, and PCA.

Materials and methods:  This retrospective, observational study compared 108 patients who underwent the Nuss procedure at a pediatric acute care children's hospital in the southeast US. Patient charts were evaluated for significant differences in LOS, opioid use, and reported pain ratings based on type of analgesia administered: INC (n = 30), ESP block (n = 19), thoracic epidural (n = 41), and PCA (n = 18). Secondary variables included emergency department visits, readmissions, opioid refills, and various anesthetic and operative costs. Analysis of variance was performed on all outcome measures.

Results:  Average LOS was significantly decreased in the INC group (2.9 days) compared with the thoracic epidural (4.7 days, p < 0.05) and the PCA groups (3.7 days, p < 0.05). Average cumulative opioid use was significantly decreased in the INC group (50.4 morphine milligram equivalents [MME]) compared with the thoracic epidural (117 MME, p < 0.05) and PCA groups (172.1 MME, p < 0.05).

Conclusions:  This study suggests that INC can be a viable and cost-effective option for reducing postoperative opioid consumption and LOS in Nuss procedure patients. Pain perception was lower in the INC group compared with the rest of the groups, except the epidurals, which were similar. However, the opioid consumption of the INC group was significantly lower than any other group. Despite the INC group having higher initial costs, it did not result in the highest total hospital charges, indicating its potential cost-effectiveness. There is a need for larger prospective randomized controlled trials to guide future research efforts.

Introduction:  Duodenal atresia is one of significant causes of neonatal intestinal obstruction. It often co-occurs with Down syndrome. This study is conducted to estimate the global prevalence of duodenal atresia in Down syndrome patients and to investigate associated factors.

Methods:  Conducting a systematic review with meta-analysis of 18 eligible studies reporting duodenal atresia prevalence in pediatric Down syndrome patients. Study quality is assessed using the Newcastle-Ottawa Scale. The subgroup analysis on region, study quality, publication year, and design is addressed. Gender-specific prevalence rates are examined.

Results:  The pooled prevalence of duodenal atresia in Down syndrome is 3.0%, with significant heterogeneity. The Middle East reports a higher prevalence of 6.0%, while Latin America, India, and Canada exhibit a lower prevalence of 1.0%. High-quality studies demonstrate 2% prevalence, while moderate-quality studies report 4.0%. Gender analysis indicates a similar incidence for females and males at 3.0%. Prevalence varies with study design: case-control studies report 4.0%, cross-sectional studies report 2.0%, and prospective cohort studies report 2.0%.

Conclusions:  Duodenal atresia is common in Down syndrome patients, affecting 3.0% of the patients worldwide. Regional variations exist, necessitating further investigation. Gender does not significantly impact prevalence. This study highlights the need for region-specific research to enhance clinical decision-making for individuals with Down syndrome and duodenal atresia.

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 was to investigate PA in EA patients without CHD compared with CHD patients and healthy controls.

Methods:  In this multicenter study, EA patients aged 6 through 17 years were included. Moderate-to-vigorous PA (MVPA, minutes per week) was assessed using the standardized and validated questionnaire Motorik-Modul Physical Activity Questionnaire. EA patients were randomly matched 1:4 for gender and age with patients with CHD (n = 1,262) and healthy controls (n = 6,233). Patients born with both EA and CHD were excluded. Means and 95% confidence intervals (95% CIs) were calculated. To identify associated factors, Spearman's 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 with 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.

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

Objective:  A novel modification of the cutback procedure, a posterior rectal advancement anoplasty (PRAA) for select male patients with an anorectal malformation and a rectoperineal fistula was recently described, which incised only within the limits of the sphincteric ellipse and eliminated an anterior rectal dissection and thus avoiding any possibility of a urethral injury. This report provides longer-term postoperative outcomes after PRAA.

Method:  A retrospective, single-institution study was performed examining male patients with a rectoperineal fistula between January 2020 and December 2023. PRAA was done only if the rectoperineal fistula was located within the anterior extent of the sphincteric ellipse, which was true for all patients encountered during this study period. We assessed postoperative outcomes, length of stay, time to first feeding, and early stooling patterns.

Results:  Eighteen patients underwent PRAA at a median age of 5.4 months (range 1 day-8 months) with a median follow-up of 14 months (range 4-40). Seven patients (39%) were repaired within the first month of life. Thirteen (72%) were repaired primarily and five (28%) had a diverting ostomy placed before referral. There were no instances of wound dehiscence, rectal prolapse, or urethral injury. Two (11%) patients developed an anal stricture requiring dilation or Heineke-Mikulicz anoplasty. All patients resumed feeds on postoperative day one. Median discharge was on postoperative day one (range 1-6). Fifteen (83%) were utilizing laxatives at their most recent follow-up.

Conclusion:  The PRAA avoids any potential urethral injury or perineal dehiscence has a low rate of anal stenosis (11%) and appears to be applicable to all male patients with a rectoperineal fistula. The technique allows for early return to diet and discharge and can be safely done in the neonatal period or in a delayed fashion without the need for a stoma.

Level of evidence:  Level III.