The management of thoracobiliary fistulas in children: a systematic review.

Thoracobiliary fistula (TBF) is a rare condition, in which an atypical communication between the bronchial tree and the biliary tree is present. A comprehensive literature search was conducted on Medline, Embase and Web of Science databases for studies reporting TBF in children. Data regarding patient demographics, site of fistula presentation, preoperative diagnostic procedures needed, and treatment modalities employed were extracted for further analysis. The study pool consisted of 43 studies incorporating 48 cases of TBF. The most frequent symptom was bilioptysis (67%), followed by dyspnea (62.5%), cough (37.5%) and respiratory failure (33%). Regarding the origin of fistula, the left hepatic duct was involved in 29 cases (60.4%), the right hepatic duct in 4 cases (8.3%), and the hepatic junction in 1 case (2%). Surgical management was employed in 46 patients (95.8%). Fistulectomy was performed in 40 patients (86.9%), lung lobectomy or pneumonectomy in 6 (13%), Roux en Y hepaticojejunostomy in 3 (6.5%), and decortication or drainage in 3 cases (6.5%). Three patients died (overall mortality 6.3%), while 17 patients suffered from postoperative complications (overall morbidity 35.4%). TBF in children is a rare but morbid entity which evolves as a result of congenital malformation in the majority of cases. Preoperative imaging of the biliothoracic communication and proper surgical treatment are the components of current management.

New Insights into the Fluid Management in Patients with Septic Shock.

The importance of fluid resuscitation therapy during the early stages of sepsis management is a well-established principle. Current Surviving Sepsis Campaign (SSC) guidelines recommend the early administration of intravenous crystalloid fluids for sepsis-related hypotension or hyperlactatemia due to tissue hypoperfusion, within the first 3 h of resuscitation and suggest using balanced solutions (BSs) instead of normal saline (NS) for the management of patients with sepsis or septic shock. Studies comparing BS versus NS administration in septic patients have demonstrated that BSs are associated with better outcomes including decreased mortality. After initial resuscitation, fluid administration has to be judicious in order to avoid fluid overload, which has been associated with increased mortality, prolonged mechanical ventilation, and worsening of acute kidney injury. The "one size fits all" approach may be "convenient" but it should be avoided. Personalized fluid management, based on patient-specific hemodynamic indices, provides the foundations for better patient outcomes in the future. Although there is a consensus on the need for adequate fluid therapy in sepsis, the type, the amount of administered fluids, and the ideal fluid resuscitation strategy remain elusive. Well-designed large randomized controlled trials are certainly needed to compare fluid choices specifically in the septic patient, as there is currently limited evidence of low quality. This review aims to summarize the physiologic principles and current scientific evidence regarding fluid management in patients with sepsis, as well as to provide a comprehensive overview of the latest data on the optimal fluid administration strategy in sepsis.

Inflammatory fibroid polyp of the anus in a 12-month-old girl: Case report and review of the literature.

Inflammatory fibroid polyp (IFP) is a rare, usually solitary and intraluminal polypoid benign tumour that can affect any part of the gastrointestinal (GI) tract. Its aetiology is unknown and clinical presentation depends on the site of involvement. We present the case of a 12-month-old girl with IFP and review all reported cases of IFP in children and adolescents <18 years. A 12-month-old girl presented with rectal bleeding. The patient underwent colonoscopy which revealed an anus polyp. Surgical resection was performed and histopathological examination of the specimen showed features of IFP. A literature review of 20 cases (including ours) between 1966 and January 2022 is also presented. To our knowledge, this is the youngest reported patient with IFP and the first in the anal area.

Career barriers for women in surgery.

BACKGROUND: Despite the increasing numbers of female medical students, surgery remains male-dominated. PURPOSE: To highlight the principal career obstacles experienced by aspiring female surgeons. METHODS: A narrative review of literature on the position and career barriers of female surgeons has been conducted, using the MEDLINE and EMBASE databases. MAIN FINDINGS: Implicit and even explicit biases against female surgeons remain prevalent, negatively impacting their training performance and overall professional trajectory. Female surgeons are globally underrepresented in leadership positions and senior academic rankings, especially that of a full professor. They feel hampered by lack of effective mentorship, whose value for a successful career has been acknowledged by all medical students, surgeons and surgical leaders. Their work-life imbalance is sometimes expressed as lower likelihood than their male contemporaries of getting married or having children and may be attributed to their conventional association with the role of caretaker, their personal desire to accommodate occupational and family duties and the inadequate implementation of parental leave and childcare policies. Female surgeons' "infertility" may be further explained by direct and indirect pregnancy-related difficulties. Female surgeons are also financially undercompensated compared to their male contemporaries. Finally, specialty-specific challenges should not be overlooked. CONCLUSIONS: While encouraging steps have been made, women in surgery feel still hindered by various obstacles. The qualitative, interview-based nature of current literature requires more meticulous studies on these barriers with a more quantitative and objective approach. Attenuation of gender imbalance in surgical specialties requires further changes in mentality and more targeted modifications in relevant policies.

Infantile hepatic hemangioma: current state of the art, controversies, and perspectives.

Infantile hepatic hemangioma (IHH) is a common vascular tumor, distinctive for its perinatal presentation, rapid growth during the first year of life, and subsequent involution. Although they generally follow a benign course, some tumors have been reported to undergo malignant transformation. The diagnosis of IHH is based on patient's medical history, physical examination, and imaging. Moreover, the management of this vascular tumor is based on clinical presentation and includes observational, medical, surgical, and radiological interventional treatment options. The present review presents the currently available data in the literature on the diverse aspects of the terminology, epidemiology, clinical presentation, pathogenesis, diagnosis, indications for surgery, malignant potential, and long-term outcomes of these tumors.Conclusion: No formal guidelines have yet been established for the treatment of these hepatic lesions, and the therapeutic strategies implemented vary widely from simple observation to medical, radiological, and surgical interventions in the prism of multidisciplinary teams.What is Known:• Infantile hepatic hemangioma is the most common benign tumor of the liver in infancy, but despite its benign nature, it can present with life-threatening complications.• The treatment strategies range from simple observation to a series of medical, surgical, and radiological interventions.What is New:• This review gives an overview of the developments and current status about the management of IHH.• The aim of this study is to clear up the confusion and controversy that exists about terminology, diagnosis, and treatment of IHH.

Robotic pyeloplasty: Technological global panacea or geo-surgical nightmare?

To the Editor, Pelvi-ureteric junction obstruction (PUJO) is a well-recognised clinical entity characterised by functionally significant impairment of drainage of urine at the level of the pelvi-ureteric junction due to extrinsic or intrinsic obstruction and is encountered both by adult and paediatric urologists alike. Management of PUJO has been surgical historically, and the gold standard has been an open Anderson-Hynes dismembered pyeloplasty [...].

Comparison of outcomes of open, laparoscopic and robot-assisted laparoscopic pyeloplasty in children with ureteropelvic junction obstruction: protocol for a systematic review and meta-analysis.

INTRODUCTION: The treatment of children with pelviureteric junction obstruction (PUJO) has naturally progressed from open, to minimally invasive approaches, including laparoscopic pyeloplasty and robot-assisted laparoscopic pyeloplasty (RALP). The RALP is now considered to be the gold standard for paediatric patients with PUJO, except for smaller infants due to size limitations. Our systematic review aims to synthesise all the available evidence regarding key postoperative outcomes for the three surgical approaches to pyeloplasties in children. Our outcomes of interest include, but are not limited to, the reoperation rate, length of hospital stay and postoperative complications as classified by the Clavien-Dindo grading system. A comprehensive assessment of all three methods in paediatric patients has yet to be conducted in the literature to date. METHODS AND ANALYSIS: A systematic search of the MEDLINE, PubMed, EMBASE and Cochrane databases will be conducted. Screening, data extraction, statistical analysis and reporting will be performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Included papers will be full-text manuscripts written between 1947 and March 2024, comparing the outcomes and complications of open, laparoscopic and RALP. Quality and study bias will be assessed using the Newcastle-Ottawa score and, if relevant, the Cochrane risk of bias tool for randomised trials. This present protocol is written in accordance with the PRISMA Protocol 2015 checklist, ensuring that the highest methodological standards are adhered to. ETHICS AND DISSEMINATION: No ethical approval shall be required, as this is a review of already published literature. Findings will be disseminated through publications in peer-reviewed journals and presentations at international and national conferences. PROSPERO REGISTRATION NUMBER: CRD42023456779.

Reasons for Delayed Diagnosis of Pediatric Acute Appendicitis during the COVID-19 Era: A Narrative Review.

Global pandemics cause health system disruptions. The inadvertent disruption in surgical emergency care during the Coronavirus Disease 2019 (COVID-19) pandemic has been the topic of several published studies. Our aim was to summarize the reasons that led to the delayed diagnosis of pediatric appendicitis during the COVID-19 era. This systematic literature search evaluated studies containing pediatric appendicitis patient data regarding outcomes, times to hospital admission or times from symptom onset to emergency department visit. Studies elucidating reasons for delays in the management of pediatric appendicitis were also reviewed. Ultimately, 42 studies were included. Several reasons for delayed diagnosis are analyzed such as changes to public health measures, fear of exposure to COVID-19, increased use of telemedicine, COVID-19 infection with concurrent acute appendicitis, recurrence of appendicitis after non-operative management and increased time to intraoperative diagnosis. Time to hospital admission in conjunction with patient outcomes was extracted and analyzed as an indicative measure of delayed management. Delayed diagnosis of acute appendicitis has been documented in many studies with various effects on outcomes. Suspicion of pediatric acute appendicitis must always lead to prompt medical examination, regardless of pandemic status. Telemedicine can be valuable if properly applied. Data from this era can guide future health system policies.

Ileal bypass for pruritus relief in a 3-year-old boy with advanced progressive familial intrahepatic cholestasis: how effective is it?

Progressive familial intrahepatic cholestasis (PFIC) is a group of liver disorders that manifest in early childhood with cholestasis and pruritus resulting progressively in liver failure. We present a case of a 3-year-old boy with advanced PFIC from refractory pruritus. In order to offer an effective treatment of pruritus, our patient underwent ileal bypass and after a 2-month period free of symptoms, unexpectedly relapsed after a Rota viral infection. Finally, the child underwent orthotopic liver transplantation. Patients with advanced PFIC do not seem to benefit from nontransplant invasive interventions regarding the relief of pruritus.

The Impact of Obesity on Perioperative Outcomes for Children Undergoing Appendectomy for Acute Appendicitis: A Systematic Review.

Today, the prevalence of obesity in the pediatric population has increased dramatically. Acute appendicitis (AA) is the most common surgical condition among pediatric patients. We aimed to investigate the impact of obesity on postoperative outcomes in terms of operative time (OT), length of stay (LOS), surgical site infection (SSI), overall complications, adverse events, and mortality in children undergoing appendectomy for acute appendicitis. An extensive search of the literature in PubMed and Google Scholar was conducted to evaluate the outcomes of normal weight (NW), overweight (OW), and obese (OB) children who underwent appendectomy. Although no statistically significant differences were noted in perioperative outcomes and overall postoperative complications between OW/OB and NW children in the majority of the included studies, prolonged OT and LOS and SSI were found in some studies. Moreover, no differences in terms of readmissions and ED visits were recorded. We conclude that the impact of obesity on postoperative outcomes for children undergoing appendectomy for AA is unclear, and, therefore, no safe conclusions can be drawn with the currently available data. Due to the lack of high-quality studies, further research is required to optimize the surgical approach and prevent unwarranted complications.

Measuring Children's Stress via Saliva in Surgical and Endoscopic Procedures and Its Measurement Intention in the Community: Reality-Future Prospects.

(1) Background: Children who undergo surgical or endoscopic procedures display high levels of stress, and various means are applied to reduce their anxiety. Salivary cortisol (S Cortisol) and salivary alpha-amylase (SAA) are often used as a valid biomarker of stress. The primary purpose of the study was the investigation of stress levels through S Cortisol and S amylase after intervention in surgical or endoscopic procedures (gastroscopy-colonoscopy). The secondary outcomes were the investigation of the intention to adopt new methods of saliva sampling. We collected saliva samples from children subjected to invasive medical procedures, with the aim of applying the Theory of Planned Behavior (TPB) as an intervention means to provide information and education to both parents and children undergoing stressful situations, and assess its efficacy in reducing stress levels. We also aimed at acquiring a better understanding of the acceptability of noninvasive biomarker collection in community settings. (2) Methods: The sample of this prospective study comprised 81 children who underwent surgical or endoscopic procedures at the Attikon General University Hospital, Athens, Greece and 90 parents. The sample was divided into two groups. The first, 'Group Unexplained', was not provided any information or education about the procedures, while the second, 'Group Explained', was informed and educated based on TPB. Thereafter, 8-10 weeks after intervention, the Theory of Planned Behavior questions were re-completed by the 'Group Explained'. (3) Results: Significant differences were detected in cortisol and amylase values between the two groups postoperatively after applying the TPB intervention. Saliva cortisol was reduced by 8.09 ng/mL in the 'Group Explained' while in the 'Group Unexplained' it was reduced by 4.45 ng/mL (p < 0.001). Salivary amylase values decreased by 9.69 ng/mL in the 'Group Explained' after the intervention phase of the study, while in the 'Group Unexplained' they increased by 35.04 ng/mL (p < 0.001). The regression explains 40.3% (baseline) and 28.5% (follow-up) of parental intention. The predictive factor of parental intention (baseline) is attitude (p < 0.001) and follow-up is behavioral control (p < 0.028) and attitude (p < 0.001). (4) Conclusions: Providing proper education and information for parents has a positive effect on reducing children's stress levels. Changing parental attitudes towards saliva collection plays the most important role, since a positive attitude can influence intention and ultimately participation in these procedures.

Investigating Non-Pharmacological Stress Reduction Interventions in Pediatric Patients Confirmed with Salivary Cortisol Levels: A Systematic Review.

For many children, hospitalization can lead to a state of increased anxiety. Being away from home, the invasive procedures undertaken, and the uncertainty of the outcome cause an uncomfortable situation in anticipation of real or imagined hazards. This systematic review aims to assess current evidence on the types of non-pharmacological interventions used and their impact on children's anxiety or distress levels when they visit the hospital for planned or unplanned admissions. The Databases PubMed, Psych INFO, and Google Scholar were queried for papers published from January 2000 to March 2023 reporting the use of non-pharmacological interventions interacting with children in hospital or clinical environments and confirmed with saliva cortisol levels. A total of nine studies were retrieved. Across these studies, four different strategies of non-pharmacological interventions were used. Anxiety and distress were found to be reduced in the majority of the studies as confirmed with salivary cortisol. Overall, there is evidence that non-pharmacological interventions hold a promising role in reducing levels of anxiety or distress in children as confirmed with saliva cortisol. However, research on saliva cortisol as a tool of anxiety measurement requires higher quality studies to strengthen the evidence base.

Sciatic lateral popliteal block with clonidine alone or clonidine plus 0.2% ropivacaine: effect on the intra-and postoperative analgesia for lower extremity surgery in children: a randomized prospective controlled study.

BACKGROUND: The effect of adding clonidine to local anesthetics for nerve or plexus blocks remains unclear. Most of the studies in adults have demonstrated the positive effects of clonidine on intra- and postoperative analgesia when used as an adjunctive agent or in some cases as a single to regional techniques. In the pediatric population, there are only few trials involving clonidine as an adjunct to regional anesthesia, and the analgesic benefits are not definite in this group of patients. The evidence concerning perineural administration of clonidine is so far inconclusive in children, as different types and volume of local anesthetic agents have been used in these studies. Moreover, the efficacy of regional anesthesia is largely affected by the operator's technique, accuracy and severity of operation. METHODS: The use of clonidine alone or combined with 0.2% ropivacaine for effective analgesia after mild to moderate painful foot surgery was assessed in 66 children, after combined sciatic lateral popliteal block (SLPB) plus femoral block. The patients were randomly assigned into three groups to receive placebo, clonidine, and clonidine plus ropivacaine. Time to first analgesic request in the groups was analyzed by using Kaplan-Meier and the log-rank test (mean time, median time, 95% CI). RESULTS: In our study, clonidine administered alone in the SLPB seems promising, maintaining intraoperatively the hemodynamic parameters SAP, DAP, HR to the lower normal values so that no patient needed nalbuphine under 0.6 MAC sevoflurane anesthesia, and postoperatively without analgesic request for a median time of 6 hours. In addition, clonidine administered as adjuvant enhances ropivacaine's analgesic effect for the first postoperative day in the majority of children (p = 0.001). Clonidine and clonidine plus ropivacaine groups also didn't demonstrate PONV, motor blockade, and moreover, the parents of children expressed their satisfaction with the excellent perioperative management of their children, with satisfaction score 9.74 ± 0.45 and 9.73 ± 0.70 respectively. On the contrary all the patients in the control group required rescue nalbuphine in the recovery room, and postoperatively, along with high incidence of PONV, and the parents of children reported a low satisfaction score (7.50 ± 0.70). CONCLUSIONS: Clonidine appears promising more as an adjuvant in 0.2% ropivacaine and less than alone in the SLPB plus femoral block in children undergoing mild to moderate painful foot surgery, with no side effects. TRIAL REGISTRATION: ClinicalTrials.gov, ISRCTN90832436, (ref: CCT-NAPN-20886).

Severe acute respiratory syndrome coronavirus 2 pandemic related morbidity and mortality in patients with pediatric surgical diseases: A concerning challenge.

The global spread of the novel severe acute respiratory syndrome coronavirus 2 has had serious consequences in terms of patient morbidity and mortality and overburdened health care systems as well as the socioeconomic implications. In the absence of effective therapies and vaccinations during the viral outbreak, the major and most concise means to control viral spread is spread prevention. Although information concerning the impact of severe acute respiratory syndrome coronavirus 2 on pediatric surgical patients has greatly expanded, relevant comprehensive studies are scarce. However, pandemic related morbidity has increased, while under normal circumstances mortality could have been minimized.

Benign anorectal disease in children: What do we know?

Benign anorectal disease refers to a diverse group of frequent anorectal complaints that cause considerable discomfort, disability, and often constitute a significant problem for the child and his or her family. Hemorrhoids, fissures, rectal prolapse, and perianal abscess and fistulas are the most common anorectal disorders in pediatric population and their appearance may be age-specific. Although they generally follow a benign course, a careful examination must be performed in order to exclude other serious and complicated underlying pathology. Their diagnosis is based on the patient's medical history, physical examination, endoscopy, and imaging. Moreover, the management of these disorders includes medical and surgical treatment options, and if they are treated promptly and properly may be limited and short lived. This review presents the currently available data in the literature on the diverse aspects of these disorders, including the definition, epidemiology, clinical presentation, pathogenesis, diagnosis, indications for surgery, and long-term outcomes.