[Influencing factors on operating times for metal bar removal after Nuss repair]

BACKGROUND

Metal bar removal after the Nuss repair procedure is prone to be cancelled in cases of operating time shortages due it being suitable to be postponed without harming patients. Consequently, planning operation times as exactly as possible could be one solution.

OBJECTIVE

Statistical modelling of operation times of metal bar removal after Nuss repair using the prespecified independent predictors of age, sex, intraoperative complications, and number of implanted metal bars.

MATERIAL AND METHODS

We included all patients whose operation notes included an operation time, which was modelled via linear regression and subject to internal validation via bootstrap. Exploratory analyses also consisted of the surgeon's experience, the number of stabilizers, the body mass index, and preceding re-do surgery for bar dislocation.

RESULTS

We included 265 patients (14% ♀) with a median age of 19 years (interquartile range 17-20 years), of whom 81% had 1 and 17% had 2 metal bars removed. The prespecified regression model was statistically significant (likelihood ratio 56; df = 5; P < 0.001) and had a bias corrected R2 of 0.148. Patient age influenced operation times by 2.1min per year of life (95% confidence interval 1.3-2.9min; P < 0.001) and 16min per explanted metal bar (95% confidence interval: 10-22min; P < 0.001).

CONCLUSION

The patient-specific factors of age and the number of explanted metal bars influenced the operation times and can be included into scheduling operation times.

Paediatric Pilonidal Sinus Disease: Early Recurrences Irrespective of the Treatment Approaches in a Retrospective Multi-centric Analysis

BACKGROUND

Incidences of pilonidal sinus disease are rising. Guidelines rarely consider children and adolescents and evidence for their treatment is rare. The literature is divided on the choice of the preferable surgical procedure. Therefore, we aimed to assess recurrences and complications following different treatment approaches in our multi-centric cohort.

METHODS

We retrospectively assessed all patients treated for pilonidal sinus disease in the paediatric surgical departments of Bonn and Mainz between 01/01/2009 and 31/12/2020. Recurrences were defined according to the German national guidelines. The pre-specified analysis via logistic regression included the operative approach, age, sex, use of methylene blue, and obesity as independent predictors.

RESULTS

We included 213 patients, of which 13.6% experienced complications and 16% a recurrence. Median time to recurrence was 5.8 months (95% confidence interval: 4.2-10.3), which was slightly higher in children than adolescents (10.3 months, 95% confidence interval: 5.3-16.2 vs. 5.5 months, 95% confidence interval: 3.7-9.7). None of the investigated procedures, excision and primary closure, excision and open wound treatment, pit picking, and flap procedures had a decisive advantage in terms of complications or recurrence. Of the independent predictors, only obesity was associated to complications (adjusted odds ratio: 2.86, 95% confidence interval: 1.05-7.79, P = 0.04).

CONCLUSIONS

We did not find a difference between the investigated procedures, but our analysis is limited by the small sample size in some subgroups. Our data corroborates that recurrences in paediatric pilonidal sinus disease occur early. Factors linked to these differences remain unknown.

COVID-19 among migrants, refugees, and IDPs: a synthesis of the global empirical literature

Background

The COVID-19 syndemic reveals social and health inequalities, putting marginalized groups such as migrants at greater risk. Yet health systems fail to routinely monitor the health of migrants, refugees, and internally displaced persons. Our systematic review provides an up-to-date synthesis of the empirical evidence on COVID-19 infection risk, transmission, outcome of disease and risk of severe course of disease among migrant populations. It further aims to compile extant evidence on COVID-19 vaccination coverage among these groups, and on the effects of pandemic control measures on their health.

Methods

Following PRISMA guidelines, we registered a review protocol, searched 14 scientific databases and 4 pre-print servers using the WHO database of global literature on COVID-19, and hand-searched relevant websites for grey literature. The search period covers the time from 12/2019 to 11/30/2021. Articles in English, German and Spanish and all study designs were included.

Results

A total of 6966 references were identified for title and abstract screening. 518 records were screened in full-text, out of which 204 articles were included so far (conflict solving at full-text stage and data extraction are ongoing). Our review presents a broad landscape of different study designs, migrant populations and COVID-19 outcomes. Based on previous work, we expect to find a higher risk of infection in migrants and their disproportionate share among COVID-19 cases, and consolidate the (mental) health impacts of pandemic control measures. Our preliminary findings indicate a vast knowledge gap on vaccination coverage among migrant groups.

Conclusions

Two years into the syndemic, this review summarizes the global empirical evidence on the impact of the COVID-19 syndemic on migrant populations. With health systems often lacking related data, the review provides an important evidence base for the consideration of migrants in future pandemic preparedness policies.

Key messages

• The systematic review provides an up-to-date synthesis of the empirical evidence on COVID-19 among diverse migrant populations globally.

• Knowledge on vaccination coverage in migrants remains patchy.

Area-level socioeconomic deprivation, non-national residency, and Covid-19 incidence

Introduction

Socioeconomic conditions affect the dynamics of the COVID-19 pandemic. We analysed the association between area-level socioeconomic deprivation, proportion of non-nationals, and Covid-19 incidence in Germany.

Methods

Using nationally representative data at the level of 401 German districts from three waves of infection (January-2020 to May-2021), we fitted Bayesian spatiotemporal models to assess the association between socioeconomic deprivation, proportion of non-nationals, and Covid-19 incidence, controlling for age, sex, vaccination coverage, settlement structure, spatial and temporal effects. We estimated risk ratios (RR) and corresponding 95% credible intervals (95%-CrI) for deprivation quintiles. We further examined the deprivation domains (education, income, occupation), interactions between deprivation, sex and the proportion of non-nationals, and explored potential pathways from deprivation to Covid-19 incidence.

Results

Covid-19 incidence risk was 15% higher (RR = 1.15, 95%-CrI=1.06-1.24) in areas with the highest deprivation quintile (Q5) compared to the least deprived areas (Q1). Medium-low (Q2), medium (Q3), and medium-high (Q4) deprived districts showed 5% (1.05, 0.98-1.13), 8% (1.08, 1.01-1.15), and 6% (1.00, 1.00-1.12) higher risk, respectively, compared to the least deprived. Districts with higher proportion of non-nationals showed higher risk compared to districts with lowest proportion, but the association weakened across the three waves. During the first wave, an inverse association was observed with highest risk in least deprived areas (Q1). Deprivation interacted with sex, but not credibly with the proportion of non-nationals.

Conclusions

Socioeconomic deprivation and proportion of non-nationals are independently associated with Covid-19 incidence. Regional planning of non-pharmaceutical interventions and vaccination strategies would benefit from consideration of area-level deprivation and non-national residency.

Key messages

Percutaneous Anorectoplasty (PARP)—An Adaptable, Minimal-Invasive Technique for Anorectal Malformation Repair

Background: Anorectal malformations comprise a broad spectrum of disease. We developed a percutaneous anorectoplasty (PARP) technique as a minimal-invasive option for repair of amenable types of lesions. Methods: Patients who underwent PARP at five institutions from 2008 through 2021 were retrospectively analyzed. Demographic information, details of the operative procedure, and perioperative complications and outcomes were collected. Results: A total of 10 patients underwent the PARP procedure during the study interval. Patients either had low perineal malformations or no appreciable fistula. Most procedures were guided by ultrasound, fluoroscopy, or endoscopy. Median age at PARP was 3 days (range 1 to 311) days; eight patients were male. Only one intraoperative complication occurred, prompting conversion to posterior sagittal anorectoplasty. Functional outcomes in most children were highly satisfactory in terms of continence and functionality. Conclusions: The PARP technique is an excellent minimal-invasive alternative for boys born with perineal fistulae, as well as patients of both sexes without fistulae. The optimal type of guidance (ultrasound, fluoroscopy, or endoscopy) depends on the anatomy of the lesion and the presence of a colostomy at the time of repair.

Availability and integration of health data on refugee and migrants in health information systems

This presentation discusses the findings of a Health Evidence Network synthesis report on availability and integration of refugee and migrant health data in health information systems in the WHO European Region. Based on an analysis of 41 full-text studies and 696 abstracts, the report found that refugee and migrant health data were available in less than half of the Region's Member States, and that data availability and integration, data collection systems, as well as indicators on migration varied markedly between states. From these findings, the report derived key policy considerations regarding the strengthening and harmonization of migrant health data collection, as well as governance and monitoring of health information systems.

Area deprivation is inversely associated with measles incidence: A spatiotemporal analysis in Germany

Background

Although measles is endemic in all WHO European regions, very few studies have directly analysed socioeconomic inequalities in disease incidence of measles. We examined the spatiotemporal association between socioeconomic deprivation and measles incidence considering relevant demographic and geographical factors at district level.

Methods

We conducted a longitudinal small-area analysis using nationally representative data of 401 districts from 2001 to 2017. We used Bayesian spatiotemporal regression models to assess the potential effects of area deprivation on measles incidence, adjusted for relevant demographic (district population size, sex, age, and proportion of non-nationals) and geographical factors (north-south-west-east effect) as well as spatial and temporal effects. We computed risk ratios (RR) for deprivation quintiles (Q1 - Q5), and district-specific adjusted relative risks (ARR) to assess the area-level risk profile of measles in Germany.

Results

The risk of measles infection in areas with lowest deprivation quintile (Q1) was 1.58 times higher (95%-credible interval [CrI] 1.32-2.00) than in those with highest deprivation (Q5). Areas with medium-low (Q2), medium (Q3), and medium-high deprivation (Q4) had higher adjusted risks of measles relative to areas with highest deprivation (Q5) (RR: 1.23 (0.99-1.51), 1.05 (0.87-1.26), and 1.23 (1.05-1.43), respectively). We identified 22 areas at high risk and 56 at medium-high risk for measles infections, with highest area-level risks in south-western Germany.

Conclusions

Socioeconomic deprivation in Germany is inversely associated with measles incidence, with elevated risk for measles infections in areas with higher socioeconomic status. Our findings contribute to current global and national debates on measles elimination strategies, and demonstrate the importance of spatial modelling techniques in identifying socioeconomic inequalities and spatial risk patterns of measles for public health actions.

Key messages

Socioeconomic deprivation is inversely associated with measles incidence in Germany, with higher risk of infection in areas with highest socioeconomic status. The social, spatial, and temporal patterns of elevated risk of measles infection require targeted public health action and policy to address the complexity underlying measles epidemiology.

[Thoracoscopic Sympathectomy for Palmar and Axillary Hyperhidrosis]

OBJECTIVE

This video is a step-by-step description of thoracoscopic sympathectomy.

INDICATION

Sweating is essential for thermoregulation. Hyperhidrosis is a condition of excess sweating from the eccrine glands and is associated with severe suffering for patients of all ages. It often worsens during adolescence. A generalised and focal type of hyperhidrosis which affects mainly the face, armpits, hands and feet can be distinguished from the focal variant. Thoracic sympathectomy has become the standard treatment for palmar and axillary hyperhidrosis worldwide.

METHODS

The procedure is performed in the supine position with the upper body elevated about 30° in an adolescent patient. Both arms are abducted at 90° and single tube endotracheal ventilation is employed. A 3 mm trocar is placed in the anterior axillary line for a 3 mm 30° optic. A 5 mm trocar placed on the anterior axillary line (or breast fold in female patients) of the 4th or 5th intercostal space is used for the bipolar forceps. The sympathetic trunk and ganglia T 2 - 4 are identified and coagulated over the heads of ribs.

CONCLUSION

The thoracoscopic approach to focal palmar and axillary hyperhidrosis allows clear identification of the sympathetic structures on each side. Under direct vision, selective ablation of the ganglia and sympathetic trunk provides long-term benefit for patients.

[Robot-Assisted Repeated Fundoplication in Children and Adolescents]

BACKGROUND

Recurrent gastroesophageal reflux symptoms in adolescents and young adults who underwent fundoplication in childhood present a technical challenge for the surgeon. The distal oesophagus and hiatus are difficult to access by laparotomy, the anatomy is modified by the primary procedure, and there are often dense adhesions between important structures. Robot-assisted surgery may be advantageous, because of the three dimensional (3D) view and the multiaxial freedom of movement afforded by the system.

PURPOSE

To describe our experience with robot-assisted Nissen re-fundoplication in adolescents who underwent primary fundoplication in childhood.

METHODS

The video shows the individual steps in robotic repeated fundoplication using the robotic system (Intuitive Surgical Inc., Sunnyvale, CA, USA). Three patients were operated with fundoplication at the age of 15 ± 2 years due to gastroesophageal reflux disease. After an average of 11,8 years after the primary procedure, they showed pathological reflux symptoms, which indicated repeated Nissen fundoplication.

RESULTS AND DISCUSSION

The 3D vision of the robotic system provided the surgeon with a good overview of the operative field. In addition, it allowed accurate dissection of the predictable adhesions around the hiatus. Mean operating time from incision to closure in the robot-assisted re-fundoplication was 174 min. Neither intra- nor postoperative complications occurred. As in conventional laparoscopic technique, there is a learning curve for the robotic surgery that can be appreciated from our data. Shorter dissection times and simplified dissection are potential benefits that need to be balanced with the higher cost of the robotic technique.

CONCLUSION

Robot-assisted re-fundoplication is an excellent alternative to the conventional laparoscopic procedure in young adults with recurrent gastroesophageal symptoms, who had a fundoplication in early childhood. The 3D-vision and the multi-axial free mobility of the instruments facilitate precise dissection that consider anatomic structures and adhesions.

Area deprivation and notifiable infectious diseases in Germany: A longitudinal small-area analysis

Background

Socioeconomic inequalities may affect the infectious disease incidence. We studied the association between area deprivation and incidence of notifiable infectious diseases in Germany to understand spatio-temporal patterns and the effects of societal factors on disease epidemiology.

Methods

Using national surveillance data of 401 districts from 2001 to 2017, we examined the incidence of infectious diseases using spatiotemporal Bayesian regression models. We analyzed eight disease classes: blood-borne viral hepatitis, gastrointestinal, vaccine preventable, vector-borne, zoonotic, other bacterial, other infectious, and overall burden of infectious diseases. As explanatory factors we considered area deprivation (measured by the German Index of Multiple Deprivation), fraction of non-nationals, sex, age, and spatiotemporal effects.

Results

A risk gradient across deprivation quintiles was observed for the overall burden of infectious diseases. The relative risk (RR) for gastrointestinal diseases in areas with medium and high deprivation relative to low deprivation was 1.65 (95%-credible interval [CrI] 1.01-2.54) and 2.64 (1.22-4.98), respectively. The RR for vector-borne diseases was 1.89 (1.27-2.73) in districts with high deprivation compared to areas with low deprivation. Lower risks in highly deprived areas relative to low deprived areas were identified in vaccine-preventable diseases (RR = 0.39; 0.14-0.88) and zoonoses (RR = 0.69; 0.48-0.96). For blood-borne viral hepatitis, other bacterial, and other infectious diseases no association with area deprivation was observed. Spatial risks of infections were predominantly concentrated in eastern parts of Germany and changed marginally over time.

Conclusions

The risks of infections tend to be higher in more deprived areas and in eastern parts of Germany, but they varied by class of disease. Our results can guide measures of infectious disease control and prevention by considering spatial risks and deprivation.

Key messages

Area deprivation has both positive and inverse associations with the incidences of infectious diseases in Germany. Regions with increased risks may benefit from targeted public health measures. Spatial risks of infections tended to be higher in eastern regions of Germany. Disparities in the incidence of infectious diseases may be still present between western and eastern Germany.

Telemedicine for pediatric surgical outpatient follow-up: A prospective, randomized single-center trial

BACKGROUND AND PURPOSE

Telemedicine is gaining popularity for a variety of indications. We performed a randomized controlled trial comparing telemedical versus conventional clinic follow-up in terms of feasibility and quality.

METHODS

Patients discharged from pediatric surgery were randomized to telemedical or onsite follow-up. In the telemedical group, video telephony was used to obtain interim history and physical findings. Onsite patients were personally seen in the outpatient clinic. Caregivers completed a postvisit survey on satisfaction and efficiency. Providers scored data transmission quality and clinical interpretability.

RESULTS

From March 2015 until January 2017, 224 patients were randomized equally to the study groups. Telemedicine was highly accepted by caregivers, and data transmission quality was sufficient for comprehensive follow-up. No important clinical findings were missed. Quality of interaction scored higher in the telemedical versus the onsite group (77.8% vs. 48%, p < 0.001) as did caregiver satisfaction (5.4 vs. 5.1, p < 0.03). Travel investment, time required, loss of earnings, and days off from work/school were all significantly lower in the telemedical group (p < 0.001).

CONCLUSIONS

Telemedical posthospitalization follow-up in pediatric surgery provides a cost-effective, time-saving alternative for patients and caregivers that is well received and accepted. The quality of clinical data transmission is sufficient to provide safe care and uncompromised clinical judgment.

TYPE OF STUDY

Prospective and randomized controlled study.

LEVEL OF EVIDENCE

Level 1b.

[Laparoscopic Resection of Urachal Cysts]

Objective This video is a step-by-step description of the laparoscopic technique for the resection of urachal cysts. Indication The urachus is an embryonic extraperitoneal structure between the urinary bladder and the umbilicus. Failure of the allantois to obliterate in utero leads to urachal anomalies such as fistulas or cysts. Because of the risk of infection and malignant degeneration later in life, urachal fistulas or cysts are usually removed by surgical excision. Method The procedure is performed in supine position with 3 mm trocars in the epigastric angle, the left upper abdomen and the left middle abdomen. During the operation, the trocar in the epigastric angle will be upsized to 5 mm in order to introduce a 5 mm polymer clip applier. We use a 5 mm 30° optic and a 3 mm monopolar hook for dissection. Conclusion This laparoscopic approach to removing urachal remnants allows for the involved structures to be clearly identified and accurately dissected. A complete resection of urachal remnants is facilitated by direct visualization of the entire anomaly down to the bladder dome.

A Novel Technique of Posterolateral Suturing in Thoracoscopic Diaphragmatic Hernia Repair

Background  Closure of the posterolateral defect in some cases of congenital diaphragmatic hernia (CDH) can be difficult. Percutaneous transcostal suturing is often helpful to create a complete, watertight closure of the diaphragm. A challenge with the technique is passing the needle out the same tract that it entered so that no skin is caught when the knots are laid down into the subcutaneous tissue. This report describes a novel technique using a Tuohy needle to percutaneously suture the posterolateral defect during thoracoscopic repair of CDH.

Case  We report a case of a 6-week-old infant who presented with a CDH and ipsilateral intrathoracic kidney that was repaired using thoracoscopic approach. The posterolateral part of the defect was repaired by percutaneous transcostal suturing and extracorporeal knot tying. To assure correct placement of the sutures and knots, a Tuohy needle was used to guide the suture around the rib and out through the same subcutaneous tract. The total operative time was 145 minutes and there were no perioperative complications. The patient was followed up for 3 months, during which there was no recurrence.

Conclusion  Our percutaneous Tuohy technique for closure of the posterolateral part of CDH enables a secure, rapid, and tensionless repair.