European Journal of Pediatric Surgery最新文献

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.

Introduction:  Abdominal adhesions following surgery can lead to complications like intestinal obstruction and pelvic pain. While no molecular therapies currently target the underlying adhesion formation process, various barrier agents exist. 4DryField® has shown promise in reducing bleeding and adhesions in adults. This study aimed to assess its effectiveness in children.

Methods:  The study examined all pediatric patients who underwent laparotomy between January 2018 and February 2022. It compared outcomes between those treated with 4DryField® and a control group. Key endpoints included surgical revision, adhesion recurrence, infections, insufficiencies, fever, C-reactive protein (CRP) levels, and time to gastrointestinal passage.

Results:  In total, 233 children had surgery for bowel adhesions. After propensity score matching, 82 patients were included in the analysis: 39 in the control and 43 in the 4DryField® group. 4DryField® did not affect the readhesion rate. Children in the treatment group had significantly more complications (47 vs. 15%, p = 0.002), more often fever, and higher CRP levels.

Conclusions:  4DryField® did not show potential in reducing adhesion formation, but it was associated with significantly more complications in pediatric patients. Thus, future prospective studies are needed to evaluate the safety and effectiveness of 4DryField® in children.

Introduction:  The perineal body preserving posterior sagittal anorectoplasty (PSARP) (PPP) is a novel modification of the original PSARP for female patients with rectovestibular fistulas designed to eliminate the risk of perineal body dehiscence. This study aims to examine the outcomes following PPP.

Methods:  A retrospective, single-institution study was performed examining female patients with rectovestibular fistula who underwent PPP between January /2020 and December 2023. Exposure was done through the intended anoplasty only. Perineal body or posterior sagittal incision was not utilized. No routine postoperative dilations were performed. The postoperative outcomes, day of discharge, time to first feeding, and early stooling patterns were assessed.

Results:  A total of 15 patients underwent a PPP at a median age of 6 months (range 2 days to 19 months) with median follow-up of 11 months (range 1-36). Three (20%) patients underwent repair within the first 3 months of life. Five (33%) had diverting ostomies prior to referral to our team. There was no incidence of dehiscence or rectal prolapse. Two (13%) patients developed an anal stricture which required revision. Fourteen (93%) patients resumed normal feeds on postoperative day 1. Eleven (73%) were discharged on postoperative day 1. All patients were stooling spontaneously at their most recent clinical encounter with 11 (73%) utilizing laxatives.

Conclusions:  PPP eliminates the risk of perineal body dehiscence and has a quick return to regular diet and home. There is a 13% stricture rate which could relate to a difference in the distal rectal mobilization compared with the traditional PSARP.

Introduction:  Anorectal malformations (ARMs) are rare congenital anomalies that involve the anus, rectum, and oftentimes the genitourinary tract. The management of ARM patients is complex, and many controversies exist. To address this issue, the European Reference Network eUROGEN for rare and complex urogenital conditions aimed to develop comprehensive guidelines for the management of ARM.

Methods:  The Dutch Quality Standard for ARM served as the basis 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 current evidence and/or expert consensus.

Results:  Prenatal and neonatal diagnostic workup as well as postsurgical follow-up of anorectal, genitourinary tract, and neurologic system were reviewed. Seven new studies were identified. The panel adapted 13 recommendations, adopted 7, and developed 8 de novo. The availability of high-quality evidence was limited, and most recommendations were based on retrospective studies, case series, or expert opinion.

Conclusion:  Patients with ARM and their families require highly specialized and comprehensive care from the prenatal period to adulthood. This guideline provides recommendations for a comprehensive diagnostic workup of children with ARM throughout their life that is applicable on a European level.