Cholestasis after Kasai operation predicts portal hypertension in native liver survivors of biliary atresia: a multicenter study.

PURPOSE: This study evaluated portal hypertension (PHT) and its predictors among native liver survivors (NLS) of biliary atresia (BA) after Kasai portoenterostomy (KPE). METHODS: This was a multicenter study using prospectively collected data. The subjects were patients who remained transplant-free for 5 years after KPE. Their status of PHT was evaluated and variables that predicted PHT were determined by regression analysis and receiver operating characteristic (ROC) curve. RESULTS: Six centers from East Asia participated in this study and 320 subjects with KPE between 1980 to 2018 were analyzed. The mean follow-up period was 10.6 ± 6.2 years. At the 5th year after KPE, PHT was found in 37.8% of the subjects (n = 121). Patients with KPE done before day 41 of life had the lowest percentage of PHT compared to operation at older age. At 12 months after KPE, PHT + ve subjects had a higher bilirubin level (27.1 ± 11.7 vs 12.3 ± 7.9 µmol/L, p = 0.000) and persistent jaundice conferred a higher risk for PHT (OR = 12.9 [9.2-15.4], p = 0.000). ROC analysis demonstrated that a bilirubin level above 38 µmol/L at 12 months after KPE predicted PHT development (sensitivity: 78%, specificity: 60%, AUROC: 0.75). CONCLUSIONS: In BA, early KPE protects against the development of PHT among NLSs. Patients with persistent cholestasis at one year after KPE are at a higher risk of this complication. They should receive a more vigilant follow-up. LEVEL OF EVIDENCE: Level III.

Retroperitoneoscopic Simple Nondismembered Pyeloplasty with Da Vinci Si Assistance to Prevent Alignment Shift.

Aims: Retroperitoneoscopic simple nondismembered pyeloplasty (SNDP) with da Vinci Si assistance was developed because of a possible risk for alignment shift after retroperitoneoscopic diamond-shaped bypass pyeloplasty (Diamond-Bypass; DP). Outcomes of SNDP and DP were compared. Materials and Methods: For SNDP, a small longitudinal incision is made on the border of the dilated pelvis and narrowed ureter at the ureteropelvic junction (UPJ). Extending this incision toward the pelvis allows identification of mucosa while maintaining the integrity of surrounding tissues that are so thin and fragile that they will not influence lumen alignment. Data for DP were obtained from a previously published article. Results: For SNDP (n = 3), mean age at surgery was 2.67 years (range: 1-4), mean operative time was 176 minutes. Mean postoperative Society of Fetal Urology (SFU) grades for hydronephrosis were 1.2, 0.7, and 0.6, 1, 2, and 3 months after stent removal, respectively. Postoperative diethylenetriaminepentaacetic acid (DTPA) was normal (n = 3). For DP (n = 5) mean age at surgery was 4.3 years (range: 1-14), mean operative time was 189 minutes. Mean postoperative SFU grades were 2.8, 2.2, and 1.6, respectively. Postoperative DTPA was normal (n = 4) and delayed (n = 1). All SNDP and DP were asymptomatic by 3 months after stent removal. Conclusion: Both SNDP and DP have favorable outcomes. If the UPJ is located at the lowest end of the renal pelvis, SNDP may improve hydronephrosis more quickly.

Pulmonary artery diameter ratio as a prognostic indicator of congenital diaphragmatic hernia.

Background: Following on from an earlier study published in 2008 about left pulmonary artery (LPA) flow measured on serial echocardiography being strongly prognostic in left-sided congenital diaphragmatic hernia (CDH) and the ratio of LPA to right pulmonary artery (RPA) diameters being a simple and reliable indicator for commencing nitric oxide (NO) therapy, the ratio of LPA:RPA diameters (PA ratio or PAR) was hypothesized to possibly reflect cardiopulmonary stresses accompanying CDH better. Methods: Subjects with isolated left-sided CDH treated between 2007 and 2020 at a single pediatric surgical center were recruited and classified according to survival. Data obtained retrospectively for subject demographics, clinical course, LPA/RPA diameters, and PAR were compared between survivors and non-survivors. The value of PAR for optimizing the prognostic value of PA diameter data in CDH were analyzed with receiver operating characteristic (ROC) curve analysis. Results: Of 65 subjects, there were 54 survivors (82.3%) and 11 non-survivors (17.7%); 7 of 11 non-survivors died before surgical repair could be performed. Mean PAR for survivors (0.851±0.152) was significantly higher than for non-survivors (0.672±0.108) (p=0.0003). Mean PAR for non-survivors was not affected by surgical repair. Characteristics of survivors were: LPA ≥2 mm (n=52 of 54; mean PAR=0.866±0.146) and RPA ≥3 mm (n=46 of 54; mean PAR=0.857±0.152). Non-survivors with similar LPA and RPA diameters to survivors had significantly lower mean PAR. ROC curve cut-off for PAR was 0.762. Subjects with high PAR (≥0.762) required high-frequency oscillatory ventilation/NO less than subjects with low PAR (<0.762) (p=0.0244 and p=0.0485, respectively) and subjects with high PAR stabilized significantly earlier than subjects with low PAR (1.71±0.68 days vs 3.20±0.87 days) (p<0.0001). Conclusions: PAR would appear to be strongly correlated with clinical outcome in CDH and be useful for planning management of cardiopulmonary instability in CDH.

Premalignant/malignant histology in excised choledochal cyst specimens from children. Experience and literature review.

BACKGROUND: Dysplasia, carcinoma in situ, and other malignant transformation or premalignant/malignant histopathology (PMMH) seem uncommon in pediatric choledochal cyst (CC). A literature review and the authors' experience are presented. METHODS: All reports about PMMH in CC patients 15 years old or younger published in English and all cases of PMMH in specimens excised from CC patients 15 years old or younger by the authors were reviewed. RESULTS: Of 20 published reports, PMMH was adenocarcinoma (n = 4), sarcoma (n = 4), and dysplasia (n = 12). Treatment for malignancies was primary pancreaticoduodenectomy (PD; n = 2) or cyst excision/hepaticojejunostomy (Ex/HJ; n = 6). Outcomes at the time of writing for malignancies: 2 deaths, 4 survivors after follow-up of 2 years, and 2 lost to follow-up. No dysplasia case has undergone malignant transformation. The authors have experienced 7 cases of PMMH; adenocarcinoma in situ (AIS; n = 1) and dysplasia (n = 6). CONCLUSIONS: The present study identified the youngest cases of AIS and dysplasia from specimens excised when they were 3 years old and 4 months old, respectively. Both are published for the first time as evidence that PMMH can complicate CC in young patients. Long-term protocolized postoperative follow-up is mandatory when PMMH is diagnosed in pediatric CC.

Remote cadaveric minimally invasive surgical training.

Objective: The aim of the study is to discuss the efficacy of live vs. remote cadaver surgical training (CST) for minimally invasive surgery (MIS). Methods: A cohort of 30 interns in their first and second years of training were divided into three groups: live observers (n = 12), live participants (n = 6), and remote observers: (n = 12). The interns had the opportunity to either observe or actively participate in two different surgical procedures, namely, laparoscopic lower anterior resection, performed by a colorectal surgical team, and laparoscopic fundoplication, performed by a pediatric surgical team. The procedures were conducted either at a base center or at a remote center affiliated with the institute. Some of the interns interacted directly with the surgical teams at the base center, and others interacted indirectly with the surgical teams from the remote center. All interns were administered questionnaires before and after completion of the CST in order to assess their understanding of various aspects related to the operating room layout/instruments (called "design"), accessing the surgical field (called "field"), understanding of anatomic relations (called "anatomy"), their skill of dissection (called "dissection"), ability to resolve procedural/technical problems (called "troubleshooting"), and their skill in planning surgery (called "planning") according to their confidence to operate using the following scale: 1 = not confident to operate independently; 4 = confident to operate with a more senior trainee; 7 = confident to operate with a peer; and 10 = confident to operate with a less experienced trainee. A p < 0.05 was considered statistically significant. Results: All scores improved after CST at both the base and remote centers. The following significant increases were observed: for remote observers: "field" (2.67→4.92; p < .01), "anatomy" (3.58→5.75; p < .01), "dissection" (3.08→4.33; p = .01), and "planning" (3.08→4.33; p < .01); for live observers: "design" (3.75→6.17; p < .01), "field" (2.83→5.17; p < .01), "anatomy" (3.67→5.58; p < .01), "dissection" (3.17→4.58; p < .01), "troubleshooting" (2.33→3.67; p < .01), and "planning" (2.92→4.25; p < .01); and for live participants: "design" (3.83→6.33; p = .02), "field" (2.83→6.83; p < .01), "anatomy" (3.67→5.67; p < .01), "dissection" (2.83→6.17; p < .01), "troubleshooting" (2.17→4.17; p < .01), and "planning" (2.83→4.67; p < .01). Understanding of "design" improved significantly after CST in live observers compared with remote observers (p < .01). Understanding of "field and "dissection" improved significantly after CST in live participants compared with live observers (p = .01, p = .03, respectively). Out of the 12 remote observers, 10 participants (83.3%) reported that interacting with surgical teams was easy because they were not on-site. Conclusions: Although all the responses were subjective and the respondents were aware that observation was inferior to hands-on experience, the results from both centers were equivalent, suggesting that remote learning could potentially be viable when resources are limited.

Comparative assessment of fully laparoscopic Duhamel-Z with minimal rectorectal dissection vs. laparoscopy-assisted Duhamel-Z with blunt manual rectorectal dissection for total colonic aganglionosis.

Aims: Early postoperative outcome (EPO) was compared between fully laparoscopic Duhamel-Z (F-Dz) and laparoscopy-assisted Duhamel-Z (A-Dz) anastomoses performed for total colonic aganglionosis (TCA). Methods: EPO was assessed quarterly for the first year after F-Dz/A-Dz using a continence evaluation score (CES) based on stool frequency (motions/day) and stool consistency (0 = liquid, 1 = soft, 2 = formed), presence of anal erosion (0 = severe, 1 = moderate, 2 = mild), and incidence of enterocolitis.Surgical technique involved taking the ileostomy down, dissecting the colon laparoscopically, and preparing the pull-through ileum through the stoma wound. In F-Dz (n = 3), a working port (SILS trocar) was inserted, and laparoscopic retrorectal dissection with forceps used to create a retrorectal tunnel from the peritoneal reflection extending downward as narrow as possible along the posterior wall of the rectum to prevent lateral nerve injury and preserve vascularity. After completing the tunnel, the ileum was pulled-through from an incision on the anorectal line and a Z-shaped ileorectal side-to-side anastomosis performed without a blind pouch. In A-Dz (n = 11), the retrorectal pull-through route was created through a Pfannenstiel incision using blunt manual (finger) dissection along the anterior surface of the sacrum. Results: Subject backgrounds were similar. Mean quarterly data were: frequency (F-Dz: 4.67, 4.67, 4.67, 3.33) vs. (A-Dz: 7.27, 7.09, 6.18, 5.36) p < .05; consistency (F-Dz: 0.33, 0.67, 0.67, 0.67) vs. (A-Dz: 0.27, 0.45, 0.70, 0.73) p = ns; anal erosion (F-Dz: 0.33, 0.33, 0.33, 0.67) vs. (A-Dz: 0.18, 0.36, 0.45, 0.64) p = ns; and enterocolitis (F-Dz: 1 episode in 1/3 cases or 33.3%) vs. (A-Dz: 7 episodes in 6/11 cases or 54.5%) p = ns. Conclusions: Overall, EPO after F-Dz was better than after A-Dz.

How many cases do instructor class pediatric surgeons need to experience to be an independent operator in performing advanced endoscopic surgery? A nationwide survey to establish an ideal curriculum for pediatric endoscopic surgery in Japan.

PURPOSE: To ensure the safe spread of pediatric endoscopic surgery, it is essential to build a training curriculum, and a survey of the current situation in Japan is necessary. The present study assessed an efficient training curriculum by clarifying instructor class pediatric surgeons' experiences, including autonomy when performing advanced endoscopic surgeries. METHODS: An online nationwide questionnaire survey was conducted among pediatric surgeons who had Endoscopic Surgical Skill Qualification (ESSQ) and board-certified instructors who had skills comparable to ESSQ. We assessed participants' training experience, opinions concerning the ideal training curriculum, and the correlation between surgical experience and the level of autonomy. The Zwisch scale was used to assess autonomy. RESULTS: Fifty-two participants responded to the survey (response rate: 86.7%). Only 57.7% of the respondents felt that they had received sufficient endoscopic surgery training. Most respondents considered an educational curriculum for endoscopic surgery including off-the-job training essential during the training period. Autonomy had been acquired after experiencing two to three cases for most advanced endoscopic surgeries. CONCLUSION: This first nationwide survey in Japan showed that instructor class pediatric surgeons acquired autonomy after experiencing two to three for most advanced endoscopic surgeries. Our findings suggest that training, especially off-the-job training, has been insufficient.

Robot-Assisted Retroperitoneoscopic Diamond Bypass Pyeloplasty.

AIM: Robot (da Vinci Si; Intuitive Surgical, Sunnyvale, CA) assisted retroperitoneoscopic diamond bypass pyeloplasty (R-RDBP) performed for ureteropelvic junction (UPJ) obstruction (n = 5) is presented. METHODS: Patients were placed affected side up and the retroperitoneal space accessed conventionally using 3-4 trocars. The diamond-shaped anastomosis involved incising the lowest part of the renal pelvis 12-15 mm transversely and the ureter distal to the obstruction 10-12 mm longitudinally. The first two sutures were placed retroperitoneoscopically; one from the mid-caudal line of the renal pelvis to the apex of the ureteric incision (the apex of the diamond) and the other from the corner of the incision in the renal pelvis to halfway along the ureteric incision. Trocars were replaced and the robot system docked. The first robot suture was placed between these two sutures, and the anastomosis completed by suturing from posterior to ventral applying minimal tension to keep the anastomosis close to the renal pelvis. All sutures were interrupted absorbable 5-0 monofilament. RESULTS: Mean age at R-RDBP was 4.3 (range: 1-14) years old. Height/weight were average. Preoperative Society for Fetal Urology (SFU) grading was 4.0 in all cases. All repairs were primary and progressed smoothly without perioperative complications; 3/5 had improved appetite postoperatively. Mean SFU grades 1-3 months postoperatively were 2.8, 2.2, and 1.6, respectively. Diuretic renography that was obstructive in all cases preoperatively was normal in four and delayed in one case, postoperatively. CONCLUSION: R-RDBP prevented rotation/kinking of the ureter, enhanced precision of suturing, and maximized the diameter at the anastomosis, facilitating smooth urine flow. LEVEL OF EVIDENCE: LEVEL IV.

Intraoperative Bronchoscopic Inspection Facilitates Thoracoscopic Repair of Esophageal Atresia with Tracheoesophageal Fistula.

Aim: The value of intraoperative bronchoscopic inspection (IBI) for accurate confirmation of the location and distance between the distal tracheoesophageal fistula (TEF) and the proximal blind end of the esophagus (GAP) was evaluated in Type C esophageal atresia (EA)+TEF. Methods: IBI involved inserting the tip of a bronchoscope into the TEF and a nasogastric tube into the blind end of the EA and measuring GAP with fluoroscopy. EA+TEF patients (n = 23) treated thoracoscopically between 2007 and 2020 were classified according to IBI as IBI+ (n = 16) and IBI- (n = 7) to compare demographics, operative time, and time taken for TEF division. Results: Demographics were similar. Mean time for TEF division (15.4 ± 4.6 minutes for IBI+ versus 38.6 ± 20.9 minutes for IBI-; p < .05) and mean operative time (215.3 ± 48.9 minutes for IBI+ versus 286.4 ± 51.7 minutes for IBI+; p < .05) were significantly shorter. Mean GAP measured radiographically was 0.5 cm (range: 0-1.2 cm); mean GAP measured with IBI was 0.9 cm (range: 0-2.2 cm). Postoperative complications were 3 anastomotic leakages (1/16 in IBI+ and 2/7 in IBI-) that resolved without surgery and 8 strictures (3/16 in IBI+ and 5/7 in IBI-) treated by dilatation. Conclusions: IBI was effective for measuring GAP and is recommended for improving the efficiency of thoracoscopic repair.

Oncologic safety of Carrel patch hepaticojejunostomy for treating cystic-type choledochal cyst in children based on 20-plus years follow-up.

AIM: During choledochal cyst (CC) excision, the hepaticojejunostomy anastomosis (HJA) can be performed conventionally (CHJA) or with a Carrel patch (CPA). CPA can increase CHD diameter to 10-13 mm, preventing anastomotic stenosis and intrahepatic bile duct (IHBD) stones but may be at risk for malignant transformation. METHODS: The medical records of 83 cystic-type CC with CHD ≤ 9 mm followed up for at least 20 years were reviewed retrospectively. Available excised CC specimens (70/83) were re-examined blindly for pre-malignant changes. A questionnaire about suturing narrow lumens was conducted. RESULTS: All 83 had pancreaticobiliary maljunction. Group data were similar. Anastomoses were CPA (n = 43) and CHJA (n = 40). Mean diameter for CPA was 11.4 mm (range: 10-13 mm); for CHJA was 7.4 mm (range: 5-9 mm). Mean follow-up was 27.7 years (range: 20-42). Postoperative anastomotic stenoses were less after CPA: 1/43 (2.3%) versus 5/40 (12.5%) (p = 0.10), but CHJA had significantly more postoperative IHBD stones: 0% versus 4/40 (10.0%) (p < 0.05). All IHBD stone patients had anastomotic stenosis. Excised specimens showed no pre-malignant cytology. Lumen diameter ≤ 9 mm was considered challenging by 10/10 surgical trainees and ≤ 7 mm by 16/22 pediatric surgeons. CONCLUSIONS: CPA appears to be oncologically safe because of the absence of malignant transformation for at least 20 years.

Case report: Gross persistent rectal prolapse. A case treated without mesh using deep retrorectal dissection/suturing.

A previously well 15-year-old male presented with a history of gross rectal prolapse (GRP) involving full-thickness rectal prolapse of increasing severity and incidence over 6 months that occurred with every bowel motion, varying from 10 to 40 cm. He denied constipation and passed a soft motion once daily, adeptly reducing his prolapsed rectum after each motion. This case illustrates technical challenges and planning for surgical intervention for optimal treatment in keeping with an FDA alert issued April, 2019 banning surgical mesh for pelvic organ prolapse. Preoperative fluoroscopic defecography confirmed rectal prolapse beginning with eversion of the anal verge identified on inspection. For surgery, general anesthesia was induced, he was placed in a Trendelenburg position, and four ports were inserted. The peritoneum was incised and blunt dissection used to expose the levator ani complex (LAC) taking care to prevent lateral nerve injury and preserve regional vascularity. Seven polypropylene sutures were used to fix the seromuscular posterior wall of the rectum to the median raphe of the LAC, the presacral fascia, and the periosteum of the sacral promontory. Operative time was 170 min. Postoperative recovery and progress were unremarkable. Currently, 5 years postoperatively, defecation is regular without recurrence of prolapse. For prolapse involving protrusion of the upper rectum without eversion of the anal verge, rectal fixation to the sacral promontory without further dissection beyond the peritoneal reflection is adequate, but when extensive prolapse is associated with eversion of the anal verge, more extensive blunt dissection from the peritoneal reflection to the LAC with multiple rectopexy sutures is valid for reducing risks for recurrence and eliminating mesh-related complications.

Changes in postoperative quality of life of pediatric total colonic aganglionosis patients: effect of pull-through technique.

AIM: To assess mid-/long-term quality of life (QOL) of total colonic aganglionosis (TCA) patients. METHODS: Modified pre-existing QOL assessment tools for general lifestyle (GL), bowel function (BF), and mental health (MH) were administered to postoperative TCA patients from five institutions, who were at least 7 years old to compare Duhamel (with pouch) and Swenson/Soave (without pouch) techniques between children (Ch 7-12 years old), teenagers (Tn 13-19), and adults (Ad 20 and over). For MH, caregivers were also interviewed, but separately. Maximum scores were 12 for GL/MH and 18 for BF. RESULTS: There were 32 subjects. GL and BF scores increased significantly from Ch (GL 4.8 ± 2.5, BF: 11.3 ± 4.6) to Tn (GL 7.8 ± 2.6, BF 16.2 ± 3.0); scores for MH did not change significantly. Mean caregiver MH scores were significantly lower than mean subject MH scores for all age groups (subject scores: 10.1, 10.7, 10.7 versus caregiver scores: 6.8, 7.8, 8.1 for Ch, Tn, Ad, respectively). PT technique/presence of a pouch did not influence the incidence of enterocolitis or QOL scores. CONCLUSION: MH responses showed subjects felt better than caregivers believed. This discrepancy could cause conflict despite steadily improving GL/BF. QOL was unaffected by PT technique/presence of a pouch.

Quality of life after type-A esophageal atresia surgery: changes over time and effect of pre-anastomotic elongation.

AIM: To assess mid-/long-term postoperative quality of life (QOL) of esophageal atresia (EA) patients. METHODS: Modified gastrointestinal quality-of-life index surveys were administered to postoperative EA patients who were at least 7 years old at evaluation to assess three topics about general lifestyle (GL), five topics about EA, and four topics about mental health (MH). For MH, caregivers were also interviewed, but separately. Subjects were divided according to age: children (7-12 years old), teenagers (13-19), and adults (20 and over) and compared according to Foker or Kimura elongation (FK) or bougienage stretching (BS). RESULTS: There were 22 patients evaluated. Responses for GL, EA, and MH did not differ significantly between age groups, but MH responses by caregivers for subjects who were children or teenagers scored significantly lower than responses they made themselves. For primary esophageal elongation technique (PET), age at esophagoesophagostomy was significantly higher in FK. Despite FK scoring 15.1 versus 12.4 for BS during EA evaluation, this difference was not statistically significant. CONCLUSION: Changes in QOL responses according to age were unremarkable. However, discrepancies in MH indicate that subjects felt better than their caregivers thought. PET did not appear to influence QOL.

Biochemical Evaluation of Laparoscopic Portoenterostomy for Treating Biliary Atresia and Redo for Failed Portoenterostomy.

Background: Postoperative outcomes of portoenterostomy (PE) and redo-PE were evaluated using selected biochemical markers (SBM) and biochemical status categories (BSC). Methods: Subjects were 70 consecutive PE performed for biliary atresia. SBM were aspartate aminotransferase (AST)/alanine aminotransferase (ALT), cholinesterase (ChE), and platelet count (PLT) assessed at 1, 2, 3, 6, and 12 months, and thence, annually for a maximum of 10 years. BSC were as follows: all SBM normal (N-SBM), normal AST/ALT (N-SLT), normal ChE (N-ChE), normal PC (N-PLT), all abnormal (A-SBM), abnormal AST/ALT (A-SLT), abnormal ChE (A-ChE), and abnormal PC (A-PLT). Subjects achieving jaundice clearance (JC) and surviving with native livers (SNL) also had gamma glutamyl transpeptidase assessed. Redo-PE indicated for failed PE was assessed postoperatively using the same SBM/BSC protocol. Results: PE were laparoscopic (LPE; n = 40) or open (OPE; n = 30). Mean age/weight at PE and duration of follow-up were similar. For JC, LPE = 34/40 (85.0%) and OPE = 22/30 (73.3%); P = .23. For SNL, LPE = 29/40 (72.5%) and OPE = 16/30 (53.3%); P = .10. LPE and OPE were similar for SBM/BSC, except for a single significant increase in ALT in OPE at 6 months. Redo-PE was performed 17-180 days (mean 67.1 days) after primary PE. AST was significantly increased at the last preredo assessment 3 months after primary PE; P < .05. After redo, AST decreased and SBM/BSC results were equivalent to nonredo subjects. Conclusion: Postoperative biochemical data for all PE cases were comparable; redo-PE would appear to be viable for restoring SBM, and AST could be valuable as a single marker of deterioration in redo cases.

Levator ani asymmetry and deviation in high-type anorectal malformation evaluated by magnetic resonance imaging.

INTRODUCTION: The levator ani (LA) complex in high-type imperforate anus (H-IA), low-type imperforate anus (L-IA), and Hirschsprung's disease (HD) patients as controls were documented using magnetic resonance imaging (MRI) and compared for symmetry. MATERIALS AND METHODS: Mean left:right LA thickness ratio (LA ratio), and deviation of the LA from the pubococcygeal line (PCL; LA angle) were calculated from thin-slice MRI images (axial 2 mm, coronal 2 mm, and sagittal 3 mm) of the puborectalis and pubococcygeus taken parallel to the PCL under sedation in H-IA (n=14), L-IA (n=16), and HD (n=9). RESULTS: MRI scans were performed between January 2018 and June 2021. LA were significantly thinner in H-IA (1.78±0.46 mm) compared with L-IA (2.97±0.55 mm) and controls (2.87±0.32 mm), p<0.0001. LA ratio was significantly lower in H-IA (0.71±0.15) compared with L-IA (0.93±0.04), and controls (0.91±0.06), p<0.0001. Mean LA-angle was significantly different in H-IA, 10.8° (range 6°-19°), versus L-IA and controls, both zero degrees (range 0°-5°), p<0.0001, respectively. CONCLUSIONS: LA was confirmed to be significantly asymmetric in H-IA. Because outcome of surgical repair involving a midline incision, such as posterior sagittal anorectoplasty could be impaired, pediatric surgeons are advised to plan surgical intervention for H-IA carefully and appropriately.

Significant neonatal intraoperative cerebral and renal oxygen desaturation identified with near-infrared spectroscopy.

INTRODUCTION: Near-infrared spectroscopy (NIRS) was used to monitor intraoperative regional oxygen saturation (rSO2) during open (Op) and minimally invasive (MI) surgery performed in neonates (N) and children. MATERIALS AND METHODS: NIRS sensors were applied to the forehead and flanks for cerebral rSO2 (C-rSO2) and renal rSO2 (R-rSO2), respectively. MI included laparoscopy (La), retroperitoneoscopy (Re) and thoracoscopy (Th). In children, Op and MI were major operations taking at least 3 h (MOp; MMI). Pathological desaturation (PD) was defined as > 20% deterioration in rSO2. RESULTS: Mean ages at surgery were N: 5.2 ± 8.2 days, MOp: 2.4 ± 2.9 years, and MMI: 3.8 ± 4.3 years. Despite significantly shorter operative times in N (169 ± 94 min; p < 0.0001), PD was significantly worse; PD(C-rSO2): N = 14/35 (40.0%) versus MOp = 3/36 (8.3%) and MMI = 7/58 (12.1%); p = 0.0006, and PD(R-rSO2): N = 27/35 (77.1%) versus MOp = 6/36 (16.7%) and MMI = 7/58 (12.1%); p < 0.0001, respectively. PD(R-rSO2) occurred immediately with visceral reduction in NOp (Fig. 1) and PD was frequent during NMI(Th) (Fig. 2). rSO2 was stable throughout MOp and MMI (Fig. 3). Fig. 1 Pathological desaturation in renal rSO2 after visceral reduction for gastroschisis. Renal rSO2 deteriorated immediately after viscera were returned to the abdominal cavity rSO2 regional oxygen saturation Fig. 2 Fragility of tissue perfusion during thoracoscopic lung lobectomy in a neonate. Pathological desaturation occurred frequently during neonatal thoracoscopic surgery rSO2 regional oxygen saturation Fig. 3 Changes in cerebral and renal rSO2 according to operative time. Cerebral and renal rSO2 did not appear to change according to operative time during major open and major minimally invasive surgery in children. rSO2 regional oxygen saturation CONCLUSIONS: NIRS is a non-invasive technique for monitoring rSO2 as an indicator of intraoperative stress and vascular perfusion. PD was so significant in neonates that intraoperative NIRS is highly recommended during thoracoscopy and procedures requiring visceral manipulation.

Umbilical microflora and pediatric surgery.

INTRODUCTION: In pediatric surgery, the umbilicus with humid environment prone to bacterial colonization has become the most common site of entrance into the peritoneum. However, the umbilical flora in children has never been reported. This study aimed to describe the characteristics of umbilical microflora in children before antiseptic skin preparation. PATIENTS AND METHODS: We prospectively reviewed all children (age, ≤ 15 years) undergoing surgical procedures using umbilical access between April 2020 and June 2021. Before antiseptic skin preparation, culture swabs were taken from the umbilicus. Data on age, sex, and surgical procedure as well as microflora results and clinical findings were analyzed. RESULTS: Overall, data on 123 children aged between 9 days and 15 years (median: 3 years) were obtained. In the umbilicus, the most frequent colonizing bacteria were coagulase-negative Staphylococcus species and Corynebacterium. The isolation of intestinal bacteria from children aged ≤ 3 years was significantly increased (P = 0.03). The results of the multidrug resistance test revealed that the bacteria from the umbilicus exhibited a high frequency of cefazolin (CEZ) resistance (46.1%). No postoperative surgical site infection was recorded in our study. CONCLUSIONS: This prospective study is the first report to investigate the umbilical microflora in over 100 children. In this study, a large spectrum of both resident and transient microflora was cultured from the umbilicus. This umbilical microflora was similar to previous reports of adult microflora except in children aged ≤ 3 years. Our data suggest that in children ≤ 3 years, preoperative and postoperative antibiotics should be chosen by considering CEZ resistance and intestinal bacteria. The result of umbilical microflora would be useful to select the antibiotics for treatment of surgical site infection (SSI), and the culture swabs from the umbilicus before the operation for the children at high risk for SSI are highly recommended.

Optimal timing for Soave primary pull-through in short-segment Hirschsprung disease: A meta-analysis.

BACKGROUND: The optimal age for endorectal pull-through (ERPT) surgery in infants with short-segment Hirschsprung disease varies, with a trend toward earlier surgery. However, it is unclear if the timing of surgery impacts functional outcomes. We undertook the present study to determine the optimal timing of ERPT in infants with short-segment Hirschsprung disease. METHODS: The NCBI PubMed database was searched for English-language manuscripts published between 2000 and 2019 analyzing functional outcomes for patient following the initial Soave ERPT for short-segment Hirschsprung disease. Raw data from these studies was obtained from the corresponding author for each manuscript. We combined data from these papers with our own institutional data and performed a meta-analysis. RESULTS: A total of 780 infants were included in our meta-analysis. Constipation occurred in 1.0-31.7%, soiling 1.3-26.0%, anastomotic stricture 0.0-14.6%, and anastomotic leak 0.0-3.4%. Regarding age at ERPT, younger infants at the time of initial corrective surgery had higher rates of soiling, stricture, and leak. On sub-group analysis, patients <2.5 months at their initial corrective surgery had higher rates of soiling (25.9% vs. 11.4%, p<0.01), as well as stricture (10.0% vs 1.7%, p<0.01) and leak (5.5% vs 1.3%, p<0.01). CONCLUSION: While age at Soave endorectal pull-through for short-segment Hirschsprung disease has decreased over time, functional outcomes associated with this trend have only recently been examined. Our findings suggest that patients <2.5 months old at the time of endorectal pull-through may have worse functional outcomes, emphasizing the need to consider further study of the timing of surgery in this population.