Assessment of pulmonary artery size at birth as a prognostic factor in congenital diaphragmatic hernia: results of a multicenter study in Japan

OBJECTIVE

To assess the reliability of pulmonary artery (PA) parameters as a prognostic marker in neonates with isolated left-sided congenital diaphragmatic hernia (IL-CDH).

STUDY DESIGN

A retrospective cohort study conducted by the Japanese CDH Study Group (JCDHSG).

RESULTS

323 IL-CDH patients registered with the JCDHSG were included. 272 patients survived to 90 days of age. Right PA (RPA) and left PA (LPA) diameters and pulmonary artery index (PAIndex) at birth were significantly larger in survivors. The cutoff values of RPA and LPA diameters and PAIndex for survival up to 90 days were 3.2 mm, 2.8 mm and 83.7, respectively, and logistic regression analysis showed that these were significantly related to survival. Multiple logistic regression analysis showed that both the PA parameters and liver herniation were significantly related to survival.

CONCLUSIONS

The three PA parameters at birth can predict clinical outcomes and are considered as independent risk factors of liver herniation.

Development of mortality prediction models for infants with isolated, left-sided congenital diaphragmatic hernia before and after birth

BACKGROUND

Mortality prediction of congenital diaphragmatic hernia (CDH) is essential for developing treatment strategies, including fetal therapy. Several researchers have reported prognostic factors for this rare but life-threatening condition; however, the optimal combination of prognostic factors remains to be elucidated.

OBJECTIVES

This study aimed to develop the most discriminative prenatal and postnatal models to predict the mortality of infants with an isolated left-sided CDH.

METHODS

This multi-institutional retrospective cohort study included infants with CDH born at 15 tertiary hospitals of the Japanese CDH Study Group between 2011 and 2016. We developed multivariable logistic models with every possible combination of predictors and identified models with the highest cross-validated area under the receiver operating characteristic curve (AUC) for prenatal and postnatal predictions.

RESULTS

Among 302 eligible infants, 44 died before discharge. The prenatal mortality prediction model was based on the observed/expected lung area to head circumference ratio (O/E LHR), liver herniation, and stomach herniation (AUC, 0.830). The postnatal mortality prediction model was based on O/E LHR, liver herniation, and the lowest oxygenation index (AUC, 0.944).

CONCLUSION

Our models can facilitate the prenatal and postnatal mortality prediction of infants with isolated left-sided CDH.

Vulnerable groups and protective habits associated with the number of symptoms caused by pesticide application in Kratie, Cambodia: a cross-sectional questionnaire study

Objective: The present study aimed to identify pesticide poisoning symptoms and related protective habits to effectively prevent pesticide poisoning among farmworkers in Kratie, Cambodia, where pesticide poisoning is an urgent public health problem. Materials and Methods: This cross-sectional study based on a questionnaire survey analyzing social demographics, number of symptoms, and protective behavior regarding pesticide application was conducted in Kratie Province from January 25 to 31, 2021. In total, 210 farmworkers completed the survey. The effects of social demographics and pesticide-protective behavioral scores on the number of symptoms were investigated using multivariable regression analysis. Results: The observed number of symptoms was 1.16 times higher among women (P=0.004), increased with the duration of work, and decreased with age. In addition, we identified five significant pesticide-protective behaviors: 1) preparing using gloves, 2) using protective equipment, 3) avoiding wiping sweat, 4) avoiding leaking, and 5) resting when feeling ill. Pesticide-protective behaviors tended to decrease with the duration of working years in the low-education group (B=-0.04, SE=0.01), whereas no association was observed in the high-education group (B=0.01, SE=0.01). Conclusion: Pesticide-protective behaviors significantly correlated with fewer symptoms. The female and aging groups required continuous special education or instructions for implementing pesticide-protective actions, especially the aforementioned five protective actions.

Lifestyle Factors Associated with Metabolic Syndrome in Urban Cambodia

This study aimed to identify lifestyle factors associated with metabolic syndrome (MetS) in urban Cambodia. In this cross-sectional study, we used existing health checkup data from a private hospital in Phnom Penh, Cambodia. The participants comprised 5459 Cambodians aged ≥20 years who underwent health checkups between 2017 and 2019. The harmonized diagnostic definition was used as the MetS criteria. The prevalence of MetS was 56.6% overall, 60.4% in men and 52.6% in women. The lifestyle factor significantly associated with MetS in both sexes were "eating quicker than others", (men: odds ratio [OR]= 2.25, 95% confidence interval [CI] = 1.68-3.03, women: OR = 1.92, 95%CI = 1.41-2.60), "walking faster than others", (men: OR = 0.78, 95% CI = 0.67-0.92, women: OR = 0.75, 95% CI = 0.62-0.89) and "drinking alcohol" (men: OR = 1.33, 95% CI = 1.10-1.61, women: OR = 1.33, 95% CI = 1.09-1.62). Other significant associations with MetS for men was "eating speed is normal", (OR = 1.73, 95%CI = 1.30-2.31), and, for women, "eating food after dinner at least 3 days a week", (OR = 1.25, 95%CI = 1.01-1.55), "skipping breakfast at least 3 days a week", (OR = 0.83, 95%CI = 0.69-0.99) and "getting enough rest from sleep" (OR = 1.19, 95% CI = 1.01-1.42) were significantly associated with MetS. Lifestyle interventions through health education and guidance may be effective in preventing MetS in Cambodia.

Discrepancy of financial burden among elderly visiting a private general hospital in Phnom Penh, Cambodia: A three-year cross-sectional study

Objectives

This study aims to clarify the financial burden of health on the elderly. Out-of-pocket payment (OOPP) in a major private general hospital in Phnom Penh was considered an indicator of financial burden.

Study design

This study is a three-year cross-sectional study.

Methods

To investigate the characteristics of patients who visited the Sunrise Japan Hospital (SJH), their data were obtained from the electronic reception database.

Results

A total of 119,938 patients who visited SJH from January 2017 to September 2019 were included. The median age (25th, 75th centiles) was 52 years (36, 66) and 38.31% of patients were aged over 60 years. The OOPP median (25th, 75th centiles was 73.78 USD (32, 161.89). The median OOPP was the lowest in the 20s and highest in the 90s. The OOPP of an emergency patient was the highest in the consultation classifications.

Conclusions

The need to raise public awareness regarding the financial burden on the elderly is becoming increasingly urgent. It is vital to establish a social system to prevent the medical catastrophes.

Regional Differences in Admission Rates of Emergency Patients Who Visited a Private General Hospital in the Capital City of Cambodia: A Three-Year Observational Study

BACKGROUND

Regional disparity is an imperative component of health disparity. In particular, providing emergency care that is equally available in rural areas is an essential part of reducing the urban-rural disparity. The objective of this study was to examine the worsening admission rate among Cambodian emergency patients in a rural area and determine their background characteristics that cause this decline.

METHODS

To investigate the disparity among patients who visited Sunrise Japan Hospital (SJH), a major general private hospital in the capital, patient data from November 2016 to September 2019 were obtained from the electronic reception patient database. The primary outcome was defined as the proportion of admission patients as an indicator of illness severity. The patients' addresses were classified into 4 areas based on distance from the capital.

RESULTS

A total of 6167 patients who visited the emergency department at SJH between January 2017 and September 2019 were included in the analysis. The proportion of patients who needed to be hospitalized or transferred increased with the distance from the capital. The proportion of patients who finished consultation decreased with the distance from the capital (P<.01: Chi-square test). The results of the logistic regression analysis showed that the admission rate in rural areas was significantly higher only among males as compared to that of the capital in multivariate analyses adjusted for age, time, and season.

CONCLUSION

The admission rate of emergency patients who visited a private general hospital in Cambodia's capital city increased with distance from the capital city. To improve regional disparity among emergency patients, further research is necessary to identify the issues among emergency patients, especially those who are vulnerable.

Difference of sociodemographic characteristics among the disabled population in Cambodia: a cross-sectional study of the demographic and health survey data

Objective: There is an urgent need to raise awareness of the significance of the social security system for vulnerable populations in developing countries and identify the widening disparities among people with disabilities. This study determined the sociodemographic characteristics of people with disabilities in Cambodia.

Materials and Methods: This was a cross-sectional study. Data from the Cambodia Demographic and Health Survey were used to determine the association between disability and sociodemographic characteristics such as age, gender, number of family members, residence (rural/urban), and economic status.

Results: The results showed that the proportion of people with disabilities greatly increased with age. The rural-urban residence difference affected the disability proportion in univariate analysis; however, the effect was not significant after adjusting for covariables in multivariate analysis. The odds of having a disability were 0.85 times lower for the high economic status group than for the low economic status group.

Conclusion: Raising awareness to expand the capacity of social support for older adults with disabilities, especially those who do not receive care from their families, may be an urgent issue in Cambodia. Therefore, a well-designed and disease-specific study is required. This study was the first to determine the sociodemographic disparities among people with disabilities in Cambodia.

Best pre-ductal PaO2 prior to extracorporeal membrane oxygenation as predictor of mortality in patients with congenital diaphragmatic hernia: a retrospective analysis of a Japanese database

PURPOSE

Predicting lethal pulmonary hypoplasia in infants with congenital diaphragmatic hernia (CDH) before extracorporeal membrane oxygenation (ECMO) initiation is difficult. This study aimed to predict lethal pulmonary hypoplasia in patients with CDH prior to ECMO.

METHODS

This was a multicenter cohort study involving neonates prenatally diagnosed with isolated unilateral CDH (born 2006-2020). Patients who required ECMO due to respiratory insufficiency were included in this study. Patients who underwent ECMO due to transient disorders were excluded from analysis. Blood gas analysis data within 24 h of birth were compared between survivors and non-survivors. Predictive abilities were assessed for factors with significant differences.

RESULTS

Overall, 34 patients were included (18 survivors and 16 non-survivors). The best pre-ductal PaO₂ was significantly lower in non-survivors than in survivors (50.4 [IQR 30.3-64.5] vs. 67.5 [IQR 52.4-103.2] mmHg, respectively; p = 0.047). A cutoff PaO₂ of 42.9 mmHg had a sensitivity, specificity, and positive predictive value of 50.0%, 94.4%, and 88.9%, respectively, to predict mortality.

CONCLUSION

The best PaO₂ within 24 h after birth predicted mortality following ECMO initiation. This should be shared to families and caregivers to optimize the best interests of the infants with CDH.

Duration from the first pale stool to portoenterostomy is prognostic in biliary atresia. Comparison with age at portoenterostomy

OBJECTIVE

Three criteria (age at first pale stool, age at portoenterostomy, and duration from the first pale stool to portoenterostomy) were assessed for prognostic value in biliary atresia.

METHODS

The medical records of 116 consecutive biliary atresia patients treated by portoenterostomy after liver transplantation became available in Japan in 1989 were identified and data from 96 were analyzed retrospectively for this study. The impact of each criterion on clearance of jaundice to normal levels (total serum bilirubin ≤1.2 mg/dL) and survival with the native liver as indicators of outcome were compared according to time (≤30 days, 31-60 days, and ≥61 days).

RESULTS

Age at first pale stool was ≤30 days in 53, 31-60 days in 26, ≥61 days in 17; age at portoenterostomy was ≤30 days in 7, 31-60 days in 35, ≥61 days in 54, and duration pre-portoenterostomy was ≤30 days in 50, 31-60 days in 36, ≥61 days in 10. Survival with the native liver was not significantly influenced by age at first pale stool or age at portoenterostomy, but prolonged duration (≥61 days) reduced survival with the native liver significantly (p = 0.003). Clearance of jaundice to normal levels was not affected by any criterion at any time.

Optimal timing of delivery for pregnancies with prenatally diagnosed congenital diaphragmatic hernia: a propensity-score analysis using the inverse probability of treatment weighting

OBJECTIVE

To evaluate the optimal timing of neonates with prenatally diagnosed congenital diaphragmatic hernia (CDH).

METHODS

Data from a retrospective cohort study conducted by the Japanese CDH Study Group between 2011 and 2018 were divided into two groups according to delivery timing: 36-37 and 38-41 weeks of gestation (wg). Death before 90 days as the primary outcome and the duration of hospitalization, oxygen therapy and tube feeding at discharge as the secondary outcomes were analyzed with generalized linear model applying inverse probability of treatment weighting method. We also performed layered analysis according to stomach position.

RESULT

Among 493 neonates with prenatally diagnosed, isolated and left CDH, 237 were born at 38-41wg. The duration of hospitalization was significantly shorter in those born at 38-41wg, especially among those with stomach malposition, and the other outcomes showed no difference.

CONCLUSIONS

Delivery at 38-41wg could be beneficial for those with high grade stomach position.

Prognosis of conventional vs. high-frequency ventilation for congenital diaphragmatic hernia: a retrospective cohort study

OBJECTIVE

To determine the appropriate initial ventilatory mode for neonatal congenital diaphragmatic hernia (CDH) by comparing patient prognosis following conventional mechanical ventilation (CMV) versus high-frequency oscillatory ventilation (HFO).

STUDY DESIGN

This multicenter retrospective cohort study was performed at 15 participating hospitals in Japan between 2011 and 2016. The 328 eligible CDH infants were classified into CMV (n = 78) and HFO groups (n = 250) to compare mortality and incidence of bronchopulmonary dysplasia (BPD). Propensity score matching was applied to reduce confounding by indication.

RESULT

While crude mortality was significantly higher in the HFO than the CMV group, adjusted odds ratio (OR) did not show significant difference in mortality between groups (OR of HFO group: 0.98, 95% confidence interval (CI): 0.57-1.67). Adjusted OR of BPD incidence showed no significant difference between groups (OR of HFO group: 1.66, 95%CI: 0.50-5.49).

CONCLUSION

Initial ventilatory mode in CDH patients, whether CMV or HFO, does not affect prognosis.

Health disparity toward noncommunicable diseases among residents in rural Cambodia: a descriptive study

Objective: Regional disparities in health services is a crucial problem in Cambodia. Particularly, a number of NCD risk factors are more common among the rural poor. Fortunately, 80% of NCDs are preventable and cost-effective interventions exist. Therefore, health care needs assessments regarding NCDs in poor rural areas are vital. The object of this pilot study was to identify health care needs regarding NCDs among residents in poor rural areas in Cambodia.

Materials and Methods: A medical health check-up and questionnaire survey were conducted with 208 rural residents who participated in a free health check-up and doctor consultation in Kaoh Peam Reang.

Results: One hundred sixteen (55.8%) females were included in the total sample size of 208 participants; the majority (52.9%) were between 35 and 65 years of age. Twenty-five participants (12%) were current smokers, and 44 (21%) were current alcohol drinkers. Eighty (38.5%) participants had hypertension and 44 participants (21.2%) had a body mass index over 25. Alcohol drinking and smoking habits were more common among men. The five most frequent medical complaints were headache (18.3%), lower back pain (14.4%), foot and hand pain (13.9%), joint pain (10.1%), and difficulty breathing (10.1%).

Conclusions: The medical need for doctor consultations regarding chronic disease and chronic pain might be higher in poor rural areas in Cambodia.

Optimal timing of surgery in infants with prenatally diagnosed isolated left-sided congenital diaphragmatic hernia: a multicenter, cohort study in Japan

PURPOSE

To date, there is no compelling evidence of the optimal timing of surgery for congenital diaphragmatic hernia (CDH). This study aimed to establish the optimal timing of surgery in neonates with isolated left-sided CDH.

METHODS

This multicenter cohort study enrolled 276 patients with isolated left-sided CDH at 15 institutions. Based on the timing of surgery, the patients were classified into four groups [< 24 h (G1), 24-47 h (G2), 48-71 h (G3), and ≥ 72 h (G4)]. The clinical outcomes were compared among the groups using a logistic regression model, after adjusting for potential confounders, such as disease severity.

RESULTS

Multivariate analyses showed that G2 also had a lower mortality rate than the other groups. In mild and severe cases, there were no significant differences in mortality across the four groups. In moderate cases, G2 resulted in significantly increased survival rates, compared with G1.

CONCLUSION

The study results suggest that surgery within 24 h of birth is not recommended for patients with moderate severity CDH, that there is no benefit in the delay of surgery for more than 72 h in mild severity CDH patients, and that there is no definite optimal time to perform surgery in severe cases of CDH.

Successful Strategy for the Conservative Management of Acquired Tracheoesophageal Fistula Due to Lithium Button Battery Ingestion

A 16-month-old boy was referred to our hospital for the management of suspected lithium button battery (LBB) ingestion. He had been previously well, but became febrile with a persistent cough resistant to oral antibiotics and dysphagia for 5 days. Radiography identified an LBB lodged in the upper esophagus. The LBB was retrieved under direct visualization with rigid laryngoscopy. He was sedated for 5 days and enteral feeding was commenced through a nasojejunal tube on the next day after procedure. On day 8 after retrieval, endoscopy and fluoroscopy identified a tracheoesophageal fistula (TEF), 6 mm in diameter. Conservative management was conducted with periodic follow-up endoscopies, which showed signs of healing in the esophagus. Following continuous antibiotics and proactive nutritional support, the TEF was found to have closed spontaneously by day 28 after the LBB removal. We present our experience of the successful nonsurgical management of acquired TEF secondary to LBB ingestion and aim to establish a protocol for managing it conservatively by reviewing the relevant literature.

Guidelines for the medical management of pediatric vesicoureteral reflux

Urinary tract infection is a bacterial infection that commonly occurs in children. Vesicoureteral reflux is a major underlying precursor condition of urinary tract infection, and an important disorder in the field of pediatric urology. Vesicoureteral reflux is sometimes diagnosed postnatally in infants with fetal hydronephrosis diagnosed antenatally. Opinions vary regarding the diagnosis and treatment of vesicoureteral reflux, and diagnostic procedures remain debatable. In terms of medical interventions, options include either follow‐up observation in the hope of possible spontaneous resolution of vesicoureteral reflux with growth/development or provision of continuous antibiotic prophylaxis based on patient characteristics (age, presence/absence of febrile urinary tract infection, lower urinary tract dysfunction and constipation). Furthermore, there are various surgical procedures with different indications and rationales. These guidelines, formulated and issued by the Japanese Society of Pediatric Urology to assist medical management of pediatric vesicoureteral reflux, cover the following: epidemiology, clinical practice algorithm for vesicoureteral reflux, syndromes (dysuria with vesicoureteral reflux, and bladder and rectal dysfunction with vesicoureteral reflux), diagnosis, treatment (medical and surgical), secondary vesicoureteral reflux, long‐term prognosis and reflux nephropathy. They also provide the definition of bladder and bowel dysfunction, previously unavailable despite their close association with vesicoureteral reflux, and show the usefulness of diagnostic tests, continuous antibiotic prophylaxis and surgical intervention using site markings.

Novel Risk Score for Fetuses with Congenital Diaphragmatic Hernia Based on Ultrasound Findings

INTRODUCTION

 We aimed to establish and validate a risk score for fetuses with congenital diaphragmatic hernia (CDH) using only prenatal ultrasound findings.

MATERIAL AND METHODS

 Derivation (2011-2016, n = 350) and validation (2006-2010, n = 270) cohorts were obtained from a Japanese CDH study group database. Using a logistic regression analysis, we created a prediction model and weighted scoring system from the derivation dataset and calculated the odds ratio of an unsatisfactory prognosis (death within 90 days of life or hospitalization duration exceeding 180 days). Five adverse prognostic factors obtained using prenatal ultrasound, including an observed/expected lung area-to-head circumference ratio (o/eLHR) <25%, liver herniation occupying more than one-third of the thoracic space, thoracic stomach, right-side CDH, and severe malformations, were used as predictors. The obtained model was validated using the validation cohort.

RESULTS

 The unsatisfactory prognosis prediction model was obtained based on the adjusted odds ratios. The C statistics of the model were 0.83 and 0.80 in the derivation and validation datasets, respectively. The five variables were weighted proportionally to their adjusted odds ratios for an unsatisfactory prognosis (o/eLHR <25%, 1 point; liver herniation occupying more than one-third of the thoracic space, 1 point; thoracic stomach, 1 point; right-side CDH, 2 points; and severe malformations, 3 points). Unsatisfactory prognosis rates for the low- (0-2 points), intermediate- (3-5 points), and high-risk (6-8 points) groups were 17, 46, and 100%, respectively (p < 0.001), in the validation cohort.

CONCLUSION

 Our simple risk score effectively predicted the prognosis of fetuses with CDH.

Indications for Nonoperative Management of Uncomplicated Appendicitis in Children: A Prospective Analysis at a Single Institution

Aim: To assess nonoperative management (NOM) of uncomplicated appendicitis (UC-appy) in children to determine factors influencing prognosis and review the literature. Materials and Methods: All UC-appy cases presenting younger than 16 years between 2015 and 2018 who had NOM (one dose of intravenous analgesia and intravenous piperacillin/tazobactam 112.5 mg/kg 8 hourly) and were followed up for at least 3 months were reviewed prospectively (n = 146). Perceived pain and fever were assessed 12 hourly, biochemistry daily. If predetermined cutoff results were not achieved at each assessment, NOM was abandoned and urgent laparoscopic appendectomy (ULA) performed. Results: NOM succeeded in 48.6% (S-NOM; n = 71) and failed in 51.4% (F-NOM; n = 75). Mean age at presentation (10.7 ± 2.5 versus 8.6 ± 3.7 years old; P < .0001) and duration of preadmission fever (1.0 ± 0.9 versus 2.1 ± 1.2 days; P < .0001) were the only significantly different criteria between S-NOM and F-NOM. Optimal cutoff values using receiver operating characteristic curve analysis were 7.0 years old (32% sensitivity and 93% specificity) and 1.0 day (95% sensitivity and 25% specificity), respectively. NOM was abandoned for persistent pain, prolonged fever, or raised white blood count at 12 hours in 20/75 (26.7%), 24 hours in 31/75 (41.3%), 36 hours in 14/75 (18.7%), and 48-72 hours in 10/75 (13.3%). At ULA, perforation was identified in 14/75 (18.7%). Complications arising within 3 months of ULA were residual abscess (n = 7/75; 9.3%) and transient ileus (n = 1/75; 1.3%). Conclusion: It would appear that surgery may be more appropriate for children with UC-appy when they are younger and febrile before admission for longer.

Scrotal/testicular status after repair of recent severe incarcerated inguinal hernia in male infants younger than 12 months old: Laparoscopic percutaneous extraperitoneal closure versus conventional open repair

INTRODUCTION

We prospectively reviewed 41 male infants younger than 12 months old who had presented with severe incarcerated inguinal hernia between 2014 and 2016 and had been treated by laparoscopic percutaneous extraperitoneal closure (LPEC) or conventional open repair (CO).

METHODS

Operative times and intraoperative findings were evaluated. Scrotal/testicular status were assessed preoperatively, 1 week, and 4 weeks after surgery.

RESULTS

There were 21 boys treated by LPEC and 20 by CO. Mean ages and mean weights at surgery were similar between the groups. The mean operative time was 19.7 min for LPEC and 45.8 min for CO (P < 0.05). The peritoneum was edematous in 13 LPEC cases (61.9%). Wound infection was observed in one CO case and in one LPEC case at the umbilicus. Postoperative scrotal/testicular swelling was observed in four cases at 1 week and two cases at 4 weeks among the CO cases and in one case at 1 week and no cases at 4 weeks among the LPEC cases (P = not significant). Postoperative testicular elevation was observed on the operated side in two CO cases and in no LPEC cases at 1 and 4 weeks (P = not significant). There has been no recurrence or testicular atrophy in either group.

CONCLUSION

Performing LPEC took significantly less time than performing CO. Although no statistically significant differences in scrotal/testicular status were identified, a larger study is warranted to prove that LPEC is associated with less surgical stress than CO.

Factors affecting non-operative management of uncomplicated appendicitis in children: Should laparoscopic appendectomy be immediate, interval, or emergency?

INTRODUCTION

We conducted a prospective non-randomized comparison of children with uncomplicated appendicitis treated either by primary laparoscopic appendectomy (PLA) or by non-operative management (NOM) followed by interval laparoscopic appendectomy (ILA) if NOM was successful or emergency laparoscopic appendectomy (ELA) if NOM was unsuccessful.

METHODS

Before 2015, all patients with uncomplicated appendicitis underwent PLA using a standard three-port technique. Postoperatively, piperacillin/tazobactam was administered until the white blood cell count was less than 10 000/μL and patients were afebrile. Since 2015, in cases of uncomplicated appendicitis, intravenous analgesia has been administered once after assessment, and then NOM has been immediately employed, with repeat doses of piperacillin/tazobactam administered every 8 h after admission. We have also used standard management cut-off criteria to determine when to perform laparoscopic appendectomy after NOM: if NOM fails, ELA is performed within 6 h, and if NOM is successful, ILA is planned.

RESULTS

There were 103 eligible subjects for this study. Eleven cases of suspected complicated appendicitis were excluded, leaving 34 PLA cases and 58 NOM cases. After NOM, 27 patients were treated with ILA and 31 with ELA. There was one recurrence after successful NOM, and in two cases, patients' parents refused to consent to ILA after successful NOM. There were more perforations and significantly more residual abscesses in ELA than in PLA. Operative time and postoperative hospitalization were significantly longer among ELA patients than among PLA patients, and operative time was significantly shorter during ILA than in PLA.

CONCLUSION

Further evaluation is required to confirm which patients will benefit most from NOM and what role PLA has in treating uncomplicated appendicitis.

In prenatally diagnosed CPAM, does the affected lobe influence the timing of symptom onset?

PURPOSE

We investigated the relationship between the affected lobe and symptom onset in prenatally diagnosed congenital pulmonary airway malformation (CPAM).

METHODS

53 CPAM patients diagnosed prenatally were reviewed retrospectively by creating 2 groups according to symptom onset. Group Sneo: (symptomatic during the neonatal period; n = 13) and group S > neo: (symptomatic after the neonatal period; n = 40) were compared for type of CPAM, affected lobes, types of symptoms/infections, treatment, duration of follow-up, and histopathology. Requirement for surgery (Sx) was then used to create three subgroups: Sneo + Sx, S > neo + Sx, and Sx-.

RESULTS

Some cases had multiple affected lobes. In Sneo, symptoms developed in 55.6%, 50.0%, 0%, 0%, and 36.8% of right upper lobes (RUL), right middle lobes (RML), right lower lobes (RLL), left upper lobes (LUL), and left lower lobes (LLL) diagnosed with CPAM, prenatally. In S > neo, symptoms developed in 0%, 0%, 6.3%, 55.6%, and 33.3% of RUL, RML, RLL, LUL, and LLL diagnosed with CPAM, prenatally.

CONCLUSION

In prenatally diagnosed CPAM, RUL and RML lesions are more likely to become symptomatic in neonates, and LUL lesions in infants. Surgery is recommended before the onset of respiratory infections after 1 year of age.

A Comparison of Laparoscopic Redo Fundoplications for Failed Toupet and Nissen Fundoplications in Children

Purpose:

We compared laparoscopic redo fundoplications performed for failed laparoscopic Toupet fundoplication (LTF) and failed laparoscopic Nissen fundoplications (LNFs).

Methods:

Redo LTF (R-LTF; n = 4) and redo LNF (R-LNF; n = 6) performed between 2007 and 2014 were assessed retrospectively for severity of intraperitoneal adhesions on a scale of 0–3, identification/preservation of the anterior/posterior/hepatic branches of the vagus nerve (VN), complications, and outcome.

Results:

Redos were performed after a mean of 34 months in R-LTF and 32 months in R-LNF (P = ns) indicated for sliding hernia (n = 3; 2 with partial wrap dehiscence) and partial wrap dehiscence (n = 1) in R-LTF and sliding hernia (n = 6; 4 with partial wrap dehiscence) in R-LNF. The mean adhesion severity score was 1.5 in R-LTF and 2.5 in R-LNF (P < 0.05). The mean number of VN branches identified/preserved was 2.0 in R-LTF and 0.8 in R-LNF (P < 0.05). Mean operative times and mean blood loss were similar. Intraoperative complications were accidental local trauma (n = 1 in R-LTF and n = 3 in R-LNF, one requiring conversion to open repair) (P = ns). Gastric outlet obstruction developed in two R-LNF cases; both were managed conservatively. There have been no further recurrences to date.

Conclusion:

Although our series is small, adhesions were less, and identification/preservation of VN was easier during R-LTF.

Comparison of laparoscopic Toupet and laparoscopic Nissen fundoplications in neurologically normal children

INTRODUCTION

We compared laparoscopic Toupet fundoplication (LTF) and laparoscopic Nissen fundoplication (LNF) in neurologically normal children.

METHODS

Forty neurologically normal children who were followed up for more than 3 years after LTF (n = 22) or LNF (n = 18) were reviewed retrospectively. LTF and LNF were performed between 2006 and 2012.

RESULTS

There were no significant differences in gender (LTF, 15 male and 7 female patients; LNF:, 12 male and 6 female patients), mean age at surgery (LTF vs LNF: 2.5 vs 2.3 years), mean weight at surgery (LTF vs LNF: 9.6 vs 8.9 kg), preoperative symptoms, preoperative pH monitoring (pH <4) (LTF vs LNF: 26.7% vs 21.8%), mean operative time (LTF vs LNF: 117 vs 126 min), postoperative recommencement of enteral feeding (LTF vs LNF: 3.7 vs 3.8 days), or duration of hospitalization (LTF vs LNF: 5.5 vs 6.3 days). Intraoperative complications were esophageal trauma (LTF; n = 1; 4.5%) and liver trauma (LNF; n = 1; 5.6%) (P = 0.70). Post-LTF complications were wrap stenosis (n = 1; 4.5%), and post-LNF complications were wrap stenosis (n = 1; 5.5%) and gastric outlet obstruction (n = 1; 5.5%) (P = 0.43); all were managed conservatively. No case required conversion to open repair. There was no recurrence after LTF, but there were three cases (16.7%) after LNF (P = 0.08). Reoperation was performed at 4, 11, and 13 months, respectively.

CONCLUSION

Despite LTF and LNF appearing to be equally effective, three LNF cases required reoperation.

Does time taken to achieve jaundice-clearance influence survival of the native liver in post-Kasai biliary atresia?

BACKGROUND

We reviewed the time taken for post-portoenterostomy (PE) biliary atresia (BA) patients to obtain jaundice-clearance (total bilirubin ≤ 1.2 mg/dL; JC) post-PE to determine if JC time (JCT) is prognostic for survival of the native liver (SNL).

METHODS

The subjects were 66 BA patients treated with PE at our institute between 1989, the year when liver transplantation (LTx) became available in Japan, and 2014. JCT was used to create three groups (≤ 30 days: n = 14; 31-60 days: n = 31; ≥ 61 days: n = 21). Medical records were reviewed retrospectively to evaluate: age at onset of symptoms, duration of symptoms pre-PE, age and weight at PE, serum liver function tests, incidence of cholangitis, and micro-bile duct size at PE.

RESULTS

Age at onset of symptoms, age and weight at PE, duration of symptoms pre-PE, and micro-bile duct size were similar for all patients in all three groups. JCT and SNL appeared to correlate because preoperative total bilirubin (7.1, 9.6, 10.2 mg/dL; P < 0.05) was significantly lower in the JCT ≤ 30 days group (P < 0.05) while there was a significant decrease in SNL (P < 0.03) and a significant increase in LTx (P < 0.01) in the JCT ≥ 61 days group. All LTx subjects who achieved JC were found to have developed cholangitis within 3 months of PE.

CONCLUSION

During the follow-up of post-PE subjects, longer JCT and cholangitis occurrence within 3 months of PE would appear to be negative prognostic factors for SNL while preoperative total bilirubin would appear to be a positive prognostic factor for SNL.

Hirschsprung's disease in the laparoscopic transanal pull-through era: implications of age at surgery and technical aspects

AIM

Detailed implications of age at laparoscopic transanal pull-through (LTAPT) on postoperative bowel function (POBF) in Hirschsprung's disease (HD) are somewhat obscure because of a spectrum of factors.

METHODS

Age at surgery was used to categorize 106 consecutive postoperative HD cases treated by our modified LTAPT (JLTPAT) between 1997 and 2015; group A: < 3 months old (n = 31); group B: 3-11 months old (n = 44); group C: 1-3 years old (n = 19); and group D: ≥ 4 years old (n = 12). POBF was assessed by reviewing outpatient records 1, 3, 5, 7, and 10 years after JLTAPT prospectively and scoring each of 5 criteria on a scale of 0-2; best score = 10.

RESULTS

Only operative time was statistically longer in group D versus groups A, B, and C. Differences in gender ratios, blood loss, duration of follow-up, and POBF scores were not statistically significant. Mean POBF scores over time were: group A: 6.8, 7.6, 8.4, 8.6, and 8.4; group B: 7.1, 7.8, 8.3, 8.5, and 9.0; group C: 6.9, 7.9, 8.1, 8.3, and 8.6; group D: 7.0, 7.4, 8.2, 8.1, and 8.5, respectively.

CONCLUSION

Age at JLTAPT was not correlated with POBF in HD.

Incidence of ureterovesical obstruction and Cohen antireflux surgery after Deflux® treatment for vesicoureteric reflux

AIM

The purpose of this study was to determine the incidence of ureteric obstruction (UB) and requirement for Cohen antireflux surgery (CAS) after Deflux^Ⓡ treatment (DT) for vesicoureteric reflux (VUR).

METHODS

Between 2011 and 2017, 494 ureters (VUR severity ≤ grade III: N=291 or >grade IV: N=203) were treated by DT at a mean age of 4.5 (range: 0.2-24) years. Epidural Catheter Assistance (ECA) was used to exclude UB by injecting diluted indigo carmine solution (1-3mL) into an epidural catheter inserted into a ureter after DT and confirming dye flow within 15min. ECA+: N=181 ureters; ECA-: N=313 ureters.

RESULTS

In ECA+, UB was detected in 5/181 (2.7%) ureters (grade II: N=1, III: N=3, and IV: N=1) treated by leaving the ECA catheter in situ overnight (N=4) or double J stent (DJS) insertion for 1month (N=2). After mean follow-up of 1.9years, one grade III DJS case has residual grade II VUR. In ECA-, 3/313 (0.9%) cases developed UB. One resolved, and one required DJS. CAS was required for 17/494 (3.4%) ureters and hindered by DT in 5/17 (29.4%) ureters. All are sequelae-free after mean follow-up of 1.8years.

CONCLUSIONS

UB may be more frequent than reported (3.3% versus 0.6%-1.8%). ECA identifies potential UB.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level III.

Sigmoidocolocystoplasty for neurogenic bladder reviewed after 20 years

BACKGROUND/PURPOSE

We report the current status of patients who underwent augmentation cystoplasty (AC) at least 20years previously.

METHODS

Surgical history, incidence of urinary tract infection (UTI) and bladder stones, vesicoureteral reflux (VUR), urine cytology, renal function, a colon cancer tumor marker (carcinoembryonic antigen: CEA), and patient outcomes were assessed.

RESULTS

Forty patients who underwent AC (mean age: 34.4years; mean follow-up time: 24.3years) were analyzed. Mean age at AC was 11years. Incidence of bladder stones was 30%. There were no incidences of carcinoma after AC, and CEA levels were not increased. Ureteral reimplantation (URI) was performed in 21 patients. URI performed at the same time as AC was successful in 14 cases (93%) and unsuccessful in 1 (7%) because of persistent VUR. UTI developed after AC in only 1 patient (2.5%) with persistent VUR. This patient required unilateral nephrectomy 18years after the AC because of repeated UTIs. Thirty-four patients (85%) were employed, and 4 (10%) were married. Two of the 19 female patients (11%) had experienced pregnancy and delivery. Five patients (13%) had mental disorders.

CONCLUSION

Ultra long-term follow-up suggests that AC is a safe procedure with manageable sequelae, although some mental health issues remain.

TYPE OF STUDY

Case series with no comparison group.

LEVEL OF EVIDENCE

Level IV.

Intraoperative ventilation during thoracoscopic repair of neonatal congenital diaphragmatic hernia

PURPOSE

To evaluate the optimal ventilation mode during thoracoscopic repair (TR) of neonatal congenital diaphragmatic hernia (CDH), we compared high-frequency oscillatory ventilation (HFOV) with conventional mechanical ventilation (CMV).

METHODS

Twenty-three neonatal CDH cases who underwent TR without intraoperative inhalation of nitric oxide at our institution between 2007 and 2016 were reviewed. Patients were initially ventilated with HFOV, which was converted to CMV if the HFOV settings were decreased to FiO₂ <0.4, stroke volume <4 mL/kg and mean airway pressure <12 cmH₂O. Arterial blood gases in the perioperative period were compared between HFOV and CMV.

RESULTS

Seventeen patients were ventilated with HFOV (group I), and six patients were ventilated with CMV (group II). Preoperative PaCO₂ was significantly higher and pH was significantly lower in group I compared with group II. In both groups I and II, intraoperative PaCO₂ increased significantly and pH decreased significantly compared with preoperation. Although intraoperative PaCO₂ and pH were not different between the groups, group II showed greater worsening of intraoperative PaCO₂ and pH as compared to their respective preoperative values.

CONCLUSIONS

HFOV seems to prevent deterioration of hypercapnia and acidosis to a greater extent than CMV during TR in neonatal cases of CDH, although patients can also be ventilated with CMV.

Changes in quality of life from infancy to school age after esophagoesophagostomy for tracheoesophageal fistula: thoracotomy versus thoracoscopy

BACKGROUND

We assessed the quality of life (QOL) of postoperative esophageal atresia (EA) with tracheoesophageal fistula (TEF) cases, comparing open with thoracoscopic repair.

METHODS

A retrospective review of consecutive EA/TEF repairs (2001-2014) was performed, excluding cases with birth weight less than 2000 g and severe cardiac/chromosomal anomalies. Of 37 cases, 13 had thoracoscopic repair (TR) and 24 had open repair (OR) according to the operating surgeon's preference. QOL was determined regularly by scoring responses to a standard questionnaire about oral intake, vomiting, bougienage, coughing, growth retardation, learning ability, and thoracic deformity. Lower scores reflected poorer outcome. QOL after TR and OR was compared 1 year postoperatively (POQ) and after starting school (ScQ).

RESULTS

Subject demographics were similar. Apart from two anastomotic leaks that resolved spontaneously after TR, there were no intraoperative complications or recurrence of TEF. Laparoscopic fundoplication was required for gastroesophageal reflux in four cases (OR 1; TR 3) (p = ns). QOL scores went from 6.5 → 11.5 in OR and 4.6 → 11.3 in TR, respectively. Final ScQ scores were similar, but POQ was significantly higher after OR (p < 0.05).

CONCLUSION

Initial QOL scores were significantly lower after TR, but by school age QOL scores were similar.

Does the Level of Transection of the Biliary Remnant Affect Outcome After Laparoscopic Kasai Portoenterostomy for Biliary Atresia?

BACKGROUND

We assessed postoperative outcome in relation to the level of transection of the biliary remnant at the time of laparoscopic Kasai portoenterostomy (LKP) in biliary atresia (BA) patients.

METHODS

The subjects for this study were 12 consecutive nonsyndromic type III BA patients who had LKP at our institute between 2009 and 2014. All LKPs were video recorded. Four board-certified pediatric surgeons assessed the level of transection of the biliary remnant and suturing during the anastomosis in each video blindly. A standard protocol was used for postoperative management.

RESULTS

The level of transection was assessed as being shallow and suturing techniques as being identical in all. Although all cases achieved jaundice disappearance, 4 required liver transplantation (NNL group) for relapse of jaundice and 8 remain anicteric with native livers after mean follow-up of 4.6 years (NL group). Demographic data (birth weight, weight and age at LKP, duration from onset of symptoms to LKP, size of microbile ducts, and preoperative biochemical markers) were similar for both groups.

CONCLUSIONS

The level of transection of the biliary remnant and suturing techniques would appear to not directly influence the outcome of LKP.

Semaphorin 3A expression following intestinal ischemia/reperfusion injury in Sox10-Venus mice

PURPOSE

Semaphorin 3A (Sema3A) is a protein secreted during development of the nervous system that plays an important role in neuronal pathophysiology. However, there is no known correlation between Sema3A and intestinal ischemia/reperfusion (I/R) injury. We assessed Sema3A expression and distribution in relation to enteric nervous system (ENS) damage seen after intestinal I/R injury in Sox10-Venus mice.

METHODS

Intestinal I/R injury was induced by vascular occlusion for 3 h. Ileal specimens were harvested 0, 3, 12, 24, 48, and 96 h after reperfusion. Stereoscopic microscopy and fluorescence microscopy were used to assess sox10-Venus⁺ cells and PGP9.5⁺ cells.

RESULTS

By 3 h after reperfusion, Sema3A expression had increased to a maximum and Sox10-Venus⁺ cells had faded to a minimum in harvested ileal segments. Both differences were statistically significant. By 96 h after reperfusion, both Sema3A and Sox10-Venus⁺ cell fluorescence had reverted to original levels. Hematoxylin and eosin staining identified histologic damage mimicking Sema3A expression, while PGP9.5⁺ cell response was minimal.

CONCLUSION

We are the first to demonstrate a correlation between Sema3A expression and ENS damage following intestinal I/R in Sox10-Venus mice.

Rectal mucosal/submucosal biopsy under general anesthesia ensures optimum diagnosis of bowel motility disorders

PURPOSE

We reviewed all rectal mucosal/submucosal biopsies (RMSBx) performed between 1986 and 2015 focusing on specimen quality, incidence of complications during and after biopsy, and parental satisfaction.

METHODS

From 1986 to 2004, RMSBx were performed without general anesthesia (GA) (N-GA; n = 98) and from 1995 to 2015 were performed under GA (GA; n = 525). In GA cases, some sections were stained intraoperatively and examined by a pathologist and pediatric surgeon immediately to identify ganglion cells.

RESULTS

Mean ages at RMSBx were similar (2.7 vs. 2.5 years; p = NS). There were significantly more inadequate specimens in N-GA [18/98 (18.4 %) vs. 0/525 (0 %); p < 0.0001]. Incidence of rectal bleeding requiring transfusion was significantly lower in GA [0/525 (0 %) versus 2/98 (2.0 %); p = 0.024]. Parents of GA subjects willingly consented to RMSBx when told GA would facilitate diagnosis. Incidentally, RMSBx was more expensive in GA (US$1320 versus US$294; using ¥120 = US$1).

CONCLUSION

RMSBx performed under GA are safe and all specimens obtained included submucosa appropriate for optimum diagnosis in all the cases.

Pneumoperitoneum and hemodynamic stability during pediatric laparoscopic appendectomy

BACKGROUND

Conventional pneumoperitoneum (CP) and automatically maintained pneumoperitoneum using AirSeal Intelligent Flow System (AiFS) were compared during pediatric laparoscopic appendectomy (LA) using intraperitoneal pressure (IPP) and hemodynamic parameters.

METHODS

A prospective review of 39 children aged 3-14years who had standard 3-trocar LA was performed. Pneumoperitoneum was either AiFS (n=18) or CP (n=21) according to the surgeon's preference. IPP during insertion of trocars in all subjects was initially 8-10mmHg, which was reduced to 5mmHg then maintained until LA was completed. Data were collected every 5min during pneumoperitoneum.

RESULTS

Subject demographics were similar for both groups. During pneumoperitoneum, average IPP (AiFS: 7.9; CP: 9.0mmHg), average systolic blood pressure (AiFS: 100.4; CP: 106.9mmHg), and average end-tidal CO₂ (EtCO₂; AiFS: 35.7; CP: 38.5mmHg) were significantly different (p<.05, respectively), while pulse (AiFS: 92.1; CP: 96.4bpm), oxygen saturation (AiFS: 98.8; CP: 98.8%), body temperature (AiFS: 37.2; CP: 37.4), urine output (AiFS: 2.7; CP: 2.4mL/kg per hour), operative time (AiFS: 72.2; CP: 76.2mins), blood loss (AiFS: 3.6; CP: 3.5mL), recommencement of oral intake (AiFS: 1.3; CP: 1.4days), and postoperative hospitalization (AiFS: 4.3; CP: 3.8days) were not.

CONCLUSION

Because IPP was significantly lower during LA with AiFS, EtCO₂ and BP were significantly lower.

LEVEL OF EVIDENCE

Treatment study; prospective comparative study - level II.

Blockade of the renin-angiotensin system prevents acute and immunologically relevant colitis in murine models

BACKGROUND

Blockade of the renin-angiotensin system (RAS) has been shown to alleviate inflammatory processes in the gastrointestinal tract. The aim of this study was to determine if blockade of the RAS would be effective in an immunologically relevant colitis model, and to compare outcome with an acute colitis model.

METHODS

A losartan analog, CCG-203025 (C₂₃H₂₆ClN₃O₅S) containing a highly polar sulfonic acid moiety that we expected would allow localized mucosal antagonism with minimal systemic absorption was selected as an angiotensin II type 1a receptor antagonist (AT1aR-A). Two colitis models were studied: (1) Acute colitis was induced in 8- to 10-week-old C57BL/6J mice by 2.5 % dextran sodium sulfate (DSS, in drinking water) for 7 days. (2) IL10-/-colitis Piroxicam (200 ppm) was administered orally in feed to 5-week-old IL-10-/-mice (C57BL/6J background) for 14 days followed by enalaprilat (ACE-I), CCG-203025 or PBS administered transanally for 14 days.

RESULTS

In the DSS model, weight loss and histologic score for CCG-203025 were better than with placebo. In the IL10-/-model, ACE-I suppressed histologic damage better than CCG-203025. Both ACE-I and CCG-203025 reduced pro-inflammatory cytokines and chemokines.

CONCLUSIONS

This study demonstrated the therapeutic efficacy of both ACE-I and AT1aR-A for preventing the development of both acute and immunologically relevant colitis.

Congenital diaphragmatic hernia in neonates: factors related to failure of thoracoscopic repair

PURPOSE

To evaluate factors related to conversion to open repair (OR) during thoracoscopic repair (TR) in congenital diaphragmatic hernia (CDH).

METHODS

CDH subjects who were diagnosed prenatally or within 6 h of birth and underwent TR at our institution from 2007 to 2015 were reviewed. Two groups were defined: Group A, subjects who tolerated TR; and Group B, subjects who required conversion to OR.

RESULTS

Twenty-nine subjects (Group A, 20; Group B, 9) underwent TR. Patients' demographics were not significantly different between the two groups. In Group A, pre-operative arterial blood gas analysis showed mean PaCO2 37.4 mmHg, mean pH 7.45, and mean PaO2 201.6 mmHg, which were not significantly different from those of Group B (PaCO2 40.6 mmHg, pH 7.43, and PaO2 251.1 mmHg). Two Group B cases required conversion due to cardiopulmonary instability. The remaining seven cases were converted for technical reasons (large defect in two, anterior location of the defect in two, bleeding from short gastric vessels or spleen in two, and insufficient operative view in one).

CONCLUSIONS

TR can be performed safely in selected cases of CDH. CDH with a large defect and/or an unusual location of the defect remains a challenge for pediatric surgeons.

Treatment of vesico-ureteral reflux in infants and children using endoscopic approaches

Vesicoureteral reflux (VUR) represents one of the most significant risk factors for acute pyelonephritis in children. Endoscopic treatment of VUR dates back to 1981 when Matouschek first described injection of the ureteral orifice in an attempt to correct VUR. In addition, also Politano and colleagues and McDonald described successful correction of reflux using endoscopic techniques. After these reports subureteral Teflon injection (STING) came to be appreciated as a viable new way to less invasively correct one of the most common pediatric urologic problems. The technique is technically easy to perform and is usually performed as an outpatient procedure. It is performed in general anesthesia in children and may require repeat injections, particularly in patients with high-grade reflux. As for endoscopic technique, a main problem existed. The success in children with high grade reflux was less than reported for open or laparoscopic reimplant techniques. However, in the past 10 years, newer products have become available that are changing the indications for endoscopic correction. In these review, we analyzed the papers published in the literature on this topic to give to the readers an updated overview about the results of endoscopic treatment of VUR after 30-years of his first description.

Surgical management of recto-prostatic and recto-bulbar anorectal malformations

PURPOSE

Laparoscopically assisted anorectoplasty (LAARP) was compared to posterior sagittal anorectoplasty (PSARP) in the treatment of male imperforate anus associated with either recto-prostatic fistula (RPF) or recto-bulbar fistula (RBF).

METHOD

19 RPF patients (12 treated by LAARP and 7 by PSARP) and 26 RBF patients (14 treated by LAARP and 12 by PSARP) between 1995 and 2014 were retrospectively assessed using a fecal continence evaluation questionnaire (FCE) (with a maximum score of 10), an FCE score coefficient variation, as well patients' MRI scores, anorectal angle values (AA), and incidence of postoperative complications. Statistical significance was determined at p < 0.05.

RESULTS

Both groups were similar in mean age and mean weight at repair, as well as sacral status. Postoperatively, mean MRI scores, mean AA, and biochemistry were also similar (p = NS). All cases treated with LAARP showed consistently higher and less variable FCES values, fewer wound infection incidence, but greater rectal mucosal prolapse unrelated with sacrum status. Significantly lower doses of postoperative analgesia were needed in all LAARP cases (p < 0.05).

CONCLUSION

Technical outcomes appear to be similar based on imaging studies, but FCES-assessed functional outcomes appear to favor LAARP for treatment of both RPF and RBF.

A Multi-Institutional Review of Thoracoscopic Congenital Diaphragmatic Hernia Repair

INTRODUCTION

Thoracoscopic repair of a congenital diaphragmatic hernia (CDH) in the neonate is controversial due to reports of increased hernia recurrence. A multicenter review on thoracoscopic CDH repair was conducted to evaluate outcomes and to identify factors that are associated with recurrence.

METHODS

A multicenter retrospective review was conducted from 2009 to 2015 in neonates who were treated for CDH with thoracoscopic repair. Demographics, preoperative, intraoperative, including repair techniques, and postoperative variables were analyzed by using descriptive statistics. Comparative analysis was performed between those patients who were repaired entirely thoracoscopically with hernia recurrence and those without.

RESULTS

One hundred nine infants, of whom 57% were male with an average gestational age at time of surgery of 39.6 ± 4.6 weeks and a weight of 3.4 ± 1.1 kg, were included. The median age at repair was 5 days (range: 3-9), 61% patients required vasopressor support, and 1.8% patients required extracorporeal membrane oxygenation (ECMO) cannulation before repair. Forty-five percent were repaired on high-frequency oscillatory ventilation (HFOV). Repair was completed thoracoscopically in 83 patients (76%), 68 (82%) were repaired primarily, 15 (18%) were repaired with a patch, and 50 (60%) had extracorporeal/rib fixation sutures. Recurrence occurred in 7 (8.4%) of those completed thoracoscopically. Factors found to be significant for recurrence included: vasopressor therapy (P = .02), repair on HFOV (P = .04), and the presence of the spleen in the chest (P = .04). There was no significant difference identified between technical variations in repair.

CONCLUSIONS

These data suggest that thoracoscopic repair of CDH is feasible in carefully selected patients. However, there is currently no evidence to support a standardized surgical approach to thoracoscopic repair.

Surgical intervention for congenital pulmonary airway malformation (CPAM) patients with preoperative pneumonia and abscess formation: "open versus thoracoscopic lobectomy"

AIM

Thoracoscopic lobectomy (TL) and open lobectomy (OL) were compared for treating congenital pulmonary airway malformation (CPAM) with preoperative complications, specifically pneumonia/abscess formation (PA).

METHODS

The medical records of 46 CPAM patients treated by lobectomy at our institution from 1990 to 2014 were reviewed retrospectively. Four groups, TL for patients without PA (n = 17; TL-), TL for patients with PA (n = 8; TL+), OL for patients without PA (n = 16; OL-), and OL for patients with PA (n = 5; OL+) were compared for operative time, intra/postoperative complications, blood loss, duration of chest tube insertion, postoperative analgesia, pre: postoperative white blood cell (WBC) ratio, and duration of hospitalization.

RESULTS

Operative time for TL+ was longest, but not statistically significant. Incidences of intra/postoperative complications were similar in all groups. Blood loss was significantly less for TL+ versus OL+ (p < .05). WBC ratio was significantly lower in TL+ versus OL+ (p < .05), similar for TL+ and TL-, and significantly higher in OL+ versus OL- (p < .01). Chest tube insertion was significantly longer in OL- versus TL- (p < .01).

CONCLUSION

PA would not appear to be a contraindication to perform TL in CPAM. TL is associated with less surgical stress than OL despite longer operative time.

Comprehensive assessment of prognosis after laparoscopic portoenterostomy for biliary atresia

PURPOSE

Total bilirubin (T-bil) is used universally for monitoring post-portoenterostomy (PE) biliary atresia (BA) patients although other biochemical markers [BM; AST/ALT and platelet count (PC)] are also prognostic. We compared open PE (OPE) with laparoscopic PE (LPE) using T-bil, AST/ALT, and PC (3BM) as more comprehensive indicators of postoperative clinical status.

METHODS

Subjects were 31 PE cases (LPE: n = 17; OPE: n = 14). BA classification was type III (n = 16), type II (n = 1) in LPE and type III (n = 12), type I (n = 1), type II (n = 1) in OPE.

RESULTS

Mean ages and weights at PE were similar: 65.5 days, 4.4 kg (LPE) versus 69.3 days, 4.1 kg (OPE); and mean follow-up was 2.5 years for both LPE and OPE. Jaundice clearance (T-bil ≤1.2 mg/dL) was achieved in 16/17 (94.1 %) after LPE versus 10/14 (71.4 %) after OPE (p = NS), but 3BM were closer to normal after OPE. At the time of review, 13/17 LPE cases (76.5 %) were alive with native livers and 4/17 had received LTx (23.5 %) and 10/14 OPE cases (71.4 %) were alive with native livers and 4/14 had received LTx (28.6 %).

CONCLUSIONS

Although JC was better after LPE, 3BM were better after OPE. Further follow-up will prove the comprehensive prognostic value of 3BM.

The effect of preoperative urinary tract infection on postoperative renal function in prenatally diagnosed ureteropelvic junction obstruction: Indications for the timing of pyeloplasty

PURPOSE

We reviewed renal function after pyeloplasty (PP) in cases of prenatally diagnosed ureteropelvic junction obstruction (PDUPJO) to determine the impact of preoperative urinary tract infection (UTI) on the timing of PP.

METHODS

We retrospectively reviewed 81 cases of PDUPJO diagnosed between 1998 and 2013. Incidence of UTI was used to divide 37 kidneys requiring PP (3 bilateral) into U(-): UTI≤1; n=25, and U(+): UTI≥2; n=12 to compare age at PP, grade of hydronephrosis (HN) on ultrasonography (US), glomerular filtration rate (GFR) on diethylenetriaminepentacetic acid (DTPA) renography, and uptake on dimercaptosuccinic acid (DMSA) scintigraphy pre/post PP.

RESULTS

Age at first UTI and age at PP were similar. HN improved significantly postPP in all cases. Although DTPA and DMSA were similar prePP, improvement postPP was better in U(-) than U(+), but only DMSA in U(-) was statistically significant (15.2%±4.0% vs. 20%±3.7%; p=0.049). There were no complications or UTI postPP.

CONCLUSION

Two or more UTIs would appear to be associated with postPP renal dysfunction in PDUPJO. Thus, PP should be performed after the initial UTI but before the second UTI.

Ureteric patency after Deflux® injection for the treatment of vesicoureteric reflux in children confirmed by a novel epidural catheter-assisted endoscopic technique

PURPOSE

We present EDCAT (epidural catheter-assisted Deflux(®) treatment) for treating vesicoureteral reflux (VUR) and confirming ureteric patency after Deflux(®) treatment.

METHODS

We treated 147 ureters in 101 children (M:F 62:39; VUR ≤ grade III: n = 72; VUR ≥ grade IV: n = 75) using EDCAT between 2011 and 2014. EDCAT involves injecting 1-3 mL of diluted indigo carmine solution through an epidural anesthesia catheter inserted into the Deflux(®)-treated ureter and observing for up to 15 min to confirm patency.

RESULTS

For EDCAT, mean age was 4.9 years and mean operative time was 30.1 ± 12.1 min; overall cure of VUR after initial treatment was 87.7 % for VUR grades I-V, 88.9 % for VUR ≤ grade III, and 86.6 % for VUR ≥ grade IV; VUR was cured in 129/147 after 1 treatment, 7/18 after 2 treatments, 7/11 after 3 treatments, and persistent in 4/4. We experienced 1 case of obstruction after an EDCAT catheter was removed before confirming patency. EDCAT catheters were left overnight in 2 ureters in 2 cases when patency could not be confirmed after 15 min to prevent obstruction. Both did not develop obstruction. Four ureters with recurrence of VUR (all grade ≤ II) are being observed.

CONCLUSION

EDCAT allows ureteric patency to be confirmed immediately and prevents obstruction.

Completely intramural bronchogenic cyst of the cervical esophagus in a neonate

Bronchogenic cysts are congenital cystic lesions of foregut origin, usually intrapulmonary or mediastinal, while esophageal cysts generally originate within the esophagus. To the best of our knowledge, this is the first report of a case of a completely intramural bronchogenic cyst of the cervical esophagus in a neonate.

Diaphragmatic eventration in children: laparoscopy versus thoracoscopic plication

AIM

To determine the best way to perform diaphragmatic plication for diaphragmatic eventration (DE) using minimally invasive surgery.

MATERIALS AND METHODS

We conducted a retrospective review of pediatric cases of DE treated between 2007 and 2012. Thoracoscopic plication (TP) is performed using single-lung ventilation with three 5-mm ports; laparoscopic plication (LP) is performed using three or four 5-mm ports. The choice of technique was determined preferentially by the treating surgeon.

RESULTS

There were 20 subjects (13 treated by LP and 7 treated by TP). Etiology of DE was phrenic nerve injury (LP, n=11; TP, n=1) and muscular deficiency (LP, n=2; TP, n=6). Mean age (LP, 18 months; TP, 25 months) and weight (LP, 8.0 kg; TP, 9.7 kg) at surgery were not significantly different. Mean operating time was 155.6 minutes in LP and 167.0 minutes in TP (P=not significant). Mean intraoperative end-tidal CO2 was 41.9 mm Hg (range, 35-52 mm Hg) in LP and 36.9 mm Hg (range, 33-41 mm Hg) in TP (P=.01). Mean duration of postoperative ventilation was 1.2 days in LP and 1.3 days in TP (P=not significant). Mean time taken to recommence feeding postoperatively was 1.6 days in both groups (P=not significant). Complications were one conversion to thoracotomy in TP, 1 case of atelectasis in each group (P=not significant), and 6 cases of recurrence in LP versus none in TP (P=.04).

CONCLUSIONS

Both TP and LP are beneficial for treating small children with DE. However, there is a higher incidence of recurrence after LP, and the role of TP in cardiac patients requiring subsequent surgery is debatable.

Vaginal anomalies and atresia associated with imperforate anus: diagnosis and surgical management

BACKGROUND

The association of vaginal atresia (or Mayer-Rokitansky-Kuster-Hauser Syndrome) with imperforate anus is rare and can present significant diagnostic and therapeutic challenges. This study describes clinical characteristics, surgical treatment and outcomes in this group of complex children.

METHODS

Records of 20 patients were retrospectively analyzed from two pediatric surgical centers.

RESULTS

Five patients were excluded from the long-term analysis due to inadequate information, leaving long-term follow-up in 15 patients. Mean follow-up was 10 years (range 1-31.1 years). The diagnosis of vaginal atresia was made pre-operatively in 12 out of 15 patients, and in three patients it was identified during the anoplasty. The anorectal malformations were rectoperineal (N=2), rectovestibular (N=6), recto-bladder neck (N=1) and imperforate anus without fistula (N=6). Satisfactory surgical repair was performed in 13 patients, while one continues to stool through a low perineal fistula awaiting definitive surgery and another underwent a colostomy and mucous fistula. Delayed vaginal reconstruction was due to a failure to identify the problem prior to anoplasty (N=3). Long-term results demonstrated that anorectal continence was much worse than initially appreciated, and many had associated urinary incontinence. Overall stooling score was far lower than in a separate group of children with imperforate anus without vaginal atresia (Levitt and Peña, 2007).

CONCLUSIONS

Vaginal atresia with imperforate anus is a rare and an extensive pre-operative workup of females with imperforate anus must include assessment of vagina patency. Vaginal reconstruction and anorectal continuity can be performed in a variety of approaches, but long-term continence is often not optimal. We propose a pathway for management of this difficult genito-anorectal disorder.

A single surgeon's experience of 65 cases of penoplasty for congenital megaprepuce, with special reference to mid- to long-term follow-up

PURPOSE

There are few reports about postoperative outcome of penoplasty (PP). We present the results of mid- to long-term follow-up of PP performed for congenital megaprepuce (CMP).

METHODS

Data from 65 CMP cases treated by PP performed by a single surgeon from 2000 to 2014 were collected prospectively. All cases were treated using the technique reported by Cuckow (Pediatric surgery. Springer, Berlin, pp 543-554, 2006).

RESULTS

Mean age at PP was 5.9 years (range 0.4-13.9). All cases presented as infants and some 12 cases (18.5 %) had PP when 10 or more years old. There were no intra- and postoperative complications. Mean duration of follow-up was 3.6 years (range 0.1-17.5). Duration of follow-up was 4 years or less in 48 (73.8 %), 5-9 years in 13 (20.0 %), and 10 or more years in 4 (6.2 %). While postoperative penile cosmesis was good in 63/65 (96.9 %) cases without scrotal deformity, 2/65 (3.1 %) had redundant penile skin excised upon the recommendation of the treating surgeon even though the patients and parents were unconcerned.

CONCLUSION

Mid- to long-term follow-up of our PP cases shows that outcome is cosmetically acceptable and stable.

Does pneumoperitoneum adversely affect growth, development and liver function in biliary atresia patients after laparoscopic portoenterostomy?

PURPOSE

We assessed the effect of high partial pressure of arterial carbon dioxide (PaCO2) due to pneumoperitoneum (PP) on growth (height/weight) and development (gross/fine motor function, receptive/expressive communication, and social interaction), by comparing outcome after portoenterostomy (PE) for biliary atresia (BA) using laparoscopic PE (LPE: n = 13) and open PE (OPE: n = 13) cases performed between 2005 and 2014.

METHODS

Our PE is based on Kasai's original PE. All data were collated prospectively.

RESULTS

Differences in duration of follow-up (LPE: 38.8 months; OPE: 38.1 months), jaundice clearance (LPE: 12/13 = 92.3 %; OPE: 9/13 = 69.2 %), survival with the native liver (LPE: 10/13 = 76.9 %; OPE: 9/13 = 69.2 %), incidence of cholangitis, hypersplenism, and incidence of esophageal varices were not significant. Mean intraoperative PaCO2 was significantly higher in LPE (LPE: 50.1 mmHg; OPE: 40.7 mmHg, p < 0.05). Liver function impairment was not statistically different, although LPE results were slightly worse. There was no overall delay in growth observed, although height/weight gain was more consistent in LPE. The pattern of developmental delay observed was similar for LPE and OPE suggesting that developmental delay is not PE-related; in other words, PP is not implicated in developmental delay.

CONCLUSIONS

PP during LPE would appear to have no adverse effects on overall growth/development and liver function in BA patients.