Introduction of a Warming Bundle to Reduce Hypothermia in Neonatal Surgical Patients

INTRODUCTION

Hypothermia in the neonatal surgical population has been linked with significant morbidity and mortality. Our goal was to decrease intra and postoperative hypothermia.

INTERVENTION

In November 2021, a radiant warmer and hat were included along with standard warming methods prior to the start of General Surgery procedures to minimize episodes of hypothermia.

PRIMARY OUTCOME

Core body temperature was measured pre, intra and post-operatively.

METHODS

Data were prospectively collected from electronic medical records from July 2021 to March 2023. A retrospective analysis was performed. Hypothermia was defined as a temperature <36.5C. Control charts were created to analyze the effect of interventions.

RESULTS

A total of 277 procedures were identified; 226 abdominal procedures, 31 thoracic, 14 skin/soft tissue and 6 anorectal. The median post-natal age was 36.1 weeks (IQR: 33.2-39.2), with a pre-surgical weight of 2.3 kg (IQR: 1.6-3.0) and operative duration of 181 min (IQR: 125-214). Hat and warmer data were unavailable for 59 procedures, both hat and warmer were used for 51 % procedures, hat alone for 29 %, warmer alone for 10 % and neither for 10 % of procedures. Over time there was a significant increase in hat utilization while warmer usage was unchanged. There was a significant increase in the mean lowest intra-operative temperature and decrease in proportion of hypothermic patients intra-operatively and post-operatively.

CONCLUSIONS

The inclusion of a radiant warmer and hat decreased the proportion of hypothermic patients during and after surgery. Further studies are necessary to analyze the impact on surgical outcomes.

LEVEL OF EVIDENCE

III.

Current management of surgical neonates: is it optimal or do we need to improve? A national survey of the Italian Society of Neonatology

PURPOSE

Few guidelines exist for the perioperative management (PM) of neonates with surgical conditions (SC). This study examined the current neonatal PM in Italy.

METHODS

We invited 51 neonatal intensive care units with pediatric surgery in their institution to participate in a web-based survey. The themes included (1) the involvement of the neonatologist during the PM; (2) the spread of bedside surgery (BS); (3) the critical issues concerning the neonatal PM in operating rooms (OR) and the actions aimed at improving the PM.

RESULTS

Response rate was 82.4%. The neonatologist is involved during the intraoperative management in 42.9% of the responding centers (RC) and only when the surgery is performed at the patient's bedside in 50.0% of RCs. BS is reserved for extremely preterm (62.5%) or clinically unstable (57.5%) infants, and the main barrier to its implementation is the surgical-anesthesiology team's preference to perform surgery in a standard OR (77.5%). Care protocols for specific SC are available only in 42.9% of RCs.

CONCLUSION

Some critical issues emerged from this survey: the neonatologist involvement in PM, the spread of BS, and the availability of specific care protocols need to be implemented to optimize the care of this fragile category of patients.

Quality of Life in Long-Term Survivors of Surgical Necrotizing Enterocolitis

OBJECTIVE

This study evaluated the quality of life (QoL) in patients who have recovered from surgical necrotizing enterocolitis (NEC).

METHODS

This is a cross-sectional study conducted in a tertiary centre and patients who have received surgery for NEC between 2000 and 2014 were invited to participate. The Pediatric Quality of Life Inventory Generic (PedsQL™) Core Scale Version 4.0 was used as the assessment tool. Values were reported as median (interquartile rage) and compared with age-matched controls.

RESULTS

During the study period, 90 patients were eligible for the study and 29 patients have completed the survey. There was no gender difference and the median age was 10 years (9-13 years). Nine patients have suffered from short bowel syndrome (SBS) as a result of the surgery. For the QoL assessment, 17 participants have completed both parent proxy and child-rated survey; 11 completed the parent-rated survey and 1 completed child-rated survey only. The scores for parent-rated survey were - overall: 86.4 (70.7-92.7); physical: 95.3 (83.6-100) and psychosocial: 82.5 (66.3-90.4). The scores for child-rated survey were - overall: 82.1 (73.4-96.2); physical: 96.9 (90.6-99.2) and psychosocial: 81.7 (64.2-95.8). Regarding the impact of previous SBS on the QoL, there were no significant difference in the overall score for both parent proxy and child-rated survey (SBS-ve vs + ve) (parent-rated: 87.5 vs 85.3, p = 0.849; child-rated: 81.0 vs 88.0, p = 0.503). There were also no differences in physical and psychosocial assessments (parent-rated: [physical] 95.3 vs 95.3, p = 0.267; [psychosocial] 84.2 vs 80.0, p = 0.274; child-rated: [physical] 95.3 vs 96.9, p = 0.395; [psychosocial] 79.2 vs 87.5, p = 0.611).

CONCLUSION

The QoL in long-term survivors of surgical NEC without major medical illnesses is comparable to normal population. However, they may have a lower psychosocial well-being that should be addressed. Previous history of SBS does not have a significant impact on the future QoL.

LEVEL OF EVIDENCE

III.

Temporal Trends of Neonatal Surgical Conditions in Texas and Accessibility to Pediatric Surgical Care

INTRODUCTION

Texas consistently accounts for approximately 10% of annual national births, the second highest of all US states. This temporal study aimed to evaluate incidences of neonatal surgical conditions across Texas and to delineate regional pediatric surgeon accessibility.

METHODS

The Texas Birth Defects Registry was queried from 1999 to 2018, based on 11 well-established regions. Nine disorders (30,476 patients) were identified as being within the operative scope of pediatric surgeons: biliary atresia (BA), pyloric stenosis (PS), Hirschsprung's disease, stenosis/atresia of large intestine/rectum/anus, stenosis/atresia of small intestine, tracheoesophageal fistula/esophageal atresia, gastroschisis, omphalocele, and congenital diaphragmatic hernia. Annual and regional incidences were compared (/10,000 births). Statewide pediatric surgeons were identified through the American Pediatric Surgical Association directory. Regional incidences of neonatal disorder per surgeon were evaluated from 2010 to 2018 as a surrogate for provider disparity.

RESULTS

PS demonstrated the highest incidence (14.405/10,000), while BA had the lowest (0.707/10,000). Overall, incidences of PS and BA decreased significantly, while incidences of Hirschsprung's disease and small intestine increased. Other diagnoses remained stable. Regions 2 (48.24/10,000) and 11 (47.79/10,000) had the highest incidence of neonatal conditions; Region 6 had the lowest (34.68/10,000). Three rural regions (#2, 4, 9) lacked pediatric surgeons from 2010 to 2018. Of regions with at least one surgeon, historically underserved regions (#10, 11) along the Texas-Mexico border consistently had the highest defect per surgeon rates.

CONCLUSIONS

There are temporal and regional differences in incidences of neonatal conditions treated by pediatric surgeons across Texas. Improving access to neonatal care is a complex issue that necessitates collaborative efforts between state legislatures, health systems, and providers.

How far We Go For Surgery: Distance to Pediatric Surgical Care in Indiana

INTRODUCTION

Despite increasing numbers of pediatric surgery training programs, access to pediatric surgical care remains limited in non-academic and rural settings. We aimed to characterize demographic and patient factors associated with increased distance to selected pediatric surgical procedures in Indiana.

METHODS

This IRB-approved retrospective review analyzed pediatric patients undergoing appendectomy, cholecystectomy, umbilical hernia repair, pyloromyotomy, and video assisted thoracic surgery (VATS) procedures from 2019 through 2021. Data was obtained from an electronic medical record warehouse and the Indiana Hospital Association. Travel distance was calculated as driving distance between patient address and hospital ZIP codes. Statistics were performed in R, with p < 0.05 indicating significance.

RESULTS

There were 6835 operations performed, and half of all operations (46%) were performed at institutions with fellowship-trained pediatric surgeons. The median travel distance for all operations was 13 miles (range 0-182); the shortest was for laparoscopic appendectomy (9 miles, IQR[0-20]). The longest distances were for pyloromyotomy (51 miles, IQR[14-84]) and VATS procedures (57 miles, IQR[13-111]), of which, nearly all were performed at tertiary pediatric care centers (97% and 93%, respectively). There was a significant linear and quadratic effect of age on travel distance (p < 0.001), with younger patients requiring farther travel. On multivariable linear regression, age and procedure type had the largest effect on travel distance (Eta squared 0.03, p < 0.001).

CONCLUSION

Younger age and more specialized procedures, including VATS and pyloromyotomy, were associated with increased travel distance. This highlights regionalization of these procedures to urban areas with pediatric care centers, while others are performed closer to home.

LEVEL OF EVIDENCE

III TYPE OF STUDY: Retrospective comparative study.

Factors affecting neurodevelopmental outcome following surgical necrotising enterocolitis: a systematic review

Surgically treated necrotising enterocolitis (sNEC) is associated with significantly worse neurodevelopmental outcomes than that seen in premature infants without NEC. We aim to review the association between factors involved in the surgical treatment of NEC and subsequent neurodevelopmental outcomes to identify potential areas for improvement. The PubMed and Embase databases were interrogated for articles reporting neurodevelopmental outcomes in babies treated surgically for NEC using key terms including: "Infant", "Necrotising enterocolitis", "Surgical", "Neurodevelopmental" and "Outcomes". The search strategy yielded 1170 articles and after applying inclusion and exclusion criteria 22 studies remained and formed the review. A diverse range of neurodevelopmental outcomes were reported. Extreme prematurity and lower birth weight were associated with worse neurodevelopmental outcomes. The use of peritoneal drains and enterostomies were associated with worse outcomes. Modifications to surgical strategies in NEC may improve neurodevelopmental outcomes but the effect of confounding factors remains unclear. Further large scale studies are required to define the optimum strategies for treating NEC surgically and to develop a core outcome set for research into NEC.

Early laparoscopic-assisted surgery is associated with decreased post-operative inflammation and intestinal strictures in infants with necrotizing enterocolitis

INTRODUCTION

In 2015, a protocol including early laparoscopy-assisted surgery in the treatment of necrotizing enterocolitis (NEC) was implemented at our institution. Carbon dioxide insufflation during laparoscopy may have an anti-inflammatory effect. We aimed to compare post-operative outcome after early laparoscopy-assisted surgery and classical laparotomy for NEC.

MATERIAL AND METHODS

Charts of premature infants undergoing surgery for NEC (2012-2021) were reviewed. Cases operated by early laparoscopy-assisted surgery (2015-2021) were compared to infants operated for NEC between 2012 and 2015 (laparotomy-NEC). Outcomes were post-operative CRP, need for reintervention, mortality, and the occurrence of post-NEC intestinal strictures. CRP was measured on the day of surgery (POD-0), 2 days (POD-2), and 7 days after surgery (POD-7). Data were compared using contingency tables for categorical variables and Student t-test or Mann-Whitney test for continuous variables.

RESULTS

Infants with NEC operated by early laparoscopy (n = 48) and laparotomy (n = 29) were similar in terms of perforation (60% vs 58%, p = 0.99) and POD-0 CRP (139 vs 124 mg/L, p = 0.94). Delay between first signs of NEC and surgery was shorter in the laparoscopy group (3 vs 6 days, p = 0.004). Early laparoscopy was associated with a lower CRP on POD-2 (108 vs 170, p = 0.005) and POD-7 (37 vs 68, p = 0.002), as well as a lower rate of post-operative intestinal stricture (34% vs 61%, p = 0.04).

CONCLUSIONS

In addition to being safe and feasible in premature infants, early laparoscopic-assisted surgery was associated with decreased NEC-related post-operative inflammation and strictures. A prospective, randomized study is needed in order to evaluate short and long-term effects of laparoscopy in infants with NEC.

LEVEL OF EVIDENCE

Level III.

Longitudinal Force Measurement and its Relationship to Technical Competence for Esophageal Anastomosis in a Thoracoscopic Esophageal Atresia/tracheo-esophageal Fistula Simulator

PURPOSE

Thoracoscopic esophageal atresia with tracheo-esophageal fistula (EA/TEF) repair requires the gentle manipulation of delicate tissue. Force sensors were attached to the upper and lower esophagus of a 3D-printed EA/TEF simulator to explore force parameters as markers of performance.

METHODS

Participants completed one intracorporeal suture between the anterior walls of upper and lower esophageal ends. Longitudinal force data were recorded at each end. A blinded pediatric surgeon marked attempt videos. Excessive force events, maximum tension, and force interquartile range (IQR) were measured. Data were reported as median (range) significance of p < 0.05.

RESULTS

17 participants of varying levels of experience performed the task. OSATS scores showed significant differences between experts and novices. Experts completed the task in a median time of 4 min. They used lower maximum tension, higher force IQR, and had fewer excess force events compared to the intermediate and novice groups.

DISCUSSION

The application of force was dependent on expertise with more skilled participants having fewer excess force events. The higher expert force IQR likely reflects the consistent tension needed for task completion. Analysis of force data may be an indicator of competence, and trainees may benefit from a thoracoscopic simulator which provides force data feedback.

LEVEL OF EVIDENCE

Not applicable.

Primary anastomosis is the preferred surgical approach for proximal intestinal atresia: a retrospective 20-year analysis

PURPOSE

We aimed to compare the outcomes of primary anastomosis (PA) and enterostomy as treatments for intestinal atresia in neonates to identify the factors influencing the choice of modality.

METHODS

We conducted a retrospective single-centre analysis of all neonates with intestinal atresia between 2000 and 2020 and measured the clinical outcomes. We performed logistic regression to identify factors that influenced the choice of surgical approach.

RESULTS

Of 62 intestinal atresia neonates, 71% received PA. There were no significant differences in gestation, gender, age at operation, birth weight, or body weight at operation between the PA and enterostomy groups. PA reoperation was not required for 78% of patients, and the PA group had shorter hospital stays. Complications, operative time, duration on parenteral nutrition, time to full enteral feeding were comparable in both groups. Upon multivariate regression analysis, surgeons favoured PA in proximal atresia [Odds ratio (OR) 38.5, 95% Confidence Interval (CI) 2.558-579] while enterostomy in smaller body size [OR 2.75, CI 0.538-14.02] and lower Apgar score [OR 1.1, CI 0.07-17.8]. Subgroup analysis in these patient groups demonstrated comparable outcomes with both surgical approaches.

CONCLUSION

Both surgical approaches achieved comparable outcomes, but PA was associated with short hospital stays and the avoidance of stoma-related complications, and reoperation was generally not required. This surgical approach was suitable for patients with proximal atresia, but enterostomy remained a sensible choice for patients with smaller body sizes and lower Apgar scores.

Factors affecting stress levels in parents of surgical neonates: A prospective observational study

BACKGROUND

There is a paucity of research focusing on the stress levels in parents of newborns undergoing surgery. Resource challenged systems have to deal with overcrowding, a shortage of workforce along with demographic and socioeconomic issues like delayed presentations and out of pocket expenses. The primary objective of this study was to understand the factors associated with stress in the parents of these congenitally malformed neonates.

METHODOLOGY

This was a prospective cohort study, which was conducted in a neonatal surgical ICU of a tertiary care teaching hospital. Factors affecting stress levels in parents of surgical neonates were studied in 100 participants. A multi-dimensional questionnaire - The PSS: NICU score was utilized in the study. The parents were interviewed on Day 3-5 after surgery.

RESULT

59% of the respondents were fathers. The majority of the parents were in the age bracket of 24 to 35 years. The mean scores for the subscales sights and sounds, looks and behavior and alteration in the parental role were 3.24±0.8, 3.52±0.63, 3.55±0.8 and 2.8 ± 0.9 respectively. The highest level of stress was found in the domains of alteration of parental role and infant appearance and behavior. Comparisons showed significantly higher maternal scores in all the domains. Overall stress scores were highest for abdominal wall defects.

CONCLUSION

Parents of neonates undergoing surgery suffer from significant stress levels and appropriate counseling targeted towards specific stressors is required to allay this important parental issue.

Association of red blood cell transfusion volume with postoperative complications and mortality in neonatal surgery

INTRODUCTION

Red blood cell transfusion (RBCT) is commonly administered in neonatal surgical care in the absence of clear clinical indications such as active bleeding or anemia. We hypothesized that higher RBCT volumes are associated with worse postoperative outcomes.

METHODS

Neonates within the National Surgical Quality Improvement Program-Pediatric database who underwent inpatient surgery (2012-2016) were stratified by weight-based RBCT volume: <20cc/kg, 20-40cc/kg, and >40cc/kg. Postoperative complications were categorized as wound, systemic infection, central nervous system (CNS), renal, pulmonary, and cardiovascular. Multivariable logistic regression and cubic spline analysis were used to evaluate the association between RBCT volume, postoperative complications, and 30-day mortality. Sensitivity analysis was conducted by performing propensity score matching.

RESULTS

Among 9,877 neonates, 1,024 (10%) received RBCTs. Of those who received RBCT, 53% received <20cc/kg, 27% received 20-40cc/kg, and 20% received >40cc/kg. Relative to neonates who were not transfused, RBCT volume was associated with a dose-dependent increase in renal complications, CNS complications, cardiovascular complications, and 30-day mortality. With cubic spline analysis, a lone inflection point for 30-day mortality was identified at a RBCT volume of 30 - 35 cc/kg. After propensity score matching, the dose-dependent relationship was still present for 30-day mortality.

CONCLUSION

Total RBCT volume is associated with worse postoperative outcomes in neonates with a significant increase in 30-day mortality at a RBCT volume of 30 - 35 cc/kg. Future prospective studies are needed to better understand the association between large RBCT volumes and poor outcomes after neonatal surgery.

LEVEL OF EVIDENCE

Level IV, Retrospective cohort study.

Occult Antenatal Fetal Abdominal Emergencies Resulting in Unplanned Preterm Delivery

Acute abdomen in the fetus can present as nonspecific fetal distress, and occasionally necessitate emergency cesarean section for the mother and subsequent emergency neonatal surgery. Often, preoperative diagnosis in utero is challenging. The authors herein report two cases, a case of primary segmental antenatal intestinal volvulus resulting in the mother presenting at 35 wk with symptoms and decreased fetal movements, and another case of a rapidly distending fetal abdominal mass at 31 wk manifesting as fetal hydrops. The postdelivery newborn management issues are presented. Early identification by the maternal and neonatal team allows for early neonatal surgery and can reduce morbidity and mortality. This can be facilitated by advanced maternal and child health services and efficient patient transport systems.

Association of prematurity with complications and failure to rescue in neonatal surgery

BACKGROUND

The majority of failure to rescue (FTR), or death after a postoperative complication, in pediatric surgery occurs among infants and neonates. The purpose of this study is to evaluate the association between gestational age (GA) and FTR in infants and neonates.

METHODS

National cohort study of 46,452 patients < 1 year old within the National Surgical Quality Improvement Program-Pediatric database who underwent inpatient surgery. Patients were categorized as preterm neonates, term neonates, or infants. Neonates were stratified based on GA. Surgical procedures were classified as low- (< 1% mortality) or high-risk (≥ 1%). Multivariable logistic regression and cubic splines were used to evaluate the association between GA and FTR.

RESULTS

Preterm neonates had the highest FTR (28%) rates. Among neonates, FTR increased with decreasing GA (≥ 37 weeks, 12%; 33-36 weeks, 15%; 29-32 weeks, 30%; 25-28 weeks 41%; ≤ 24 weeks, 57%). For both low- and high-risk procedures, FTR significantly (trend test, p < 0.01) increased with decreasing GA. When stratifying preterm neonates by GA, all GAs ≤ 28 weeks were associated with significantly higher odds of FTR for low- (OR 2.47, 95% CI [1.38-4.41]) and high-risk (OR 2.27, 95% CI [1.33-3.87]) procedures. A lone inflection point for FTR was identified at 31-32 weeks with cubic spline analysis.

CONCLUSIONS

The dose-dependent relationship between decreasing GA and FTR as well as the FTR inflection point noted at GA 31-32 weeks can be used by stakeholders in designing quality improvement initiatives and directing perioperative care.

LEVEL OF EVIDENCE

Level IV, Retrospective cohort study.

Uncomplicated gastroschisis care in the US and Kenya: Treatment at two tertiary care centers

BACKGROUND

Gastroschisis is a common birth defect with < 5% mortality in high income countries, but mortality in sub Saharan Africa remains high. We sought to compare gastroschisis management strategies and patient outcomes at tertiary pediatric referral centers in the United States and Kenya.

METHODS

This retrospective chart review examined uncomplicated gastroschisis patients treated at Riley Hospital for Children in Indianapolis, USA (n = 110), and Shoe4Africa Children's Hospital in Eldoret, Kenya (n = 75), from 2010 to 2018. Analyzed were completed using Chi square, Fisher's exact, and independent samples t tests and medians tests at the 95% significance level.

RESULTS

Survival in the American cohort was double that of the Kenyan cohort (99.1% vs 45.3%, p< 0.001). Sterile bag use for bowel containment was lower in Kenya (81.3% vs 98.1%, p< 0.001), but silo use was comparable at both institutions (p = 0.811). Kenyan patients had earlier median enteral feeding initiation (4vs 10 days, p< 0.001) and accelerated achievement of full enteral feeding (10vs 23 days, p< 0.001), but none received TPN. Despite earlier feeding, Kenyan patients displayed a higher prevalence of wound infections (70.8% vs 17.1%, p< 0.001) and sepsis (43.9% vs 4.8%, p< 0.001). In Kenya, survivors and non survivors displayed no difference in sterile bag use, hemodynamic stability, all cause infection rates, or antibiotic free hospital days. Defect closure (p< 0.001) and enteral feeding initiation (p< 0.001) were most predictive of survival.

CONCLUSION

Improving immediate response strategies for gastroschisis in Kenya could improve survival and decrease infection rates. Care strategies in the US can center on earlier enteral feeding initiation to reduce time to full feeding.

LEVEL OF EVIDENCE

Level III.

The role of preserved bowel and mesentery fixation in apple-peel intestinal atresia

Objective

This study explored the feasibility of mesoplasty with end-to-side anastomosis in the treatment of different apple-peel mesenteric defects with high jejunal atresia.

Methods

A retrospective analysis was performed on 42 premature infants admitted to the hospital between 2014 and 2021. Prenatal ultrasound scans revealed bowel dilatation. The patients experienced vomiting after birth and produced white or no meconium. Plain radiography showed double or triple bubble signs and the patients underwent emergency laparotomy. High jejunal atresia with different apple-peel atresia appearance was discovered intraoperatively, involving mobilization of the ileocecal region. Patients received end-to-side anastomosis between the enlarged blind pouch and atretic bowel, as well as mesoplasty. A jejunal feeding tube was placed trans-nasally. Patients were discharged after achieving full enteral feeding. We also reviewed the literature on the subject.

Results

Three patients died and 39 survived. The discharged patients were followed up for 12 months, and none showed post-operative complications such as intestinal obstruction, malnutrition, or chronic diarrhea. All surviving patients reached the expected height and weight for children of the same age.

Conclusion

For cases of high jejunal atresia with apple-peel intestinal atresia, mesoplasty may be a good option to avoid postoperative volvulus.

The role of motion tracking in assessing technical skill acquisition using a neonatal 3D-printed thoracoscopic esophageal atresia/tracheo-esophageal fistula simulator

INTRODUCTION

Acquiring the technical skills required for thoracoscopic repair of esophageal atresia with tracheo-esophageal fistula (EA/TEF) is challenging. A high-fidelity 3D-printed pediatric thoracoscopic EA/TEF simulator has been developed to address this issue. This study explored motion-tracking as an assessment tool to distinguish between surgeons of different expertise using the simulator.

METHODS

Participants performed a single intracorporeal suture between the esophageal ends in EA with TEF. Total relative path lengths of the right and left surgical instruments were recorded during the task. Each video-recorded attempt was assessed by a blinded pediatric surgeon using a modified Objective Structured Assessment of Technical Skills (OSATS) score. Data recorded as median (range) and statistical significance as p<0.05.

RESULTS

The task was performed by 17 participants. The median OSATS scores identified a significant difference between experts and novices. A difference between left- and right-hands was only found in the mid-skill level group. Right-hand path length was greatest in novices and lowest in experts. Left-hand path length was greatest in novices and the mid-skill level group compared to experts.

CONCLUSION

Experts had the lowest total path length for either hand, suggesting they had the greatest efficiency of movement. The similar high path lengths in both hands for novices indicate their relatively low level of skill with either hand. The difference between right- and left-hand path lengths in the mid-skill level group likely reflects the improved right-handed technical skills in contrast to the still developing left hand. Further focus on the left hand during simulation training may improve left-handed economy of movement.

Laparoscopic Versus Open Surgical Repair of Duodenal Atresia: An NSQIP-Pediatric Analysis

INTRODUCTION

Laparoscopic repair of duodenal atresia in neonates has gained popularity among some pediatric surgeons. Single-center studies suggest comparable short-term outcomes to open surgery. The purpose of this study was to utilize a large, multi-institutional pediatric dataset to examine 30-day post-operative outcomes by operative approach for newborns who underwent duodenal atresia repairs.

METHODS

We identified neonates aged ≤1 wk in the 2016-2018 National Surgical Quality Improvement Program-Pediatric -database that underwent a laparoscopic or open repair for duodenal atresia. Preoperative characteristics were compared between operative approaches. Postoperative complications, operative time, postoperative length of stay (LOS), and supplemental nutrition at discharge were assessed using multivariate regressions.

RESULTS

There were 267 neonates who met inclusion criteria. There were 233 (87%) infants who underwent open repairs and 34 (13%) who underwent laparoscopic repairs. Ten (29%) children who had laparoscopy were converted to open. After adjusting for confounding, laparoscopy was associated with an increase in operative time by 65 min (95% confidence interval 45-87 min, P < 0.001) but a five-day shorter LOS (95% confidence interval -9 to -2, P = 0.006) when compared to laparotomy. There were no significant differences in postoperative complications or supplemental nutrition at discharge.

CONCLUSIONS

Our findings suggest that laparoscopic repairs of duodenal atresia are associated with shorter postoperative LOS but longer operative times when compared to open repairs. Although the conversion rate to laparotomy remained relatively high, the laparoscopic approach was associated with comparable 30-day postoperative outcomes.

Complex gastroschisis with apple peel jejunoileal atresia, primary closure, and Santulli procedure as a surgical alternative. Case report

BACKGROUND

Gastroschisis is a closure defect of the abdominal wall classified as complex when it presents with necrosis, volvulus, or atresia of the gastrointestinal tract. Jejunoileal atresia is caused by abnormal closure, discontinuity, or narrowing of the intestine. Apple Peel or type IIIb is the rarest presentation, with an incidence of 1.3 per 10,000 live births. In addition to presenting a high mortality rate.

PRESENTATION OF CASE

We present a preterm newborn patient of 30 weeks with a diagnosis of gastroschisis and jejunoileal atresia type IIIB. The congenital wall defect was closed in the first surgical stage, and he was then taken at four weeks to correct the atresia. In the second surgery, we found a difference in intestinal calibers of 8:1, and the surgical team decides to perform remodeling of the proximal sac with a mechanical stapler and perform anastomosis using the Santulli technique. On day 6 of life, enteral feeding began through a nutrition tube localized under intestinal anastomosis with progressive nutritional increase. Subsequently, intermittent and progressive occlusion of the stoma was performed, leading the patient to a definitive surgical closure one month later.

CONCLUSIONS

The mortality rate for gastroschisis and complex intestinal atresia is high. Advances in prenatal diagnosis, neonatal intensive care, and proper surgical correction are crucial to improving survival rates. The Santulli procedure is a surgical alternative for intestinal atresias with a caliber discrepancy greater than 4 to 1 or when the characteristics of the distal part do not allow a primary anastomosis to be performed.

A case of successful slide tracheoplasty for long-segment congenital tracheal stenosis in a neonate with a congenital diaphragmatic hernia and Fallot's tetralogy

Background

Congenital tracheal stenosis (CTS) is a rare and life-threatening airway disorder, which is often associated with cardiac malformations. Among them, neonatal symptomatic CTS with cardiac malformations has an extremely poor prognosis. In contrast to cardiac malformation, congenital diaphragmatic hernia (CDH) has rarely been associated with CTS. We report a neonatal case in which slide tracheoplasty and intracardiac repair were performed simultaneously for CTS and Fallot’s tetralogy (TOF).

Case presentation

An infant with left CDH and Fallot's tetralogy (TOF) was born by cesarean section at 38 weeks of gestation. At the time of resuscitation, a 2.5 mm (ID) endotracheal tube could only be inserted just below the vocal cords. After repairing the CDH at 3 days of age, planned extubation was performed at 7 days of age. However, the patient required re-intubation due to life-threatening episodes after 2 days of the extubation. Enhanced CT revealed a long segment CTS from the upper trachea to the right bronchus (length of stenosis: 40 mm, minimum inner diameter: 2 mm). At 24 days of age, veno-arterial extracorporeal membrane oxygenation (ECMO) was introduced due to severe respiratory failure. At 28 days of age, slide tracheoplasty and palliative right ventricular outflow tract reconstruction (RVOTR) was performed with cardiopulmonary bypass (CPB). After tracheoplasty, a 3.5 mm tracheal (ID) tube could be placed in the reconstructed trachea in a patient with CTS. ECMO was completed 7 days after the operation. On the 17th day after the operation, he was extubated successfully. He was discharged 5 months after birth with home oxygenation therapy.

Conclusions

We reported the successful simultaneous correction of slide tracheoplasty and palliative RVOTR for a neonate with CDH. ECMO was used for respiratory management before and after surgery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40792-022-01422-9.

Is postoperative transanastomotic feeding beneficial in neonates with congenital duodenal obstruction?

PURPOSE

We aimed to evaluate possible positive and negative effects of postoperative use of transanastomotic feeding tube (TAFT) in neonates operated for congenital duodenal obstruction (CDO).

METHODS

This is a retrospective study reviewing medical records of neonates operated for CDO during 2003-2020 and comparing postoperative feeding outcomes and complications in patients with and without TAFT. Approval from the hospital's data protection officer was obtained.

RESULTS

One hundred patients, 59% girls, were included, and 37% received TAFT. Mean birth weight and gestational age were 2628 (675.1) grams and 36.6 (2.4) weeks, respectively. Furthermore, 45% had no other malformations, and 36% had Down syndrome. Patient demographics were similar for TAFT and not-TAFT patients, except that not-TAFT neonates weighed median 335 g less (p = 0.013). The TAFT group got parenteral nutrition 2 days shorter (p < 0.001) and started enteral feeds 1.5 days earlier (p < 0.001) than the not-TAFT group. Fewer neonates with TAFT got a central venous catheter [65 vs 89%, (p = 0.008)]. In the TAFT group, 67% were breast fed at discharge compared to 49% in the not-TAFT group (p = 0.096).

CONCLUSION

Neonates with TAFT had earlier first enteral feed, fewer days with parenteral nutrition and fewer placements of central venous catheters.

The Relationship Between Neonatal Surgery, Postpartum Depression, and Infant Clinical Course

OBJECTIVE

Postpartum depression (PPD) affects 10-15% of mothers in the general population, and studies show increased incidence for mothers of infants with serious health conditions. This study investigates incidence of PPD in mothers of surgical patients in the neonatal intensive care unit (NICU) and characterizes these patients' clinical and neurodevelopmental outcomes.

METHODS

This retrospective cohort study analyzed Nebraska's Tracking Infant Progress Statewide (TIPS) database and referring hospital medical records from February 2013 to June 2018. Upon NICU discharge, children were referred to the TIPS program, with scheduled follow-up appointments at approximately 6 months corrected age. All patients seen in NICU follow-up clinic with recorded scores for maternal Edinburgh postnatal depression screen (EPDS) were eligible except infants with congenital heart disease as this cohort was previously studied. Patients were stratified into groups based on presence or absence of a general surgical procedure within the first 6 months of life and positive (≥ 10) or negative (< 10) EPDS score. Statistical analyses assessed for significant differences between groups regarding gestational age, birth weight, maternal age, length of NICU stay (LOS), number of days on a ventilator, payment method, ethnicity, developmental testing, and rate of referral for early intervention services.

RESULTS

Of 436 patients, 83 were surgical patients (16 with positive EPDS; 19.3% incidence), and 353 were non-surgical patients (44 with positive EPDS; 12.5% incidence). Statistical analysis showed no significant relationship between neonatal surgery and positive EPDS (χ² = 2.6, p = 0.1). While the surgical cohort had longer LOS and days on ventilator, maternal EPDS did not predict these factors. In the surgical cohort, mothers of children not independent on oral feeding at discharge were more likely to screen positive for depression (7/14, 50% vs. 7/61, 11%; p < 0.05).

CONCLUSION

Mothers of surgical patients are not significantly more likely to screen positive for post-partum depression compared to other NICU mothers. This underscores the importance of routine screening for PPD in mothers of both surgical and non-surgical NICU patients in order to identify parents and children at risk.

Hyponatremia at the onset of necrotizing enterocolitis is associated with intestinal surgery and higher mortality

It has previously been shown that hyponatremia reflects the severity of inflammation in pediatric gastrointestinal diseases. Interpretation of electrolyte disorders is a common, but not well studied challenge in neonatology, especially in the context of early detection of necrotizing enterocolitis and bowel necrosis. The aim of this study was to assess if hyponatremia, or a decrease in plasma sodium level, at the onset of necrotizing enterocolitis (NEC) is associated with intestinal ischemia/necrosis requiring bowel resection and/or NEC-related deaths. This was a retrospective cohort study including patients with verified NEC (Bell's stage ≥ 2) during the period 2009-2014. Data on plasma sodium 1-3 days before and at the onset of NEC were collected. The exposure was hyponatremia, defined as plasma sodium < 135 mmol/L and a decrease in plasma sodium. Primary outcome was severe NEC, defined as need for intestinal resection due to intestinal ischemia/necrosis and/or NEC-related death within 2 weeks of the onset of NEC. Generalized linear models were applied to analyze the primary outcome and presented as odds ratio. A total of 88 patients with verified NEC were included. Fifty-four (60%) of them had severe NEC. Hyponatremia and a decrease in plasma sodium at onset of NEC were associated with increased odds of severe NEC (OR crude 3.91, 95% CI (1.52-10.04) and 1.19, 95% CI (1.07-1.33), respectively). Also, a sub-analysis, excluding infants with pneumoperitoneum during the NEC episode, showed an increased odds ratio for severe NEC in infants with hyponatremia (OR 23.0, 95% CI (2.78-190.08)).

CONCLUSIONS

The findings of hyponatremia and/or a sudden decrease in plasma sodium at the onset of NEC are associated with intestinal surgery or death within 2 weeks.

WHAT IS KNOWN

• Clinical deterioration, despite optimal medical treatment, is a relative indication for surgery in infants with necrotizing enterocolitis. • Hyponatremia is a common condition in preterm infants from the second week of life.

WHAT IS NEW

• Hyponatremia and a decrease in plasma sodium level at the onset of necrotizing enterocolitis are positively associated with need of surgery or death within 2 weeks. • In infants with necrotizing enterocolitis, without pneumoperitoneum, where clinical deterioration despite optimal medical treatment is the only indication for surgery, hyponatremia, or a decrease in plasma sodium level can predict the severity of the disease.

Understanding risk factors for postoperative mortality in neonates based on explainable machine learning technology

PURPOSE

We aimed to introduce an explainable machine learning technology to help clinicians understand the risk factors for neonatal postoperative mortality at different levels.

METHODS

A total of 1481 neonatal surgeries performed between May 2016 and December 2019 at a children's hospital were included in this study. Perioperative variables, including vital signs during surgery, were collected and used to predict postoperative mortality. Several widely used machine learning methods were trained and evaluated on split datasets. The model with the best performance was explained by SHAP (SHapley Additive exPlanations) at different levels.

RESULTS

The random forest model achieved the best performance with an area under the receiver operating characteristic curve of 0.72 in the validation set. TreeExplainer of SHAP was used to identify the risk factors for neonatal postoperative mortality. The explainable machine learning model not only explains the risk factors identified by traditional statistical analysis but also identifies additional risk factors. The visualization of feature contributions at different levels by SHAP makes the "black-box" machine learning model easily understood by clinicians and families. Based on this explanation, vital signs during surgery play an important role in eventual survival.

CONCLUSIONS

The explainable machine learning model not only exhibited good performance in predicting neonatal surgical mortality but also helped clinicians understand each risk factor and each individual case.

Incisional hernia after abdominal surgery in infants: A retrospective analysis of incidence and risk factors

PURPOSE

Incisional hernia (IH) is a complication following abdominal surgery extensively studied in adults but less so in infants. This study aimed to identify the incidence, high risk diseases and risk factors of IH following abdominal surgery in infants.

METHODS

Infants undergoing abdominal surgery before the age of three years in our tertiary centre between 1998 and 2018 were included. Patient demographics, peri‑operative details and the course during follow up were retrospectively extracted from patient records. Multivariate logistic regression was performed to identify risk factors.

RESULTS

The incidence of incisional hernia was 5.2% (107/2055). Necrotizing enterocolitis (12%), gastroschisis (19%), and omphalocele (17%) had the highest incidences of IH. Wound infection (OR: 5.3, 95%-CI:2.9-9.5), preterm birth (OR: 4.2, 95%-CI:2.6-6.7) and history of stoma (OR 1.7, 95%-CI:1.1-2.8) were significant risk factors for IH. Whilst age at surgery, surgical approach and total number of operations did not significantly influence IH development. The IH resolved in 15% (16/107) without surgery.

CONCLUSION

One in twenty infants experiences IH following abdominal surgery, which is higher than previously described. Understanding the incidence of IH and associated risk factors will allow physicians to identify infants that may be at increased risk for IH and to possibly act pre-emptively.

Influence of birthplace on gastroschisis outcomes in a state in the southeastern region of Brazil

OBJECTIVE

To characterize the influence of birthplace on outcomes of patients with gastroschisis admitted to three hospitals in a state in Brazil's southeastern region, according to condition inborn (born in a reference center) or outborn (born outside the reference center).

METHODS

Retrospective multicenter cohort study of patients with gastroschisis. The sample size utilized was of patients admitted in three hospitals with a diagnosis of gastroschisis ICD 10 Q79.3 between January 2000 to December 2018. Patients were divided into two groups, inborn and outborn. Characteristics of prenatal, perinatal and postoperative were compared using statistical tests. The level of significance adopted was P-value < 0.05.

RESULTS

In total, 144 cases of gastroschisis were investigated. The outborn patients group had higher rates of absence of antenatal diagnosis (p = 0.001), vaginal delivery (p = 0.001), longer time between birth and abdominal wall closure surgery (p = 0.001), to silo removal (p = 0.001), to first enteral feeding (p = 0.008), for weaning from mechanical ventilation (p = 0.034), used less peripherally inserted central catheter (PICC) and required more venous dissections (p = 0.001), and lower mean of serum sodium (p = 0.015). There were no differences in mortality rates and length of hospital stay between the inborn and outborn groups.

CONCLUSION

Although outborn patients with gastroschisis were less likely to have an antenatal diagnosis and were more prone to a longer time to undergo surgical and feeding procedures, and to spend more time in mechanical ventilation, these disadvantages seemed not to reflect on the death rate and the length of hospital stay of patients from this group.

Long term digestive outcome of œsophageal atresia

Œsophageal atresia is a rare neonatal malformation consisting in an interruption of the continuity of the œsophagus, with or without a tracheo-œsophageal fistula. Although mortality rate is now low and most cases can benefit from successful surgical repair soon after birth, morbidity -specially digestive and nutritional-remains high. Many of the adults born with œsophageal atresia will suffer from dysphagia, gastro-œsophageal reflux and/or œsophageal dysmotility, leading to nutritional consequences and quality of life impairment. Barrett's œsophagus, potential risk of œsophageal cancer as well as risk of anastomotic stenosis and eosinophilic œsophagitis justify transition to adulthood and a lifelong prolonged follow-up.

Neonatal surgical outcomes: a prospective observational study at a Tertiary Academic Hospital in Johannesburg, South Africa

PURPOSE

The neonatal period is the most vulnerable period for a child. There is a paucity of data on the burden of neonatal surgical disease in our setting. The aim of this study was to describe the frequency with which index neonatal surgical conditions are seen within our setting and to document the 30-day outcome of these patients.

METHODS

This was a single-centre prospective observational study in which all neonates with paediatric surgical pathology referred to the paediatric surgical unit with a corrected gestational age of 28 days were included.

RESULTS

Necrotising enterocolitis was the most frequent reason for referral to the paediatric surgical unit (n = 68, 34.34%). Gastroschisis was the most frequent congenital anomaly referred (n = 20, 10.10%). The overall morbidity was 57.58%. Surgical complications contributed to 18.51% of morbidities. The development of gram negative nosocomial sepsis was the most frequent cause of morbidity (n = 98, 50.78%). Mortality at 30 days was 21.74% (n = 40). Sepsis contributed to mortality in 35 patients (87.5%), 16 of which had gram negative sepsis.

CONCLUSION

Gram-negative sepsis was a major contributing factor in the development of morbidity and mortality in our cohort. Prevention and improvement in infection control are imperative if we are to improve outcomes in our surgical neonates.

Comparing 30-day outcomes between early versus delayed repair of anorectal malformations with perineal or rectovestibular fistulas: An analysis of the ACS NSQIP-Pediatric database

BACKGROUND

Anorectal malformations (ARMs) have a wide spectrum of presentation ranging from mild defects with perineal fistulas to more severe defects requiring complex management. A primary repair of ARMs with perineal or rectovestibular fistulas has been shown to have good outcomes. However, the timing of the reconstruction is still debated. The aim of this study is to investigate the safety of early versus delayed repair.

METHODS

This study was performed using data from the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) from 2012 to 2017. Patients who underwent repair of anorectal malformation with perineal or vestibular fistula were included in the study. Patients with associated diagnosis for Hirschsprung disease, cloaca, rectal prolapse or stenosis, bladder exstrophy, and tracheoesophageal fistula were excluded. 30-day postoperative outcomes included wound and nonwound complications, readmissions, and reoperations. Outcomes were compared by early (≤7 days of age) versus delayed repair (6 weeks to 8 months).

RESULTS

A total of 291 patients were included, with 66 in the early and 231 in the delayed group. Patients in the early group were more likely to be male (68.2% vs 31.8%; p < 0.01) and have cardiac risk factors (71.2% vs 49.4%, p < 0.01). The mean operative time was significantly shorter in the early group (90.1 vs 129.6 min; p < 0.01). 30-day complications were not statistically significant between the two groups (p = 0.76). After multivariate analysis, timing of repair did not affect 30-day complications (p = 0.15).

CONCLUSION

Our study shows that early repair of low anorectal malformations with a perineal or vestibular fistula appears to be associated with no increase in risk of postoperative complications as compared to delayed repair. At present, the decision remains dependent on the surgeon's experience and judgment.

LEVEL OF EVIDENCE

Level III. Retrospective comparative study.

How can we improve perinatal care in isolated multiple intestinal atresia? A retrospective study with a 30-year literature review

INTRODUCTION

Multiple intestinal atresia (MIA) is a rare cause of neonatal intestinal obstruction. To provide an overview of the current prenatal, surgical, and nutritional management of MIA, we report our experience and a literature review of papers published after 1990.

METHODS

All cases of isolated MIA (non-hereditary, not associated with apple-peel syndrome or gastroschisis) treated at our institution between 2005 and 2016 were reviewed and compared with cases found in the literature.

RESULTS

Seven patients were prenatally suspected of having intestinal obstruction and were postnatally diagnosed with MIA, with a mean 1.7 (1-2) resections-anastomoses (RA) and 6 (1-10) strictureplasties performed, resulting in a mean resected bowel length of 15.1cm (15-25 cm). Median time to full oral feed was 46 days (14-626 days). All patients were alive and none had orality disorder after a mean follow-up of 3.1 years (0.2-8.1 years). Three surgical strategies were found in the literature review: multiple RA (68%, 34/50) including Santulli's technique in four of 34 (12%) and anastomoses over a transanastomotic tube (32%, 16/50), with a 98% survival rate, and short-bowel syndrome for only two patients.

CONCLUSION

Bowel-sparing surgery and appropriate medical management are key to ensuring a favorable nutritional and gastrointestinal outcome and a good prognosis. Prenatal assessment and standardization of the surgical course of treatment remain challenging.

Preoperative diagnosis of a "humanoid" fetus in fetu using multimode ultrasound: a case report

Background

Fetus in fetu (FIF) is a rare congenital anomaly. The preoperative diagnosis of FIF and differentiating it from teratoma and other abdominal tumors can be challenging for radiologists. Clarification of the blood supply and the relationship with the surrounding vessels is especially helpful for successful surgery; however, multimode ultrasound (US) performed for FIF has rarely been explored. Here, we first report a “humanoid” FIF case diagnosed by multimode US examinations, with the use of contrast-enhanced ultrasound (CEUS) for clarifying the blood supply features.

Case presentation

A 25-day-old preterm male infant was referred to our hospital for surgery. The US and computed tomography (CT) examinations led to a diagnosis of teratoma at the local hospital. The laboratory workup at our hospital revealed an elevation of total bilirubin, direct bilirubin, indirect bilirubin, alpha-fetoprotein, and neuron-specific enolase levels. A precise diagnosis and differentiation from teratoma, hepatoblastoma, neuroblastoma and other abdominal tumors were needed. In addition, the blood supply and the relationship with the surrounding vessels needed clarification prior to surgery. Multimode US examinations were performed and the features of a “humanoid” FIF as well as the blood supply for the abdominal lesion of the infant were suggested by grayscale US, color Doppler flow imaging (CDFI), and CEUS. Furthermore, CDFI and CEUS revealed an aorta-like structure and umbilical cord-like blood vessels in the “humanoid” FIF, and the CEUS helped with marking the surface of the infant’s abdominal wall. To the best of our knowledge, this is the first case report of CEUS in FIF, and the blood supply was clearly demonstrated in the FIF. The intraoperative findings confirmed our multimode US findings and revealed a “humanoid” FIF. The infant quickly recovered after the operation and had no positive findings at the 2-year follow-up visit.

Conclusions

Multimode US was helpful in diagnosing the rare FIF without radiation exposure. Specifically, CEUS clearly demonstrated the limb branch vessel-like structures, the abdominal aorta-like structure and the blood supply, which was useful for the FIF diagnosis and for avoiding damage to important vessels during the operation.

Cerebral Autoregulation in Sick Infants: Current Insights

Cerebrovascular autoregulation is the ability to maintain stable cerebral blood flow within a range of cerebral perfusion pressures. When cerebral perfusion pressure is outside the limits of effective autoregulation, the brain is subjected to hypoperfusion or hyperperfusion, which may cause vascular injury, hemorrhage, and/or hypoxic white matter injury. Infants born preterm, after fetal growth restriction, with congenital heart disease, or with hypoxic-ischemic encephalopathy are susceptible to a failure of cerebral autoregulation. Bedside assessment of cerebrovascular autoregulation would offer the opportunity to prevent brain injury. Clinicians need to know which patient populations and circumstances are associated with impaired/absent cerebral autoregulation.

Successful lung response after surgical repair in an infant with right-sided congenital diaphragmatic hernia

Congenital diaphragmatic hernia is a rare condition associated with pulmonary complications as the abdominal viscera herniated into the chest may affect lungs development. We present the case of a male newborn baby with a prenatal diagnosis of a posterolateral defect (Bochdalek hernia) involving the right side. The infant underwent surgical repair at 3 days of life, and the post-surgery chest X-ray did not reveal morpho-structural alterations of the lungs and diaphragmatic profile. Our clinical case shows that patients may have a better lung outcome despite an initial unfavorable picture. Prenatal diagnosis is essential in identifying infants with congenital diaphragmatic hernia, especially those cases at higher risk for the worse outcomes, to optimize their clinical and surgical management.

Incidence, risk factors, and outcomes of acute kidney injury in neonates after surgical procedures

BACKGROUND

Acute kidney injury (AKI) is common and associated with poor outcomes in critically ill neonates. The objective of this study was to study the incidence, risk factors, and clinical outcomes of AKI in neonates receiving non-cardiac surgery.

METHODS

We performed a single-center retrospective study between January 2017 and December 2018 of neonates who had received abdominal and thoracic surgical procedures. AKI was defined by the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Patient information, clinical data, and outcomes were collected and analyzed. Logistic regression was used to analyze risk factors of AKI and association between AKI and mortality.

RESULTS

Fifty-four (33.8%) of 160 patients developed AKI after surgical procedures. Compared with neonates without AKI, neonates with AKI had higher mortality rate (18.5% VS 5.7%, p = 0.022), lower gestational age (30.5 weeks, interquartile range [IQR] 28-33.5, VS 34.5 weeks, IQR 33-37.5, p = 0.035), higher rates of very low birth weight (33.3% VS 17.0%, p = 0.019), longer duration of mechanical ventilation (0.5 days, IQR 0-1.5, VS 0 days, IQR 0-1, p = 0.043) and higher rates of sepsis (35.2% VS 19.8%, p = 0.034). Risk factors of AKI included gestational age under 32 weeks (OR 4.8, 95% CI 1.8-12.6; p = 0.001), sepsis (OR 4.3, 95% CI 1.7-11.3; p = 0.003), operation time longer than 120 min (OR 2.7, 95% CI 1.1-6.6; p = 0.024), and diagnosis of necrotizing enterocolitis (OR 3.5, 95% CI 1.3-9.1; p = 0.011). AKI after surgery was significantly associated with mortality (OR 4.3, 95% CI 1.1-16.9; p = 0.036).

CONCLUSIONS

AKI is common and associated with poor outcomes in surgical neonates. Early recognition and intervention of AKI in these patients are important.

Insufflation in minimally invasive surgery: Is there any advantage in staying low?

AIM

Minimally invasive repair of esophageal atresia with tracheoesophageal fistula (EA/TEF) and congenital diaphragmatic hernia (CDH) is feasible and confers benefits compared to thoracotomy or laparotomy. However, carbon dioxide (CO₂) insufflation can lead to hypercapnia and acidosis. We sought to determine the effect of lower insufflation pressures on patients' surrogate markers for CO₂ absorption - arterial partial pressure of CO₂ (PaCO₂), end tidal CO₂ (EtCO₂) and pH.

METHODS

Single center retrospective review, including neonates without major cardiac anomaly. Selected patients formed 2 groups: Historical pressure (HP) group and low pressure (LP) group. We reported on the patients' preoperative characteristics that potentially confound the degree of CO₂ absorption or elimination. Outcome measures were perioperative PaCO₂, EtCO₂, arterial pH and anesthetic time.

RESULTS

30 patients underwent minimally invasive surgery for CDH and 24 patients for EA/TEF with similar distribution within the HP and LP group. For CDH patients as well as for EA/TEF patients, there were no significant differences in their preoperative characteristics or surgery duration comparing HP and LP groups. With a decrease in insufflation pressure in CDH patients, there were a significant decrease (p = 0.002) in peak PaCO₂ and an improvement in nadir pH (p = 0.01). For the EA/TEF patients, the decrease in insufflation pressure was associated with a significant decrease (p = 0.03) in peak EtCO₂. Considering all 54 patients, we found EtCO₂ to be highly significantly inversely correlated with pH and positively correlated with intraoperative PaCO₂ (p < 0.001). Baseline Hb was inversely correlated with mean EtCO₂ (p < 0.001).

CONCLUSION

With lower insufflation pressures, CDH patients had significantly improved hypercapnia and acidosis, while EA/TEF patients had significantly reduced EtCO₂. EtCO₂ was correlated with acidosis and hypercapnia.

TYPE OF STUDY

Retrospective case control study.

LEVEL OF EVIDENCE

Level III.

Tracheoesophageal fistula in the developing world: are we ready for thoracoscopic repair?

PURPOSE

Tracheoesophageal fistula (TEF) is a bellwether for a country's ability to care for sick newborns. We aim to review the existing literature from low- and middle-income countries in regard to management of those newborns and the possible approaches to improve their outcomes.

METHODS

A review of the existing English literature was conducted with the aim of assessing challenges faced by providers in LMIC in terms of diagnostic, preoperative, operative and post-operative care for TEF patients. We also review the limited literature for performing thoracoscopic repair in the developing world context and suggest methods for introduction of advanced thoracoscopic procedures including techniques for providing anesthesia to these challenging babies.

RESULTS

While outcomes related to technique from LMIC are comparable to the developed world, rates of secondary complications like sepsis and pneumonia are higher. In many areas, repairs are conducted in a staged fashion with minimal utilization of thoracoscopic approach. The paucity of resources creates strain on intraoperative and post-operative management.

CONCLUSION

Clearly, not all developing world contexts are ready to attempt thoracoscopic repair but we outline suggestions for assessing the existing capabilities and a stepwise gradual implementation of advanced thoracoscopy when appropriate.

Anesthesia for Major Surgery in the Neonate

Perioperative risk of morbidity and mortality for neonates is significantly higher than that for older children and adults. At particular risk are neonates born prematurely, neonates with major or severe congenital heart disease, and neonates with pulmonary hypertension. Presently no consensus exists regarding the safest anesthetic regimen for neonates. Regional anesthesia appears to be safe, but does not reduce the overall risk of postoperative apnea. Former preterm infants require postoperative observation for apnea. The anesthesiologist caring for the neonate for major surgery should be knowledgeable of the unique physiology of the neonate and maintain the highest level of vigilance throughout.

Laparoscopy-Assisted Versus Open Surgery in Treating Intestinal Atresia: Single Center Experience

INTRODUCTION

Surgical management of jejuno-ileal atresia/stenosis (JIA) is shifting to a minimally invasive approach. Our purpose is to evaluate the safety and feasibility of laparoscopy-assisted surgery (LAS) in JIA by comparing outcomes with a control group of open surgery (OS).

METHODS

A retrospective review of JIA cases was performed. Demographic, surgical, and outcomes data were extracted. LAS cases were compared with OS. Fisher's exact-test for qualitative and Mann-Whitney-test for quantitative values were used. p values <0.05 were considered significant.

RESULTS

Forty-seven patients (24/23, F/M) were included. In 19 (40%), the LAS technique was successfully performed, while 3 (17%) required conversion to OS. No differences were observed between the LAS and OS (n = 28) groups concerning demographic data (sex, mean gestational age, mean weight, associated anomalies) and type of JIA. Operative time was shorter in LAS (112 ± 46 min) compared to OS (138 ± 40 min), p = 0.04. Time to start enteral feeding and time to full enteral was shorter in LAS compared to OS, p = 0.04. No difference was observed between the two groups concerning duration of parenteral nutrition, length of hospitalization and weight at discharge. Overall rate of postoperative complications was 14% (n = 7), with a slightly prevalence in OS (18%) compared to LAS (10%), p = 0.68.

CONCLUSIONS

The LAS technique in the treatment of neonatal JIA is safe and feasible. LAS is associated with shorter operative and restoration of enteral feeding times. The post-operative outcomes in LAS are similar with OS, with a lower rate of postoperative complications.

Needs and stressors of parents of term and near-term infants in the NICU: A systematic review with best practice guidelines

Having a sick infant in the NICU can be quite stressful and overwhelming to parents. They require support and may have varied needs. A systematic review of qualitative and quantitative studies from 5 electronic databases (Ovid Medline, EMBASE, PsycINFO, CINAHL and Sociological Abstracts), covering January 2001 - March 2016 identified the needs and stressors of parents of term or near-term Infants in the NICU. Six articles addressed the needs and 14 identified the stressors of parents. Parents' most important need was for accurate and honest information. Needs focused around sensitive infant care and involvement in decision-making. The greatest stressor for parents was alteration to the parental role, followed by infant appearance. Fathers and parents of infants undergoing surgery are an under-researched population. Based on the evidence, enhancing staff-parent communication would better meet parental needs and reduce stressors. Our key recommendations highlight the need for family-centred and individualised care practices in the NICU.

high-volume institutions: a KID inpatient database outcomes and cost study after repair of congenital diaphragmatic hernia, esophageal atresia, and gastroschisis

BACKGROUND/PURPOSE

The volume-outcome relationship and optimal surgical volumes for repair of congenital anomalies in neonates is unknown.

METHODS

A retrospective study of infants who underwent diaphragmatic hernia (CDH), gastroschisis (GS), and esophageal atresia/tracheoesophageal fistula (EA/TEF) repair at US hospitals using the Kids' Inpatient Database 2009-2012. Distribution of institutional volumes was calculated. Multi-level logistic/linear regressions were used to determine the association between volume and mortality, length of stay, and costs.

RESULTS

Total surgical volumes were 1186 for CDH, 1280 for EA/TEF, and 3372 for GS. Median case volume per institution was three for CDH and EA/TEF, and four for GS. Hospitals with annual case volumes ≥ 75th percentile were considered high volume. Approximately, half of all surgeries were performed at low-volume hospitals. No clinically meaningful association between volume and outcomes was found for any procedure. Median cost was greater at high- vs. low-volume hospitals [CDH: $165,964 (p < 0.0001) vs. $104,107, EA/TEF: $85,791 vs. $67,487 (p < 0.006), GS: $83,156 vs. $72,710 (p < 0.0009)].

CONCLUSIONS

An association between volume and outcome was not identified in this study using robust outcome measures. The cost of care was higher in high-volume institutions compared to low-volume institutions.

LEVEL OF EVIDENCE

III.

Early CDH repair on ECMO: Improved survival but no decrease in ECMO duration (A CDH Study Group Investigation)

PURPOSE

"Early on-ECMO" repair of CDH entails repair within 48-72 h of cannulation in an effort to optimize pulmonary physiology, shorten ECMO duration, and, ultimately, improve survival. This study evaluated the effect of early on-ECMO repair as compared to leaving patients unrepaired during ECMO.

METHODS

The CDH Study Group database was queried for CDH patients requiring ECMO who either underwent repair within the first 72 h after cannulation or remained unrepaired on ECMO. Primary outcomes were survival to decannulation and ECMO duration.

RESULTS

A total of 248 patients underwent early repair and 922 remained unrepaired on ECMO. The early repair group had increased risk factors for poor outcomes, including higher odds of cardiac defects and thoracic liver location, and lower odds of hernia sac presence. Nonetheless, ECMO survival for the early repair group was 87.1% compared to 78.4% in the unrepaired group (p = 0.002). However, the early repair group had a longer median ECMO duration than the unrepaired group (240.6 vs 196.8 h, p = 0.001).

CONCLUSION

While early ECMO repair does not shorten ECMO duration, it results in increased survival to decannulation as compared to those unrepaired on ECMO. This suggests that there may be a physiologic benefit leading to increased ECMO survival in a subset of patients undergoing on-ECMO repair over those designated to undergo post-ECMO repair.

LEVEL OF EVIDENCE

Level III.

Burden and Outcomes of Neonatal Surgery in Uganda: Results of a Five-Year Prospective Study

BACKGROUND

Ninety-four percent of congenital anomalies occur in low- and middle-income countries. In Uganda, only three pediatric surgeons and three pediatric anesthesiologists serve more than 20 million children. This study estimates burden, outcomes, coverage, and economic benefit of neonatal surgical conditions in Uganda.

METHODS

A prospectively collected database was reviewed for neonatal surgical admissions from January 1, 2012, to December 31, 2017, at the only two sites with specialist pediatric surgical coverage. Outcomes were compared with high-income countries. Met and unmet need were estimated using disability-adjusted life years. Economic benefit was estimated using a value of statistical life-year approach.

RESULTS

For 1313 neonatal admissions, the median age of presentation was 3 d, overall mortality was 36%, and median distance traveled was 40 km. Anorectal malformations were most common (18%). Postoperative mortality was 24%. Mortality was significantly associated with surgical intervention (P < 0.0001). Met need was 4181 disability-adjusted life years per year, which corresponds to a $3.5 million net economic benefit to Uganda, with a potential additional benefit of $153 million if unmet need were fully addressed. Approximately 2% of the total need is met by the health care system.

CONCLUSIONS

Neonatal surgery is associated with improved survival for most conditions. Despite increases in workforce and infrastructure, a limited proportion of the need for neonatal surgery is currently being met. This is multifactorial, including lack of access to surgical care and severe shortages of workforce and infrastructure. Current and potential economic benefit to Uganda appears substantial.

Short-term respiratory outcomes of neonates with symptomatic congenital lung malformations

INTRODUCTION

The purpose of this study was to evaluate short-term respiratory outcomes in neonates with symptomatic congenital lung malformations (CLM).

METHODS

Consecutive newborns who underwent surgical resection of a CLM were retrospectively reviewed. Demographic, prenatal, and outcomes data were analyzed as appropriate (p < 0.05).

RESULTS

Twenty-one neonates were managed at a median gestational age of 36.2 weeks [interquartile range (IQR), 33.8-39.0]. Endotracheal intubation was required in 14 (66.7%) for a median of 7.5 days [interquartile range (IQR), 3.0-25.8]. Three (14.3%) children underwent ex utero intrapartum treatment-to-resection, and another 14 (66.7%) had neonatal lung resections performed at a median age of 2.0 days (IQR, 0.08-19.5 days). Excluding one patient who received comfort care at birth, all neonates survived to hospital discharge with a median length of hospitalization of 36.5 days (IQR, 23.8-56.5). More than one-quarter were discharged on supplemental oxygen by nasal cannula. Based on a median follow up of 35.5 months (IQR, 19.0-80.8), CLM-related morbidity was still evident in 55.0%.

CONCLUSION

Our study suggests a high incidence of complications and chronic respiratory morbidity after neonatal lung resection for symptomatic CLMs. These data highlight the need to provide realistic expectations in perinatal counseling discussions with families and the importance of coordinating appropriate multidisciplinary follow up for these children.

LEVEL OF EVIDENCE

Level IV.

Benefits of spinal anesthesia for urologic surgery in the youngest of patients

INTRODUCTION

Increasing concerns regarding potential negative effects of early use of inhalational and intravenous anesthetics on neurocognitive development have led to a growing interest in alternative forms of anesthesia in infants. The study institution's outcomes with spinal anesthesia (SA) for urologic surgery in infants aged less than 90 days are reported and their outcomes with a matched cohort of patients who underwent general anesthesia (GA) are compared.

METHODS

This is a retrospective single-center analysis. Patients aged less than 90 days who underwent SA for four urologic surgeries (inguinal hernia repair, scrotal exploration, posterior urethral valve ablation, and ureterocele puncture) were identified from the study institution's SA database. An age- and procedure-matched control cohort was identified from a list of patients who underwent the aforementioned four procedures under GA since 2013. Outcomes of interest included success rate of SA, complications from spinal placement, narcotic use, need for supplemental medications and oxygen, and length of hospital stay.

RESULTS

Forty patients were identified; 20 in the SA and 20 in the GA group. Mean patient age was 54 (standard deviation, 35) days. There were no significant differences between the groups in age, gender, weight, history of prematurity, or presence of comorbidities. Eighty percent of SA patients had successful SA; reasons for conversion to GA included failure of spinal needle placement (75%) and agitation during operative procedure (25%). Ninety-six percent of patients who received GA (primarily or converted) had an endotracheal tube (ETT) placed. No patient in the SA group had a complication from spinal needle placement. Patients in the SA group were less likely to receive narcotics during the operative procedure (P = 0.001) and also had a lower mean morphine equivalent dose/kilogram (P = 0.002). Patients in the SA group were also less likely to receive any supplemental medications during the operative procedure (P = 0.001), particularly intravenous corticosteroids (P < 0.001). There were no significant differences in the length of hospital stay.

CONCLUSIONS

The use of SA has clear advantages for this medically vulnerable population. For the majority of patients, it obviates the need for ETT placement and airway management and avoids the potential negative effects of GA on neurocognitive development. It also decreases the use of narcotics and other supplemental medications. In scenarios in which the benefit of surgery must be weighed against the risk of GA, such as neonatal torsion, SA may allow a paradigm shift in the timing of surgery.

Body composition and cognition in preschool-age children with congenital gastrointestinal anomalies

BACKGROUND

Children with congenital gastrointestinal anomalies (CGIAs) experience multiple stressors while hospitalized in neonatal intensive care units during an essential time of growth and development. Early stress and inadequate nutrition are linked to altered growth patterns and later neurodevelopmental delays. In other at-risk populations, improved fat-free mass (FFM) accretion is associated with improved cognitive outcomes.

OBJECTIVE

To determine if body composition is associated with cognitive function in preschool-age children with CGIAs.

STUDY DESIGN

An observational study examined body composition and cognition in 34 preschool-age children with CGIAs. Anthropometric measurements and body composition testing via air displacement plethysmography were obtained. Measurements were compared with a reference group of healthy, term-born children. Cognition was measured with the NIH Toolbox Early Childhood Cognition Battery. Linear regression was used to test the association of body composition with cognitive function.

RESULTS

Compared with the reference group, children with CGIAs had similar anthropometric measurements (weight, height, and body mass index z-scores) and body composition at preschool-age. Processing speed scores were lower than standardized means (p = 0.001). Increased FFM was associated with higher receptive vocabulary scores (p = 0.001), cognitive flexibility scores (p = 0.005), and general cognitive function scores (p = 0.05).

CONCLUSIONS

At preschool-age, children with CGIAs have similar growth and body composition to their peers. In children with CGIAs, higher FFM was associated with higher cognitive scores. Closer tracking of body composition and interventions aimed at increasing FFM may improve long-term outcomes in this population.

The Relationship Between Pre-operative Left Ventricular Longitudinal Strain and Post-operative Length of Stay in Patients Undergoing Arterial Switch Operation Is Age Dependent

INTRODUCTION

Post-operative length of stay (LOS) after the arterial switch operation (ASO) is variable. The association between pre-operative non-invasive measures of ventricular function and post-operative course has not been well established. The aims of this study were to (1) evaluate the relationship between pre-operative non-invasive measures of ventricular function and post-operative LOS and (2) evaluate the change in ventricular function after ASO.

METHODS

Data were reviewed in consecutive ASO patients between 2010 and 2016. The primary outcome was post-operative LOS. Echocardiograms obtained during the pre-operative period and at the time of discharge were retrospectively analyzed using speckle-tracking echocardiography. Pearson's correlation between patient-specific, pre-operative, and echocardiographic data versus post-operative LOS was assessed.

RESULTS

Fifty-two patients were included in analyses, 39 neonates and 13 infants. Left ventricular (LV) longitudinal strain correlated with post-operative LOS for infants age > 28 days (r = 0.62, p = 0.03), but not for neonates (r = 0.14, p = 0.40). Operative age (r = - 0.42, p = 0.003), weight at surgery (r = - 0.48, p ≤ 0.001), and cardiopulmonary bypass time (r = 0.30, p = 0.045) also correlated with post-operative LOS. Standard 2D measures of ventricular function did not correlate with post-operative LOS. LV ejection fraction and longitudinal strain worsened post-operatively.

CONCLUSION

Higher pre-operative LV longitudinal strain (representing worse LV function) is associated with increased post-operative LOS after ASO in infants > 28 days, but not in neonates. LV ejection fraction and longitudinal strain worsened after ASO. Future studies should assess the utility of performing STE in risk stratifying patients prior to ASO.

Nonoperative management of giant omphalocele leading to early fascial closure

PURPOSE

We describe our series of giant omphalocele patients treated with a serial taping method for gradual reduction of the abdominal contents and early fascial closure.

METHODS

Between 2010 and 2017 we cared for ten newborns with giant omphaloceles. The average gestational age was 35.5 weeks (range 29-38) and average birthweight was 2.84 kg. Seven infants had other major anomalies, including one with a variant of Pentology of Cantrell. Four had abnormal chromosomes. None had any attempt to primarily close the defect. Omphalocele defects were serially taped at bedside in the NICU with the child awake until the viscera were completely reduced, and the defect could be closed.

RESULTS

Mean time to closure was 13.7 days (median 14 days). Six were closed primarily without a patch. The remaining four infants required Gore-Tex patch (covered by skin) which was later removed and fascia closed in three infants (at 70 days, 75 days, and 11 months of age). Total length of stay was a mean 71.8 days (median 71).

CONCLUSIONS

Serial taping achieves early fascial closure and avoids complications of a staged surgical approach, such as multiple anesthetics, loss of fascial margin integrity, silo dehiscence, and fistula formation. Compression of the viscera is slow enough to avoid abdominal compartment syndrome and the fascia and amnion are left intact leaving the option available to use escharotic agents if required.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level III.

Contaminated or dirty wound operations and methicillin-resistant Staphylococcus aureus (MRSA) colonization during hospitalization may be risk factors for surgical site infection in neonatal surgical patients

PURPOSE

Establishment of evidence-based best practices for preventing surgical site infection (SSI) in neonates is needed. SSI in neonates, especially those with a low birth weight, is potentially life-threatening. We aimed to identify risk factors associated with SSI in neonates.

METHODS

A retrospective review was performed using 2007-2016 admission data from our institution. Neonatal patients who were admitted to the neonatal intensive care unit and underwent surgery were evaluated for a relationship between development of SSI and perinatal or perioperative factors and methicillin-resistant Staphylococcus aureus (MRSA) colonization during hospitalization.

RESULTS

One hundred and eighty-one patients were enrolled in this study. Overall SSI incidence was 8.8%. Univariate analysis showed that SSI was significantly more frequent in both patients with contaminated or dirty wound operations and patients with MRSA colonization during hospitalization. Both of these factors were identified as independent risk factors for SSI by multivariate analysis [hazard ratio (HR): 6.1, 95% confidence interval (CI) 2.0-19.9; HR: 3.3, 95% CI 1.1-10.4, respectively].

CONCLUSIONS

This study identified contaminated or dirty wound operations and MRSA colonization during hospitalization as risk factors for SSI in neonates. MRSA colonization may be a preventable factor, unlike previously reported risk factors.

Experience in the Early Surgical Management of Myelomeningocele in Zanzibar

BACKGROUND

Neural tube defects are a large health burden for East African countries. Health strategies in the prevention of this disease include nutritional prophylaxis, prenatal diagnosis, and availability of early neonatal neurosurgery. The main objective of this study is to describe our experience in the early surgical management of neural tube defects in the Zanzibar archipelago.

METHODS

From December 2016 to December 2017, we prospectively collected data on all patients admitted with the diagnosis of myelomeningocele. We collected variables regarding demographics, maternal health, preoperative imaging, surgical procedures, and complications at follow-up.

RESULTS

We collected data on 19 patients. Mean age was 9.8 ± 18.7 days. Of these patients, 52.6% were male and 47.3% were female; 47.3% patients were from Unguja, 42.0% from Pemba, and 5.2% from mainland Tanzania; 68.4% of all mothers were found to have undergone prenatal ultrasonography and 89.5% of all patients received surgery. Surgical wound infection was present in 29.4% of all surgical patients and 52.9% developed secondary hydrocephalus.

CONCLUSIONS

Neural tube defects are a prevailing condition in East Africa. We believe that more health initiatives should address its prevention, mainly through maternal nutrition. On the basis of our findings, we consider early neonatal neurosurgery as the most important factor in reducing immediate morbidity and mortality.

The effect of gestational age on clinical and radiological presentation of necrotizing enterocolitis

BACKGROUND/PURPOSE

To test the hypothesis that clinical and radiological features of necrotizing enterocolitis vary with gestational age in all neonates with NEC and in subgroup of surgically treated patients.

METHODS

This was a retrospective study case series. NEC cases treated in Stockholm County from 2009 to 2014 were identified in the National Quality Register. Patients were included in the study if they had a verified NEC diagnosis and they were divided into 2 groups according to the gestational age.

RESULTS

A total of 89 patients were included. Of these 60 (67.4%) neonates had a gestational age <28 and 29 (32.6%) infants ≥28weeks. Surgical NEC patients were 57 (64%). Pneumatosis intestinalis at the abdominal radiographs was noted significantly more often in neonates born at ≥28weeks of gestation (86.2%) compared to extremely preterm newborns (60.0%). Neonates born at ≥28weeks of gestation presented more often bloody stools (58.6%) compared to extremely preterm newborns (20.0%). In surgical NEC patients gasless abdomen was detected in 35.6% of the neonates born <28weeks compared to 6.7% of the more mature neonates.

CONCLUSIONS

Extremely preterm neonates with NEC show less specific clinical and radiological signs of NEC compared to more mature neonates. This suggests that Bell's classification is not adequate for the diagnosis and staging of NEC in extremely preterm neonates.

LEVEL OF EVIDENCE

III.

Acute kidney injury in necrotizing enterocolitis predicts mortality

BACKGROUND

Morbidity and mortality with necrotizing enterocolitis (NEC) remains a significant challenge. Acute kidney injury (AKI) has been shown to worsen survival in critically ill neonates. To our knowledge, this study is the first to evaluate the prevalence of AKI and its impact on outcomes in neonatal NEC.

METHODS

We carried out a single-center retrospective chart review of all neonates treated for NEC between 2003 and 2015 (N = 181). AKI is defined as a rise in serum creatinine (SCr) from a previous trough according to neonatal modified KDIGO criteria (stage 1 = SCr rise 0.3 mg/dL or SCr 150 < 200%, stage 2 = SCr rise 200 < 300%, stage 3 = SCr rise ≥300%, SCr 2.5 mg/dL or dialysis). Primary outcome was in-hospital mortality and secondary outcomes were hospital length of stay (LOS) and need for and type of surgery.

RESULTS

Acute kidney injury occurred in 98 neonates (54%), with 39 stage 1 (22%), 31 stage 2 (18%), and 28 stage 3 (16%), including 5 requiring dialysis. Non-AKI and AKI groups were not statistically different in age, weight, Bell's NEC criteria, and medication exposure (vasopressors, vancomycin, gentamicin, or diuretic). Neonates with AKI had higher mortality (44% vs 25.6%, p = 0.008) and a higher chance of death (HR 2.4, CI 1.2-4.8, p = 0.009), but the effect on LOS on survivors did not reach statistical significance (79 days, interquartile range [IQR] 30-104 vs 54 days, IQR 30-92, p = 0.09). Overall, 48 (27.9%) patients required surgical intervention.

CONCLUSIONS

This study shows that AKI not only occurs in over half of patients with NEC, but that it is also associated with more than a two-fold higher mortality, highlighting the importance of early recognition and potentially early intervention for AKI.