Application of the Clavien-Dindo classification to a pediatric surgical network

Robotic-assisted vs. Laparoscopic Heller's Myotomy for Achalasia in Children

INTRODUCTION

Robotic-assisted Heller-Dor procedure has been proposed as an alternative minimally invasive approach to traditional laparoscopy for the treatment of achalasia in children. Our aim is to compare the effectiveness, safety and associated costs between both procedures.

METHODS

A retrospective single center study was conducted among consecutive children operated for achalasia (Heller-Dor operation) between 2005 and 2021, who were divided into two groups according to the surgical approach: laparoscopic (LAP-group) or robotic (ROB-group). Demographics, clinical features, surgery time, length of hospital stay (LOS), postoperative complications, long-term outcomes and economic data were compared between both groups.

RESULTS

A total of 24 patients were included (12 in LAP-group; 12 in ROB-group), with no demographic or clinical differences between them. ROB-group patients presented lower intraoperative blood loss (23 ± 15 vs. 95 ± 15 ml; p < 0.001), shorter surgery time (178 ± 25 vs. 239 ± 55 min; p = 0.009) and shorter LOS, with a median of 2 days (Q1-Q3: 2-3) when compared to LAP-group (4 days [Q1-Q3:3-5]; p = 0.008). Three post-operative complications were reported, all in LAP-group (2 esophageal perforations and 1 esophageal tightness). After a median follow-up of 11 years, ROB-group patients presented fewer recurrences (0 vs 5; p = 0.039), less reintervention rate (0 % vs 41.7 %; p < 0.039) and lower associated economic costs (28,660$ vs. 60,360$; p < 0.001).

CONCLUSION

This is the first comparative study of robotic and laparoscopic treatment of achalasia in children. Initial outcomes of robotic-assisted Heller-Dor procedure suggests some intraoperative (less blood loss and surgical time) and postoperative advantages (fewer complications and reinterventions). However, long-term studies with larger numbers of patients are needed.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

III.

Risk factors for complications after emergency surgery for paediatric appendicitis: a national prospective observational cohort study

Appendicectomy is a common procedure in children with a low risk of mortality, however, complication rates and risk factors are largely unknown. This study aimed to characterise the incidence and epidemiology of postoperative complications in children undergoing appendicectomy in the UK. This multicentre prospective observational cohort study, which included children aged 1-16 y who underwent surgery for suspected appendicitis, was conducted between November 2019 and January 2022. The primary outcome was 30-day postoperative morbidity. Data collected included: patient characteristics; comorbidities; and physiological status. Multivariable regression analysis was used to identify independent risk factors for poor outcomes. Data from 2799 children recruited from 80 hospitals were analysed, of which 185 (7%) developed postoperative complications. Children from black and 'other' minority ethnic groups were at significantly higher risk of poor outcomes: OR (95%CI) 4.13 (1.87-9.08), p < 0.001 and 2.08 (1.12-3.87), p = 0.021, respectively. This finding was independent of socio-economic status and type of appendicitis found on histology. Other risk factors for complications included: ASA physical status ≥ 3 (OR (95%CI) 4.05 (1.70-9.67), p = 0.002); raised C-reactive protein (OR 95%CI 1.01 (1.00-1.01), p < 0.001); pyrexia (OR (95%CI) 1.77(1.20-2.63), p = 0.004); and peri-operative oxygen supplementation (OR (95%CI) 4.20 (1.44-12.24), p = 0.009). In the UK NHS, which is a universally accessible healthcare system, ethnicity, but not socio-economic status, was associated with an increased risk of postoperative complications in children having surgery for acute appendicitis. Further evaluations and interventions are required to address this health inequality in keeping with NHS and international priorities.

Double major curvature treated with vertebral body tethering of both curves: how do outcomes compare to posterior spinal fusion?

PURPOSE

Vertebral body tethering (VBT) is a non-fusion alternative to posterior spinal fusion (PSF). There have been few reports on VBT of two curvatures. We aim to compare the radiographic outcomes between VBT and PSF in patients with double curvatures in which both curves were instrumented.

METHODS

29 AIS patients matched by Lenke, age (± 2 years), triradiate cartilage closure status, major Cobb angle (± 8°), and T5-T12 kyphosis (± 10°). Variables were compared using Wilcoxon rank-sum tests, Student's t tests, and chi-Square. Clinical success was defined as major curve < 35°.

RESULTS

Group baseline demographics were similar. Major thoracic (T) curve types had significantly better major (VBT 51.5 ± 7.9° to 31.6 ± 12.0° [40%] vs. PSF 54.3 ± 7.4° to 17.4 ± 6.5° [68%]; p = 0.0002) and secondary curve correction in the PSF group. 71% of major T VBT patients were clinically successful versus 100% of PSF. Major thoracolumbar (TL) curve types experienced comparable major (VBT 52.3 ± 7.0° to 18.3 ± 11.4° (65%) vs. PSF 53.0 ± 5.2° to 23.8 ± 10.9° (56%); p = 0.2397) and secondary curve correction. 92% of major TL VBT patients were clinically successful versus 75% in the PSF group. There was no difference in T5-12 kyphosis or lumbar lordosis between groups for any curve type. There were 4 patients (13.8%) with major complications in the VBT group compared to 0 (0%) in the PSF.

CONCLUSION

Patients with double major AIS who underwent VBT with major T curve types had less correction than PSF; however, those with major TL curves experienced similar radiographic outcomes regardless of procedure. Complications were greater for VBT.

Abdalgadir E, Saad A, Saad MM, Saad El-Tanekhy A, Saadi C, Saadu T, Saber M, Sabir Yassin FM, Sabo VY, Sabra TA, Saeid DA, Safar A, Sagboze S, Sahnoun L, Salahu BM, Salami K, Salawu AI, Saleh H, Saleh IA, Saleh KM, Salele AM, Salem F, Salem O, Salih MAIA, Salisu I, Sall M, SAMB CF, Sangak IA, Sanoussi NM, Sanya D, Sanyang AB, Sarpong P, SARR JN, Schnaubelt R, Searyoh K, SECK NF, Secka AS, Seif M, Seilbea Y, Semret Hailu B, Sepenu P, Sewlall J, Seyi-Olajide J, Shai S, Shalaby AMO, SHAPHAT IBRAHIM, Shava G, Sheidu Owuda A, Sheshe AA, Shetiwy M, Shezi N, Shihab MH, Shitakumuna H, Shitaye N, Shitta AH, Sholadoye TT, Shouasha P, Shu'aibu NG, Shuiap NM, Sibeko B, Sikhakhane S, Sikwete G, Sime Gizaw H, Simelane N, Simon E, Singh U, SIRAJALDIN A, Siriboe E, Siyothula T, Siyotula T, Smart-Yeboah A, SMITH S, Solala S, Soliman EA, Solo CE, Sombéwendin Charles I, Sonaike M, Songden DZ, Sottie D, Soualili Z, Soula E, Souleymane S, SOWANDE OA, Spytko A, Srir DOM, Ssebuguzi L, Stegmann GF, Strauss L, Struwig E, Succi M, Suleiman AR, Suliman M, Swartz M, Taha TM, Takai IU, Takou BH, Takrouney MH, Takure A, TALABI AO, Tall M, Taute C, Tawfik M, Taylor J, Tembe DS, Temesgen F, Tesfaye E, Theko D, Thiart M, Thompson R, Thuer L, Tientcheu Fabrice T, Tilahun ZB, Tilahun Woldetsadik T, Timo M, Timotews N, Tjiyokola D, Tolani MA, TOUABTI S, Traoré D, Tsegha LJ, Tseli M, Tumuhimbise C, Tumukunde J, Tunkara SFS, Turshan L, Turton E, Uchendu CC, UDIE GU, UDOSEN JE, Ugalahi M, Ugwu EM, UGWU IE, Ugwu JO, Ugwunne CA, Ukpabio UE, Umar AM, UMEH CL, Ungen R, Usang U, Usenbo T, Usman MI, UWAYESU R, Van Aswegen B, van der Byl A, van der Linde P, van der Walt S, van Schalkwyk HP, van Tonder C, van Vuuren S, van Wyk J, van Zyl S, Wabule A, Wacays A, Waheed Mowafy G, Waisiko B, Walawah D, Walithandia E, Wamwaki J, Wataaka N, Wessels N, Wessels N, Williams E, WILLIAMS O, Woldegiorgis A, Wolfaardt G, Wondossen M, Woodun R, Workineh ST, Wubetu S, Yahia M, Yakubu H, Yakubu SY, Yalewu DZ, YAMEOGO TAC, Yeboah F, YENYI AHUKA LONGOMBE T, Younes E, Young C, Younis N, Younus TYI, YUSUF STEPHEN, Zaki F, Zbida I, Zenda T, ZERIZER Y, Zingoni K, Zitouni H, ZONGO PV, Zubi A, Zulu N, Zulu N, Yakubu H, Yakubu SY, Yalewu DZ, YAMEOGO TAC, Yeboah F, YENYI AHUKA LONGOMBE T, Younes E, Young C, Younis N, Younus TYI, YUSUF STEPHEN, Zaki F, Zbida I, Zenda T, ZERIZER Y, Zingoni K, Zitouni H, ZONGO PV, Zubi A, Zulu N, Zulu N. Outcomes after surgery for children in Africa (ASOS-Paeds): a 14-day prospective observational cohort study

BACKGROUND

Safe anaesthesia and surgery are a public health imperative. There are few data describing outcomes for children undergoing anaesthesia and surgery in Africa. We aimed to get robust epidemiological data to describe patient care and outcomes for children undergoing anaesthesia and surgery in hospitals in Africa.

METHODS

This study was a 14-day, international, prospective, observational cohort study of children (aged <18 years) undergoing surgery in Africa. We recruited as many hospitals as possible across all levels of care (first, second, and third) providing surgical treatment. Each hospital recruited all eligible children for a 14-day period commencing on the date chosen by each participating hospital within the study recruitment period from Jan 15 to Dec 23, 2022. Data were collected prospectively for consecutive patients on paper case record forms. The primary outcome was in-hospital postoperative complications within 30 days of surgery and the secondary outcome was in-hospital mortality within 30 days after surgery. We also collected hospital-level data describing equipment, facilities, and protocols available. This study is registered with ClinicalTrials.gov, NCT05061407.

FINDINGS

We recruited 8625 children from 249 hospitals in 31 African countries. The mean age was 6·1 (SD 4·9) years, with 5675 (66·0%) of 8600 children being male. Most children (6110 [71·2%] of 8579 patients) were from category 1 of the American Society of Anesthesiologists Physical Status score undergoing elective surgery (5325 [61·9%] of 8604 patients). Postoperative complications occurred in 1532 (18·0%) of 8515 children, predominated by infections (971 [11·4%] of 8538 children). Deaths occurred in 199 (2·3%) of 8596 patients, 169 (84·9%) of 199 patients following emergency surgeries. Deaths following postoperative complications occurred in 166 (10·8%) of 1530 complications. Operating rooms were reported as safe for anaesthesia and surgery for neonates (121 [54·3%] of 223 hospitals), infants (147 [65·9%] of 223 hospitals), and children younger than 6 years (188 [84·3%] of 223 hospitals).

INTERPRETATION

Outcomes following anaesthesia and surgery for children in Africa are poor, with complication rates up to four-fold higher (18% vs 4·4-14%) and mortality rates 11-fold higher than high-income countries in a crude, unadjusted comparison (23·15 deaths vs 2·18 deaths per 1000 children). To improve surgical outcomes for children in Africa, we need health system strengthening, provision of safe environments for anaesthesia and surgery, and strategies to address the high rate of failure to rescue.

FUNDING

Jan Pretorius Research Fund of the South African Society of Anaesthesiologists and Association of Anesthesiologists of Uganda.

Validation of the Clavien-Madadi Classification for Unexpected Events in Pediatric Surgery: A Collaborative ERNICA Project

BACKGROUND

The Clavien-Madadi classification is a novel instrument for the assessment and grading of unexpected events in pediatric surgery, based on the Clavien-Dindo classification. The system has been adjusted to better fit the pediatric population in a prospective single-center study. There is a need now to validate the Clavien-Madadi classification within an international expert network.

METHODS

A pediatric surgical working group created 19 case scenarios with unexpected events in a multi-staged process. Those were circulated within the European Reference Network of Inherited and Congenital Anomalies (ERNICA) and surgeons were instructed to rate the scenarios according to the Clavien-Madadi vs. Clavien-Dindo classification.

RESULTS

59 surgeons from 12 European countries completed the questionnaire. Based on ratings of the case scenarios, the Clavien-Madadi classification showed significantly superior agreement rates of the respondents (85.9% vs 76.2%; p < 0.05) and was less frequently considered inaccurate for rating the pediatric population compared to Clavien-Dindo (2.1% vs 11.1%; p = 0.05). Fleiss' kappa analysis showed slightly higher strength of agreement using the Clavien-Madadi classification (0.74 vs 0.69). Additionally, intraclass correlation coefficient was slightly higher for the Clavien-Madadi compared to the Clavien-Dindo classification (ICCjust 0.93 vs 0.89; ICCunjust 0.93 vs 0.89). More pediatric surgeons preferred the Clavien-Madadi classification for the case scenarios (43.0% vs 11.8%; p = 0.002) and advantages of the Clavien-Madadi were confirmed by 81.4% of the surgeons.

CONCLUSION

The Clavien-Madadi classification is an accurate and reliable instrument for the grading of unexpected events in pediatric surgery. We therefore recommend its application in clinical and academic pediatric surgical practice.

LEVEL OF EVIDENCE

III.

I Walk the Line: Between Basic Science and Paediatric Surgery

The role of a basic scientist working with paediatric surgeons is not an obvious one. However, there are several levels at which science can contribute to the speciality, and also ways that scientists can learn useful lessons from paediatric surgery. As most conditions treated by paediatric surgeons have low case numbers, we need to find ways of defining optimal treatment and developing novel therapies within a challenging number of patients.

Robotic-assisted versus laparoscopic splenectomy in children: a costeffectiveness study

Laparoscopic elective splenectomy is considered as a safe surgical treatment of spleen non-traumatic blood disorders. However, robotic assisted splenectomy is becoming a promising alternative, although there are scarce studies in pediatric patients. Our aim is to compare the effectiveness and associated costs of both procedures in children. A single-institution retrospective study was performed among consecutive children undergoing splenectomy between 2004 and 2021, who were divided according to the surgical approach: LAS group (laparoscopic splenectomy) and RAS group (robotic assisted splenectomy). Demographics, clinical features, intraoperative blood loss, surgery time, length of hospital stay (LOS), postoperative complications, need for postoperative blood transfusion, readmission rate and economic data were compared. A total of 84 patients were included (23 LAS group; 61 RAS group), without demographic or clinical differences between them. RAS patients presented lower intraoperative blood loss (42 ± 15 vs. 158 ± 39 ml; p < 0.021) and shorter surgery time (135 ± 39 vs. 182 ± 68 min; p = 0.043), with no differences in median LOS (3 days in both groups). No intraoperative complications or conversion was reported. Five postoperative complications were observed: 4 in LAS patients (17.4%) versus only one in RAS (1.6%; p = 0.021). One reintervention was required in LAS group due to hemoperitoneum 12 h after splenectomy. RAS patients had lower postoperative blood transfusion requirements (1.6% vs. 13.0%; p = 0.025) and lower readmission rate (3.3 vs. 17.4%; p = 0.042). No differences were observed when comparing the median economic costs ($25,645 LAS vs. $28,135 RAS; p = 0.215). Robotic assisted splenectomy may be considered as a safe and feasible option in children compared to the traditional laparoscopic approach. Level of evidence: III.

A comparison of ultrasound-guided aspiration with open surgical drainage in the management of pediatric acute suppurative cervical lymphadenitis

OBJECTIVES

Image-guided aspiration has been proposed as an alternative to the traditional open drainage in acute suppurative cervical lymphadenitis, although little evidence comparing these approaches exists. The aim of this study was to compare ultrasound-guided aspiration and open surgical drainage in the management of pediatric acute suppurative cervical lymphadenitis.

METHODS

Patients treated for acute suppurative cervical lymphadenitis at a tertiary referral pediatric hospital over a three-year period were retrospectively analyzed.

RESULTS

Of eighteen patients included, 9 (50 %) underwent aspiration and 9 (50 %) underwent open surgical drainage. None required repeat intervention or readmission over a median follow up of 10.5 weeks. Those undergoing aspiration had a shorter post-operative length of stay (1.67 vs 4.33 days, p = 0.001) compared with open surgical drainage.

CONCLUSION

Ultrasound-guided aspiration of pediatric acute suppurative cervical lymphadenitis is a safe and effective alternative to open drainage.

Postoperative outcome of neonatal emergency surgeries in a tertiary care institute-A prospective observational study

AIMS

Neonatal surgical mortality continues to be high in developing countries. A better understanding of perioperative events and optimization of causative factors can help in achieving a favorable outcome. The present study was designed to evaluate the perioperative course of surgical neonates and find out potential factors contributing to postoperative mortality.

METHODS

This prospective observational study enrolled neonates, undergoing emergency surgical procedures in a tertiary care institute. Primary outcome was 6 weeks postsurgical mortality. The babies were observed till discharge and subsequently followed up telephonically for 6 weeks after surgery. Multivariable logistic regression analysis of various parameters was performed.

RESULTS

Out of the 324 neonates who met inclusion criteria, 278 could be enrolled. The median age was 4 days. Sixty-two (27.7%) neonates were born before 37 weeks period of gestation (POG), and 94 (41.8%) neonates weighed below 2.5 kg. The most common diagnoses was trachea-esophageal fistula (29.9%) and anorectal malformation (14.3%). The median duration of hospital stay for survivors was 14 days. The in-hospital mortality was 34.8%. Mortality at 6 weeks following surgery was 36.2%. Five independent risk factors identified were POG < 34 weeks, preoperative oxygen therapy, postoperative inotropic support postoperative mechanical ventilation, and postoperative leukopenia. In neonates where invasive ventilation was followed by non-invasive positive pressure ventilation in the postoperative period, risk of postoperative surgical mortality was significantly reduced.

CONCLUSION

Present study identified preterm birth, preoperative oxygen therapy, postoperative positive pressure ventilation, requirement of inotropes, and postoperative leukopenia as independent predictors of 6-week mortality. The possibility of early switch to noninvasive positive pressure ventilation was associated with a reduction in neonatal mortality.

Evaluating the clinical efficacy and limitations of indocyanine green fluorescence-guided surgery in childhood hepatoblastoma: A retrospective study

BACKGROUND

Indocyanine green (ICG) fluorescence guided surgery has been used to treat childhood hepatoblastoma (HB), but the advantages and disadvantages of this technique have not been fully discussed. The purpose of this study is to summarize the experience and to explore the clinical value of this technique for children with HB.

METHODS

45 children with HB who underwent ICG fluorescence guided surgery (n = 22) and general surgery (n = 23) in our center from January 2020 to December 2022 were enrolled retrospectively.

RESULTS

All the liver tumors in the ICG group showed hyperfluorescence, including total and partial fluorescent types. With the help of ICG navigation, minimally invasive surgery was performed in 3 cases. 18.2 % of cases with tumors could not be accurately identified under white light, but could be identified by fluorescence imaging. The fluorescent cutting lines of 59.1 % of cases were consistent with the safe cutting lines. In 36.4 % of cases, the fluorescence boundary was not clear because of tumor necrosis. In 36.4 % of cases, the fluorescence could not be detected on the inner edge of the tumors because of the depth. A total of 29 ICG (+) suspicious lesions were found during the operations, of which 5 were true positive lesions.

CONCLUSION

ICG fluorescence guided surgery is safe and feasible in children with HB. This technique is helpful for locating tumors, determining margin and finding small lesions with negative imaging, especially in minimally invasive surgery. However, preoperative chemotherapy, tumor necrosis, tumor depth, and ICG administration impact the effect of fluorescence imaging.

Sarcopenia as a Prognostic Factor in Patients with Hepatoblastoma: Does It Influence Surgical Outcomes and Survival? Preliminary Retrospective Study

AIM

Sarcopenia is associated with poor prognosis in adult oncologic patients, with little evidence of this association in pediatric population, including hepatoblastoma.

METHODS

Retrospective study in patients with hepatoblastoma, divided into those with or without sarcopenia. Sarcopenia was assessed by measuring psoas muscle area (PMA) at L4-L5 level on the CT/MR and defined as z-score values ≤ 2. Relapse and mortality were analyzed.

RESULTS

Twenty-one patients (57.1% male) were included, with median age 35.7 months (IQR: 23.5-58.5). Seven (33.3%) had sarcopenia on initial studies compared to 14 (66.7%) who did not. No differences were found between groups in age, weight, PRETEXT, surgical treatment or. α-fetoprotein levels. Sarcopenia was associated with a higher rate of metastases at diagnosis (49.2% vs 0.0%; p = 0.026) and surgical complications (57.1% vs 21.4%, p = 0.047). After a median follow-up of 65.1 months (1.7-144.8), 2 patients (28.6%) had tumor relapse in sarcopenic group compared to 1 (7.1%) in non-sarcopenic group. Two patients died in sarcopenic group and 1 in non-sarcopenic group. Median event-free survival (EFS) was lower in sarcopenic group (100.38 ± 25.63 vs 118.91 ± 11.52 months) as well as overall survival (OS) (101.72 ± 24.86 vs 121.78 ± 8.75 months) with no statistical significance. Five-year EFS was also lower in sarcopenic group (71% vs 93%) as well as 5-year OS (71% vs 87%).

CONCLUSIONS

Sarcopenia at diagnosis was associated with a higher rate of metastases and surgical complications in hepatoblastoma. Our data shows the first evidence of its role as a possible poor prognostic factor, influencing survival and risk of relapse.

LEVEL OF EVIDENCE

II.

TYPE OF STUDY

Original article. Retrospective study.

Paediatric Adhesive Small Bowel Obstruction is Associated with a Substantial Economic Burden and High Frequency of Postoperative Complications

BACKGROUND

Intra-abdominal adhesions can lead to adhesive small bowel obstruction (ASBO). The incidence of ASBO is higher in paediatric surgery than in adult surgery. However, ASBO related complications, economic burden and clear management guidelines in the treatment of ASBO are lacking. The aims of this study were to investigate underlying diagnoses, treatments, complications and costs in paediatric ASBO.

METHOD

An observational retrospective study in children 0-15 years, hospitalised for ASBO during 2000-2020. Data were extracted from the medical records. Complications were classified based on Clavien Dindo Classification of Surgical Complications. Descriptive statistics were presented as median, continuous variables and categorical variables summarised with frequencies. Time to ASBO was presented as a Kaplan-Meier estimate.

RESULTS

In total, 101 patients with 137 episodes of ASBO were included whereof 58.4% underwent first (index) surgery during the neonatal period. Median follow-up was 11.3 (0.6-19) years and median time to the first ASBO was 3.76 months (95%CI 2.23-12.02). The most common diagnoses at index surgery were necrotising enterocolitis, duodenal obstruction and primary ASBO. In 86.6% of the patients, first ASBO did not resolve with conservative treatment and a laparotomy was needed. Postoperative complications were found in 52%. Median cost for one episode of acute ASBO was 36 236 USD (1629-236 159).

CONCLUSION

Neonatal surgery was the dominating cause of ASBO and surgical intervention the most common treatment with a high frequency of postoperative complications and significant healthcare costs. Future studies are needed to develop safe management guidelines for the treatment of paediatric ASBO.

LEVELS OF EVIDENCE

III.

Evaluation of the usefulness of the Clavien-Dindo classification of surgical complications

The Clavien-Dindo (CD) classification is widely used in the reporting of surgical complications in scientific literature. It groups complications based on the level of intervention required to resolve them, and benefits from simplicity and ease of use, both of which contribute its to high inter-rater reliability. It has been validated for use in many specialties due to strong correlation with key outcome measures including length of stay, postsurgical quality of life and case-related renumeration. Limitations of the classification include concerns over differentiating grade III and IV complications and not classifying intraoperative complications. The Comprehensive Complication Index is an adaptation of the CD classification which generates a morbidity score from 0 to 100. It has been proposed as a more effective method of assessing the morbidity burden of surgical procedures. However, it remains less popular as calculations of morbidity are complicated and time-consuming. In recent years there have been suggestions of adaptations to the CD classification such as the Clavien-Dindo-Sink classification, while in some specialties, completely new classifications have been proposed due to evidence the CD classification is not reliable. Similarly, the Surgical Expertise and Validity Evaluation project aims to determine benchmarks against which surgeons may compare their own practice.

Clinical application of indocyanine green fluorescence imaging navigation for pediatric renal cancer

Background

Indocyanine Green (ICG) fluorescence imaging has been widely used in the surgical treatment of adult renal cancers, but its application in pediatric renal cancers has rarely been reported. This study aims to summarize the experience of ICG fluorescence imaging in pediatric renal cancers and explores its safety and feasibility.

Methods

The clinical features, surgical information, ICG administration regimen, near infrared radiography data in vivo and ex vivo and pathological results of children with renal cancers using ICG navigation were analyzed and summarized.

Results

There were 7 cases of renal cancer, including 4 cases of Wilms tumor (WT), 1 case of malignant rhabdoid tumor of the kidney (MRTK) and 2 cases of renal cell carcinoma (RCC). By intraoperative intravenous injection of ICG from 2.5 to 5 mg (0.05-0.67 mg/kg), the tumors were visualized in 6 cases in vivo or ex vivo, and the tumor visualization failed in 1 case due to renal artery embolization before operation. By injecting 5 mg ICG into the normal renal tissue during the operation, 3 patients achieved fluorescent localization of sentinel lymph nodes. No ICG-related adverse reactions were found in any of the patients during or after operation.

Conclusions

ICG fluorescence imaging is safe and feasible for renal cancers in children. Intraoperative administration can achieve tumor and sentinel lymph node visualization which will facilitate the development of nephron sparing surgery (NSS). However, the technique is affected by ICG dose, anatomical conditions around the tumor, and renal blood flow. A proper dose of ICG and the complete removal of perirenal fat are helpful for the fluorescence imaging of the tumor. It has potential in the operation of renal cancer in children.

Definition, Documentation, and Classification of Complications in Pediatric Surgical Literature-A Plea for Standardization

Severity grading systems for complications in surgical patients have been used since 1992. An increasing assessment of these instruments in pediatric surgery is also noticed, without their validation in children. To analyze the current practice, we performed a literature review with focus on the assessment and grading of complications. The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Studies reporting on postoperative complications as a primary or secondary endpoint using a severity grading system were included. Definition for simple adverse events, classification systems used, and the time horizon of postoperative documentation were analyzed. A total of 566 articles were screened, of which 36 met the inclusion criteria. About 86.1% of the papers were retrospective and 13.9% prospective analyses. None of the studies were prospective-randomized trials. Twenty (55.6%) studies did not include a definition of adverse events, whereas the remaining 16 (44.4%) showed variations in their definitions. All studies applied the Clavien-Dindo classification, whereas five (13.9%) additionally used the Comprehensive Complication Index. One study compared alternative grading instruments with the Clavien-Dindo classification, without demonstrating the superiority of any classification in pediatric surgery. Twenty-two studies (61.1%) did not report the time horizon of perioperative complication documentation, while 8 studies (22.2%) used 30 days and 6 studies (16.7%) used 3 months of postoperative documentation. Definition and classification of postoperative complications are inconsistent in the pediatric surgical literature. Establishment of a standardized protocol is mandatory to accurately compare outcome data.

The long-term outcome following thoraco-amniotic shunting for congenital lung malformations

AIM OF THE STUDY

Insertion of a thoraco amniotic shunt (TAS) during fetal life is a therapeutic option where there is a high risk of death secondary to large congenital lung malformations (CLM). The aim of this study is to present our center's long-term experience.

METHODS

Retrospective single center review of the period (Jan 2000-Dec 2020). We included all fetuses that underwent TAS insertion for CLM with detailed analysis of those live newborns managed in our center. Data are quoted as median (range).

MAIN RESULTS

Thirty one fetuses underwent 37 TAS insertions at a 25 (20-30) weeks gestational age. This was successful on 1st attempt in 30 (97%) fetuses. In 6 cases a 2nd shunt was required at 6.5 (2-10) weeks following the 1st insertion. Twenty-eight survived to be born. Sixteen (9 male) infants were delivered in our center at 39 (36-41) weeks gestational age and birth weight of 3.1 (2.6-4.2) kg. All infants underwent surgery at 2 (0-535) days (emergency surgery, n = 9; expedited n = 4; elective surgery, n = 3). Final histopathology findings were CPAM Type 1 (n = 14, n.b. associated with mucinous adenocarcinoma, n = 1), CPAM Type 2 (n = 1) and an extralobar sequestration (n = 1). Postoperative stay was 16 (1-70) days with survival in 15/16 (94%). One infant died at 1 day of life secondary to a combination of pulmonary hypoplasia and hypertension. Median follow up period was 10.7 (0.4-20.4) years. Nine (60%) children developed a degree of chest wall deformity though none have required surgical intervention. Clinically, 14/15 (93%) have otherwise normal lung function without limitations of activity, sporting or otherwise. One child has a modest exercise limitation (FVC - 70% predicted).

CONCLUSIONS

TAS insertion is associated with high perinatal survival and should be considered in fetuses at risk of hydrops secondary to large cystic lung malformation. Their long term outcome is excellent although most have a mild degree of chest wall deformity.

Assessing the perioperative timeline and incidence of postoperative complications to optimize care for pediatric surgery patients from Northern Quebec

BACKGROUND

Patients from remote communities often require relocation to urban centres to receive surgical care. This study examines the timeline of care for pediatric surgical patients presenting to the Montreal Children's Hospital from two remote communities in Quebec serving largely Indigenous populations. It aims to identify factors contributing to length of stay, including the incidence of post-operative complications and risk factors for complications.

METHODOLOGY

This was a single-center retrospective study of children from Nunavik and Terres-Cries-de-la-Baie-James who underwent general or thoracic surgery between 2011 and 2020. Patient characteristics, including risk factors for complications, and any postoperative complications were summarized descriptively. The timeline of the patient's stay from consultation to post-operative follow-up was determined through chart review, identifying the dates and modality of post-operative follow up.

RESULTS

There were 271 eligible cases, including 213 urgent (79.8%) and 54 elective (20.2%) procedures. In total, four patients (1.5%) experienced a postoperative complication at follow-up. All complications occurred among patients who underwent urgent surgery. Three complications (75%) were surgical site infections, managed conservatively. Among patients who underwent elective surgery, 20% waited over 5 days prior to operation The average length of time between discharge and follow-up was one week, regardless of surgical urgency. This was the main contributor to the total time in Montreal.

CONCLUSION

Postoperative complications identified at one-week follow-up were rare and only seen following urgent surgery, suggesting that telemedicine can safely replace many in-person post-surgical follow up visits. In addition, there is room to improve wait times for those from remote communities by prioritizing displaced patients where possible.

A randomized, controlled multicenter feasibility pilot trial on imaging confirmed uncomplicated acute appendicitis: Appendectomy vs. symptomatic treatment in pediatric patients (the APPSYPP) trial study protocol

INTRODUCTION

Imaging-confirmed uncomplicated acute appendicitis can be effectively and safely treated with antibiotics in most adults and children. Symptomatic treatment may have similar efficacy and safety.

METHODS AND ANALYSIS

The APPSYPP trial is a randomized national multicenter feasibility superiority pilot study comparing appendectomy with symptomatic treatment in children with imaging-confirmed uncomplicated acute appendicitis.

INCLUSION CRITERIA

1) age ≥ 7 and < 16 years, 2) imaging-confirmed uncomplicated acute appendicitis and 3) CRP ≤ 65 mg/l. Patients are randomized to receive emergency laparoscopic appendectomy or symptomatic treatment. To ensure patient safety, symptomatically treated patients are hospitalized for at least 24 h receiving standard practice intravenous fluids and analgesics according to standard clinical practice. Primary outcome is 30-day treatment success defined by the absence of any treatment failure criteria. In appendectomy, treatment failure is defined as normal appendiceal histopathology or any postintervention complication requiring general anesthesia. In symptomatic treatment, treatment failure is defined as 1) inability for hospital discharge without appendectomy within 48 h after randomization with a finding of histopathologically inflamed appendix, 2) appendectomy during the initial hospital stay due to clinical progression of appendicitis with complicated acute appendicitis both histopathologically and surgically, 3) appendectomy with a histopathological finding of acute appendicitis after hospital discharge, or 4) any complication of appendicitis requiring general anesthesia. Detailed predefined secondary outcomes will be analyzed.

ETHICS AND DISSEMINATION

Study was approved by Ethics Committee of Helsinki University Hospital (ID:HUS/1993/2021), conducted in compliance with the declaration of Helsinki with results disseminated in peer-reviewed scientific journals.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT05289713).

STRENGTHS AND LIMITATIONS OF THIS STUDY

Early postoperative complications in pediatric abdominal solid tumor surgery according to Clavian-Dindo classification

PURPOSE

Postoperative period after abdominal solid tumor surgery is critical regarding complications. This study aimed to detect incidence and treatment of complications.

METHODS

Single center retrospective study including years 2010-2019 for early postoperative complications were documented and graded according to Clavian-Dindo classification.

RESULTS

The overall complication rate was 10% and they were chylous leak (n = 8, 2%), collection in surgical field (n = 8, 2%), acute renal failure (n = 7, 1.7%), hemorrhage (n = 5, 1.3%), intestinal obstruction (n = 4, 1%), surgical site infection (n = 3, 0.7%), thromboembolism (n = 3, 0.7%) and peripheric neuronal event (n = 2, 0.5%). Distribution of complications according to Clavian-Dindo classification was as follows: 2 grade I, 23 grade II, 9 grade IIIb, 5 grade IVa and 1 grade V. While age and percentage of benign or malignant disease were not different in groups with or without complications (p = 0.11, p = 0.24), males had more complications than female patients (p = 0.008). Having more than one surgery aiming tumor resection was associated with increased postoperative complications (p = 0.002). Incidence of complications were highest after extragonadal germ cell tumor (35%) and hepatic tumors (29%).

CONCLUSIONS

Postoperative complications of abdominal tumor surgery are diverse in children. They are related with prolonged hospital stay and need for medical or surgical interventions. Number of surgeries, organ of origin and tumor type have an influence on risk of complications.

Pediatric Abdominal Malignancies and Intravascular Extension: Contemporary Single-Center Experience

INTRODUCTION

Inferior vena cava (IVC) thrombus is an uncommon and challenging complication of abdominal malignancies in the pediatric population, which significantly influences the treatment options and clinical outcomes in this population.

METHODS

In this review, we present the presentation, treatments, interventions, and outcomes with this clinically and technically challenging oncological finding from a free-standing children's hospital from 2006 to 2017.

RESULTS

Fourteen patients with IVC thrombus were identified as having an associated abdominal malignancy. The abdominal malignancies consisted of eight Wilms tumors (63% stage III and 37% stage IV), and one spindle cell sarcoma, neuroblastoma (stage III), kidney clear cell sarcoma (stage III), sclerosing epithelioid fibrosarcoma, hepatoblastoma-epithelial (stage IV), and hepatic embryonal sarcoma (stage IV). 50% of patients were male, 71% White, 29% Black, 7% Hispanic; mean age at diagnosis was 4.09 (SD 2.43) years. CT imaging identified IVC tumor thrombus for 79% of patients, US abdomen complete recorded 14%, and MRI lumbar 7%. 3Out of 14 patients, 13 patients were taken to the operating room with 12 patients undergoing concurrent tumor resection and IVC thrombectomy. Of the remaining patients, one had IVC thrombectomy via femoral cutdown by interventional radiology, and one was noted to have resolution of IVC thrombus with neoadjuvant chemotherapy. Of patients who underwent resection, one required IVC ligation, and one patient required IVC interposition vein graft reconstruction using a right IJ conduit. 60% of patients undergoing thrombectomy received neoadjuvant chemotherapy. Mean time from the diagnosis of IVC tumor thrombus to surgical thrombectomy was 46 (SD 44) days. No operative mortalities were reported. There were five major complications (hemothorax, pulmonary embolisms, seroma, and sepsis) and two minor complications (pneumonia and UTI). With exclusion of patient who underwent IVC ligation, no patients developed signs of IVC compression or recurrent thrombosis after thrombectomy.

CONCLUSIONS

IVC tumor thrombus can significantly alter the clinical treatment, surgical options, and outcomes of malignant abdominal tumors. Treatment of IVC tumor thrombus included adjuvant chemotherapy, segmental IVC resection with or without reconstruction, thrombectomy with intimal stripping, or resection of the thrombus with part of the IVC wall. Evidence for standard treatment practices for IVC tumor thrombus in the setting of abdominal malignancy is lacking due to the rarity of this finding and the varied clinical presentations.

Classification of cochlear implant complications using a modified Clavien-Dindo classification

OBJECTIVES

Cochlear implantation (CI) surgery is a highly effective procedure for severe to profound hearing loss, with a low complication rate. There are currently multiple grading systems for CI surgery complications, making comparison of outcomes difficult. We propose a modification to the Clavien-Dindo classification of complications, and use this modified classification to analyse our complications.

METHODS

Complications were classified as: I - Self-limiting complications requiring no treatment or simple pharmacological therapies; II - Complications requiring pharmacological interventions other than those permitted under the criteria for Grade I, or non-invasive radiological imaging; IIIa - Complications necessitating surgical, radiological or endoscopic intervention, but excluding implant explantation and/or reimplantation. IIIb - Complications necessitating implant explantation and/or reimplantation.

RESULTS

1053 patients were recorded as having had at least one cochlear implant inserted with 114 complications reported in 90 patients. The 114 complications were classified into the proposed classification with 18 (15.7%) as Grade I, 36 (31.5%) as Grade II, 17 (14.9%) as Grade IIIa and 43 (34.2%) as Grade IIIb.

DISCUSSION

We found a low complication rate, and were able to use the modified Clavien-Dindo classification system to analyse our data. We would strongly advocate for a uniform reporting system and propose this modification of a widely used system.

Keep it Simple, Laboratory Parameters to Predict Complicated Acute Appendicitis in Children Younger Than Five Years

BACKGROUND

The clinical presentation of acute appendicitis in the youngest age lacks specific signs and symptoms, and it is difficult to obtain an accurate clinical diagnosis. Once the diagnosis is made, it is necessary to determine if the appendicitis is simple and able to be managed non-surgically, or complicated, therefore requiring surgery. Together with the clinical picture and imaging, routine laboratory values play a vital role in this decision. The aim of this study is to evaluate routine blood in their ability to differentiate between complicated and uncomplicated acute appendicitis.

METHOD

A retrospective analysis was conducted from a single pediatric surgery department of all children 5 years of age or younger who underwent surgery for acute appendicitis between the years 2010-2020.

RESULTS

728 children were diagnosed with acute appendicitis, and 42 children were under the age of 5 years. There was a significant difference in the C-reactive protein, white blood cell count, neutrophil/lymphocyte ratio, and platelet/lymphocyte ratio in the complicated group versus the uncomplicated group. The value of these together for prediction complicated appendicitis were 84.8% sensitivity, 80.9% specificity, 82.8% positive predictive value, and 72.8% negative predictive value. These values were all higher than both the Alvarado score and the PAS (P  <  .05).

CONCLUSIONS

C-reactive protein, neutrophil/lymphocyte ratio, and platelet/lymphocyte ratio are simple laboratory parameters that can help identify complicated versus uncomplicated appendicitis in children 5 years old or younger. These universal parameters may help guide the treatment and decision to operate on a difficult to diagnose population.

Escalated grades of complications correlate with incremental costs of video-assisted thoracoscopic surgery major lung resection for lung cancer in China

OBJECTIVE

Few studies have focused on factors associated with the incremental cost of video-assisted thoracoscopic surgery (VATS) in China. We aim to systematically classify the complications after VATS major lung resection and explore their correlation with hospital costs.

METHODS

Patients with pathologically stage I-III lung cancer who underwent VATS major lung resections from January 2007 to December 2018 were included. The Thoracic Mortality and Morbidity (TM&M) Classification system was used to evaluate postoperative complications. Grade I and II complications, defined as minor complications, require no therapy or pharmacologic intervention only. Grade III and IV complications, defined as major complications, require surgical intervention or life support. Grade V results in death. A generalized linear model was used to explore the correlation of incremental hospital costs and complications, as well as other clinicopathologic parameters between 2013 and 2016.

RESULTS

A total of 2881 patients were enrolled in the first part, and the minor and major complications rates were 24.3% (703 patients) and 8.3% (228 patients), respectively. Six hundred and eighty-two patients were enrolled in the second part. The complications grade II (odds ratio [OR] 1.12, 95% confidence interval [CI] 1.05-1.2, p = 0.0005), grade III (OR 1.55, 95% CI 1.26-1.9, p < 0.0001), grades IV and V (OR 1.09, 95% CI 1.04-1.13, p = 0.0002), diffusion capacity of carbon dioxide (OR 0.998, 95% CI 0.997-1.000, p = 0.004), and duration of chest drainage (OR 1.03, 95% CI 1.02-1.04, p < 0.001) and were independent risk factors for the increase in in-hospital costs of VATS major lung resections.

CONCLUSIONS

The severity of complications graded by the TM&M system was an independent risk factor for increased in-hospital costs.

The uncharted severity of complications after appendectomy for acute appendicitis in children: results from 348 consecutive patients

Appendectomy is the most frequently performed emergent procedure in paediatric patients. However, there is a wide heterogeneity in outcome definitions and, conversely, a lack of information about complications' severity. This study aims to analyse the outcome of children operated for acute appendicitis, with reference to complications' severity grading. This is a retrospective analysis of a prospectively collected database including all children who underwent emergent appendectomy between September 2013 and March 2020. Postoperative complications were defined according to standardized definitions and graded following Clavien-Dindo classification (CDC). The outcome was analysed in terms of postoperative morbidity, severity of complications, hospital readmission and length of hospital stay (LOS). 348 patients were analysed. Postoperative complications occurred in 18 (5.2%) patients; superficial and organ/space surgical site infections represented the most frequent complications (1.7% and 2.9%, respectively). Major complications (CDC ≥ IIIa) were seen in 4 (1.1%) patients. Median postoperative LOS was 4 (iqr 3-5) days, while hospital readmission was 1.1%. Postoperative complications, preoperative C-reactive protein values and presence of drainage were significantly associated with longer LOS at multivariate analysis. No difference in incidence and severity of complications was found in relation to children's adolescent age. Major complications among paediatric patients undergoing appendectomy for acute appendicitis in a general surgery department are rare. The application of standardized definitions and severity-based grading of complications is crucial for outcome analysis: our results are a useful reference for comparison between forthcoming studies.

The Burden of Disease and Pathology at a Rapidly Expanding Tertiary Paediatric Surgical Unit in South Africa

BACKGROUND

The precise burden of paediatric surgical care in South Africa is unknown. In the absence of epidemiological data, hospital-based study is a first step to gauge the burden and profile of paediatric surgical disease. We aim to describe the profile of pathology, pattern of referrals, and complications of paediatric surgical care at Chris Hani Baragwanath Academic Hospital (CHBAH).

METHODS

A 1-year retrospective record review for the period 3/1/2019 to 1/1/2020 was conducted by evaluation of the morbidity and mortality databases of the Department of Paediatric Surgery (DPS). Number of admissions, consultations, complications, and surgeries performed were analysed and classified.

RESULTS

A total of 11,932 unique patient encounters occurred. Emergencies (79%, 1841/2329) accounted for the majority of admissions. Trauma accounted for 49% (896/1841) of emergency admissions. Elective surgery constituted 52% (1202/2316) and emergency surgery 48% (1114/2316) of all procedures performed. The emergency department (55%, 1271/2329), outpatients department (19%, 447/2329), and peripheral hospitals (16%, 378/2329) were the source of the majority of admissions. A complication rate of 9% (208/2316) was observed.

CONCLUSION

The high-volume subspecialist environment at CHBAH presents the ideal environment for delivery of specialist paediatric surgical services and training. Injury prevention, optimal use of existing resources, and additional physical, human and financial resources are required to meet the existing and predicted future burden of paediatric surgical disease.