Patches in Congenital Diaphragmatic Hernia: A systematic review.

OBJECTIVE: This systematic review aims to evaluate current choice in practice and outcomes of biomaterials used in patch repair of congenital diaphragmatic hernia (CDH). BACKGROUND: Multiple biomaterials, both novel and combinations of pre-existing materials are employed in patch repair of large size CDH. METHODS: Literature search was performed across Embase, Medline, Scopus, and Web of Science. Publications that explicitly reported patch repair, material used and recurrences following CDH repair were selected. RESULTS: Sixty-three papers were included, presenting data on 4598 patients of which 1811 (39.4%) were managed using 19 types of patches. Goretex® (GTX) (n=1259) was the most frequently employed patch followed by Surgisis® (n=164), Dualmesh® (n=114), Marlex®/GTX® (n=56), Tutoplast dura® (n=40), Dacron® (n=34), Dacron®/GTX® (n=32), Permacol® (n=24), Teflon® (n=24), Surgisis®/GTX® (n=15), Sauvage® Filamentous Fabric (n=13), Marlex® (n=9), Alloderm® (n=8), Silastic® (n=4), Collagen coated Vicryl® mesh (CCVM) (n=1), Mersilene® (n=1), and MatriStem® (n=1) Biomaterials were further subgrouped as: Synthetic non-resorbable (SNOR) (n=1458), Natural-resorbable (NR) (n=249), Combined natural and synthetic non-resorbable (NSNOR) (n=103), and Combined natural and synthetic resorbable (NSR) (n=1). Overall recurrence rate for patch repair was 16.8% (n=305). For patch types with n>20, recurrence rate was lowest in GTX/Marlex (3.6%), followed by Teflon (4.2%), Dacron (5.6%), GTX (13.8%), Permacol (16.0%), Tutoplast Dura (17.5%), Dualmesh (20.2%), SIS/GTX (26.7%), SIS (36.6%), and Dacron/GTX (37.5%).When analysed by biomaterial groups, recurrence was highest in NSR (100%), followed by NR (32.9%), NSNOR (17.5) and SNOR the least (14.0%). CONCLUSION: In this cohort, over one-third of CDH were closed using patches. To date, 19 patch types/variations have been employed for CDH closure. GTX is the most popular, employed in 70% of patients; however excluding smaller cohorts (n<20) GTX/Marlex is associated with the lowest recurrence rate (3.6%). SNOR was the material type least associated with recurrence while NSR experienced recurrence in every instance.

Laparoscopic repair of duodenal atresia: systematic review and meta-analysis after consistent implementation of the technique in the past decade.

BACKGROUND: Laparoscopic repair of duodenal atresia (LRDA) remains a technically challenging procedure and its benefits ambiguous. To assess the safety and efficacy of LRDA, we performed a systematic review of techniques and material for LRDA and a meta-analysis comparing outcomes with open repair (OR). METHODS: Comprehensive search of EMBASSE, PubMed and Cochrane was performed from 2000 to 2023. Studies comparing LRDA with OR were identified and outcomes extracted included operative time, time to enteral feeds, length of hospitalisation, anastomotic leaks and stricture and total complications. χ2 was used to assess associations between complications and conversions rates of different LRDA approaches (laparoscopic technique, suturing technique). Comprehensive meta-analysis was used for Meta-analysis. RESULTS: Twelve studies were identified and 1731 patients were enrolled in the study (398 [LRDA] and 1325 [OR]). Total rate of complications and conversion for LRDA was 15.58% and 18.84%, respectively. Complication rates were not significantly affected by operative technique and suturing technique. Conversion rates were not significantly affected operative technique; using a combination of interrupted and running suturing was significantly higher than using running or interrupted (χ2 = 7.45, p < 0.05). Anastomotic leaks, strictures and total complications were equivocal between LRDA and OR (OR 1.672, 95% CI 0.796-3.514; OR 2.010, 95% CI 0.758-5.333; OR 1.172, 95% CI 0.195-7.03). Operative time was significantly greater for LRDA (SDM 1.035, 95% CI 0.574-1.495, p < 0.001). Time to initial and full enteral feeds and length of hospitalisation were shorter in the LRDA group (SDM - 0.493, 95% CI - 2.166 to 1.752, p = 0.466; SDM - 0.207, 95% CI - 1.807 to 0.822, p = 0.019; SDM - 0.111, 95% CI - 1.101 to 0.880, p = 0.466, respectively). CONCLUSIONS: LRDA showed equivalent complication rates compared to OR with an additional benefit of quicker establishment of feeds. There was no significant difference in complication and conversion rates between laparoscopic techniques. Despite a longer operative time, LRDA provides a safe minimal access approach for neonates after this consistent implementation of the technique in the past decade.

Choice of topical substances in the conservative management of Exomphalos - A systematic review.

AIM: Exomphalos is a congenital anomaly found in 1/4500 newborns. Choice of non-operative management of exomphalos major unamenable to primary repair is controversial. This study aims at reviewing conservative management modalities and compare outcomes and complications. METHODS: A systematic review was performed according to PRISMA guidelines of all English publications in MEDLINE and EMBASE databases. Search words were exomphalos OR omphalocoele AND conservative OR non-operative AND management. Studies were scrutinised for patient demographics, co-morbidities, mode of treatment, time to full feeds, time to full epithelialisation, length of stay, complications and mortality. Studies not specifically describing mode of management and/or describing primary or staged surgical repairs were excluded. RESULTS: Initial search resulted in 1243 studies. Forty-two studies were deemed suitable offering 822 patients for analysis after excluding duplicates and non-eligible studies. Management methods varied including painting with Alcohol, Mercurochrome, silver products, Povidone Iodine, honey and other materials. Mortality was mostly due to associated anomalies. There was mixed reporting of alcohol, silver, Povidone Iodine and mercury toxicity as well as infection during the course of treatment. CONCLUSION: This report has recognised the variations in topical substances employed for conservative management with no clear consensus. Reports on safety of different methods remain unclear.

European expert recommendations on clinical investigation and evaluation of high-risk medical devices for children.

Several high-risk medical devices for children have become unavailable in the European Union (EU), since requirements and costs for device certification increased markedly due to the EU Medical Device Regulation. The EU-funded CORE-MD project held a workshop in January 2023 with experts from various child health specialties, representatives of European paediatric associations, a regulatory authority and the European Commission Directorate General Health and Food Safety. A virtual follow-up meeting took place in March 2023. We developed recommendations for investigation of high-risk medical devices for children building on participants' expertise and results of a scoping review of clinical trials on high-risk medical devices in children. Approaches for evaluating and certifying high-risk medical devices for market introduction are proposed.

Esophagus stretch tests: Biomechanics for tissue engineering and possible implications on the outcome of esophageal atresia repairs performed under excessive tension.

BACKGROUND: Esophageal biomechanical studies are important to understand structural changes resulting from stretches during repair of esophageal atresias as well as to obtain values to compare with the biomechanics of tissue-engineered esophagus in the future. This study aimed to investigate light microscopic changes after uniaxial stretching of the ovine esophagus. METHODS: In vitro uniaxial stretching was performed on esophagi (n = 20) of 1-month-old lambs within 4-6 h post-mortem. Esophagi were divided into 5 groups: control and stretched (1.1, 1.2, 1.3 and 1.4). Force and lengthening were measured with 5 cycles performed on every specimen using a PBS organ bath at 37 °C. Histological studies were performed on the 5 groups. RESULTS: Low forces of ~ 2 N (N) were sufficient for a 1.2-1.25 stretch in the 1st cycle, whereas a three times higher force (~ 6 N) was needed for a stretch of 1.3. In the 2nd to 5th cycle, the tissue weakened and a force of ~ 3 N was sufficient for a stretch of 1.3. Histologically, in the 1.3-1.4 stretch groups, rupture of muscle fibers and capillaries were observed, respectively. Changes in mucosa and collagen fibers could not be observed. CONCLUSIONS: These results offer norm values from the native esophagus to compare with the biomechanics of future tissue-engineered esophagus. Esophageal stretching > 1.3 leads to tears in muscle fibers and to rupture of capillaries. These findings can explain the decrease in microcirculation and scarring in mobilized tissue and possibly offer clues to impaired motility in esophagus atresias repaired under excessive tension.

Postoperative "complications" following laparoscopic-assisted anorectoplasty: A systematic review.

AIM: This study reviewed the literature on the postoperative complications following laparoscopic-assisted anorectoplasty (LAARP). METHODS: A Medline and Embase search was performed for the terms "anorectal malformation" (ARM) "laparoscopic" and "complication". Articles without English full text, review articles, systematic reviews, case reports, case series < 5 cases and duplicate articles were excluded. Two reviewers independently performed the eligibility assessment and data extraction. Data were collected for type of malformation, surgical technique, postoperative complications and functional outcomes RESULTS: The search retrieved 108 articles, of which 38 met the inclusion criteria and offered 1058 patients for analysis. Rectoprostatic and rectobladder neck fistula were the most common types of ARM in males, whereas it was the common cloaca in females. Analysis of complications demonstrated rectal prolapse (n = 149; 14.08%) being the most prominent, followed by urethral diverticulum (n = 32; 3.02%), anal stenosis (n = 37; 3.49%), recurrent fistula (n = 7; 0.66%) and rectal stricture (n = 4; 0.37%). Krickenbeck classification was used for functional assessment in 638 patients, with fecal soiling grade 2 or > 2 in 79. Data on functional outcome specific to the type of malformation was available for 246 patients: fecal soiling grade 2 or > 2 in 15/94 (15.95%) with rectoprostatic fistula, 26/73 (35.61%) with rectobladder neck fistula, 6/47 (12.76%) with common cloaca, and 1/22 (4.54%) with no fistula. CONCLUSION: Rectal prolapse, posterior urethral diverticulum and anal stenosis are the most common complications after LAARP. Inconsistent and non-uniform functional assessment and non-availability of information about the sacrum and spine make it difficult to analyze the functional outcome following LAARP.

Outcomes of laparoscopic incarcerated inguinal hernia repair in children.

AIM: Laparoscopic inguinal hernia repair (LIHR) is gaining widespread acceptance, but its role in the management of incarcerated cases is not well outlined. This review analyses the outcomes of laparoscopic repair of incarcerated inguinal hernia in children. PATIENTS AND METHODS: Literature was searched on PubMed® using terms 'laparoscopic', 'incarcerated', 'inguinal', 'hernia' and 'children'. Age, sex, side, sac content, operative technique, follow-up period, complication and recurrence rate were analysed. RESULTS: Fifteen articles with 689 paediatric incarcerated inguinal hernias were identified between 1998 and 2018. Median age of patients was 22.4 months (2 weeks-16 years; M:F = 2.2:1). Side was mentioned in n = 576: n = 398 (69.1%) right and n = 178 (30.9%) left. In n = 355 (51.5%) manual reduction and delayed surgery (MRDS), in n = 34 (4.9%) manual reduction in general anaesthesia (MRGA) followed by emergency LHR and in n = 300 (43.5%) intraoperative reduction (IOR) was necessary. Incarcerated contents were documented in n = 68: intestine n = 36 (52.9%), ovary n = 14 (20.6%), omentum n = 11 (16.2%), appendix n = 5 (7.4%) and Meckel's diverticulum n = 2 (2.9%). Among the n = 18 girls in IOR group, n = 14 (77.8%) had ovaries incarcerated. For LHR, the hook method was used in 376 (54.6%) and purse-string suture in 313 (45.4%), with two conversions in IOR group. Mean followup was 15 months (3-80 months), with one (0.15%) testicular atrophy, and 4 (0.58%) recurrences in MRDS and 1 (0.15%) in IOR. All five cases were closed with pursestring technique. Total recurrence rate was 0.73%; significantly higher (P = 0.014) with pursestring (n = 5, 1.6%) than with the hook (none). CONCLUSION: Hook and purse-string methods are equally popular in LHR for paediatric incarcerated hernias, with 50% hernia reductions possible at the time of surgery. Recurrence rate is low and comparable with non-incarcerated hernias; however, it is significantly higher in purse-string method than hook technique.

Comparison of esophageal submucosal glands in experimental models for esophagus tissue engineering applications.

OBJECTIVE: Esophagus tissue engineering holds promises to overcome the limitations of the presently employed esophageal replacement procedures. This study investigated 5 animal models for esophageal submucosal glands (ESMG) to identify models appropriate for regenerative medicine applications. Furthermore, this study aimed to measure geometric parameters of ESMG that could be utilized for fabrication of ESMG-specific scaffolds for esophagus tissue engineering applications. METHODS: Ovine, avian, bovine, murine, and porcine esophagus were investigated using Hematoxylin-Eosin (HE), Periodic Acid Schiff (PAS), and Alcian Blue (AB), with AB applied in 3 pH levels (0.2, 1.0, and 2.5) to detect sulphated mucous. Celleye® (version F) was employed to gain parametric data on ESMGs (size, perimeter, distance to lumen, and acini concentration) necessary for scaffold fabrication. RESULTS: Murine, bovine, and ovine esophagus were devoid of ESMG. Avian esophagus demonstrated sulphated acid mucous producing ESMGs with a holocrine secretion pattern, whereas sulphated acid and neutral mucous producing ESMGs with a merocrine secretion pattern were observed in porcine esophagus. Distance of ESMGs to lumen ranged from 127-340 µm (avian) to 916-983 µm (porcine). ESMGs comprised 35% (avian) to 45% (porcine) area of the submucosa. ESMG had an area of 125000 µm2 (avian) to 580000 µm2 (porcine). CONCLUSION: Avian and porcine esophagus possesses ESMGs. However, porcine esophagus correlates with data available on human ESMGs. Geometric and parametric data obtained from ESMG are valuable for the fabrication of ESMG-specific scaffolds for esophagus tissue engineering using the hybrid construct approach.

Is laparoscopic approach for wandering spleen in children an option?

Aim: Wandering spleen present generally as an acute abdomen after twisting of the splenic vascular pedicle. This study aimed to review the literature with regard to the management and outcomes of the laparoscopy in children with wandering spleen. Methods: The literature was reviewed for articles on PubMed with regard to the following search terms 'laparoscopy', 'wandering', 'spleen' and 'children'. The inclusion criteria included article only in the paediatric age group of 0-16. Articles that did not meet the inclusion criteria were excluded from the study. Results: The PubMed search from 1998 to 2016 identified 15 articles. There were 20 children with an age range from 2 to 16 years who underwent the laparoscopic procedure for wandering spleen. The median age was 8 years. Associated conditions were present in 45% of patients: gastric volvulus (n = 3), torsion of the distal pancreas (n = 3), splenic cyst (n = 2), mental retardation and myotonic dystrophy (n = 1). In two cases, the spleen was twisted around the pedicle and was non-viable, and therefore, a splenectomy was performed. Other 18 cases were managed by splenopexy using a 3-5-port technique. An extraperitoneal pocket was created using a balloon device in five patients. Fixation of the spleen was performed using a mesh in 10 cases and omentum in three cases. In one case, additional support was created by plicating the phrenicocolic ligament. Simultaneous gastropexy was performed in four patients. There were no post-operative complications. Conclusions: Wandering spleen is a rare entity and in the paediatric age group 10% cannot be salvaged for which splenectomy is the only option. Of the 90% that can be pexied, the literature has favoured the application of meshes followed by the extraperitoneal pockets and omental pouch. Laparoscopic splenopexy is feasible, with no reported conversions or complications.

Surgical perspectives regarding application of biomaterials for the management of large congenital diaphragmatic hernia defects.

This review focuses on the surgical viewpoints on patch repairs in neonates with large congenital diaphragmatic hernia defects. The main focus  is on the various biomaterials that have been employed to date with regard to their source of origins, degradation properties as well as tissue integration characteristics. Further focus  is on the present knowledge on patch integration when biomaterials are placed in the diaphragmatic defect. The review will also look at the present evidence on the biomechanical characteristics of the most commonly used biomaterials and compares these materials to diaphragmatic tissue to offer more  insight on the present practice of patch repairs in large defects. Since tissue engineering and regenerative medicine has offered another dimension to diaphragmatic replacement, a detailed overview of this technology will be undertaken with regard to cell sourcing, scaffolds, in vitro versus in vivo implants as well as quality of tissue produced, to explore the limitations and the feasibility facing the scientific community in its clinical implementation of skeletal muscle-engineered tissue beyond laboratory research for diaphragmatic replacement.

Analysis of Complications After Button Battery Ingestion in Children.

AIM: Button battery ingestion (BBI) in children may cause severe complications. This analysis is a literature review of complications after pediatric BBI. METHODS: Literature was searched on PubMed (1995-2015) using the terms "button battery," "ingestion," and "children." End points were age, type and diameter of battery, complications, affected organ, and fatality. RESULTS: A total of 31 publications were analyzed. Patients from 4 months to 19 years old were included (n = 136,191, with n = 102,143 or 75% aged <6 y). In 6262, the diameter of the battery was documented. Batteries of 20 mm or greater in size were more prone to complications (n = 226). With regard to the anatomy, BBI caused complications mainly in the esophagus (n = 88, 38.94%). Sixty-one fatal outcomes were reported. CONCLUSIONS: Children younger than 6 years are the most prone to BBI, with lithium batteries of 20 mm or greater in size associated with complications. Complications have been estimated at 0.165%, with lethality of 0.04%. The esophagus is the most affected organ, but vascular involvement is often fatal.

Tissue repair in neonatal and pediatric surgery: analysis on infections in surgically implanted natural biomaterials.

INTRODUCTION: Over the past 4 decades commercially available natural and synthetic biomaterials have been employed for various reconstructive procedures in the pediatric population. The aim of this study was to identify the types of commercially available natural biomaterials and their areas of application in the pediatric age group. Furthermore, to perform an analysis to identify areas of application and types of biomaterials those have increased susceptibility to infections in the pediatric population. EVIDENCE ACQUISITION: The literature was reviewed from 1970-2015 using a Medline search and data concerning application of different natural biomaterials was collected. Specific search was performed regarding to infections associated with these biomaterials. EVIDENCE SYNTHESIS: The rate of major infection after implantation of the biomaterial in the group of 298 reviewed cases was 5%. Patients with acute burn wounds which were treated with biomaterials presented the group with higher infection rates of 5-33%. CONCLUSIONS: The demand for these biomaterials has exponentially increased due to the worldwide rise in interest in tissue engineering research. Even using the appropriate techniques of implantation and professional postoperative care biomaterial associated infections cannot be eliminated. However, the current rate of infections is not a limiting factor for using the biomaterials in pediatric surgery.

Predictors of mortality in neonates with giant omphaloceles.

INTRODUCTION: This analysis performed a review of giant-omphaloceles to determine the predictors of mortality. EVIDENCE ACQUISITION: PubMed and KoBson databases were searched for terms "giant," "omphalocele," and "mortality." Primary end points included mortality correlation with gestational age (GA), birth weight (BW), eviscerated organs, associated anomalies and management. To calculate mean and median values IBM SPSS v. 23.0 was used. EVIDENCE SYNTHESIS: After de-duplication and review search revealed 42 articles of which 23 met the inclusion criteria with 396 giant-omphaloceles for this analysis. Median gestational age (GA) was 36 weeks for all neonates (range 21-41); 21 neonates were reported as premature with median GA 33.5 (range 21-36). Overall median birth weight (BW) was 3100 g (range 1100-4100 g). The diameter of abdominal wall defect was 4-15 cm with the average size of 7.6 cm except for non-giant giant omphaloceles (N.=7) where the defect was measuring between 2.7 and 4 cm. Amniotic sac contents beside intestines included liver (N.=154), stomach (N.=11), spleen (N.=2), pancreas (N.=1), gallbladder (N.=5), and 5 giant omphaloceles were reported to contain only liver; sac was ruptured in 22. Giant omphaloceles were associated with a variety of other anomalies, most often with cardiac anomalies (N.=93; 23.4%) and pulmonary hypoplasia and/or pulmonary hypertension (N.=39; 9.8%). Management included conservative treatment N.=264 (66.6%), primary closure (N.=17; 4.3%), staged closures (N.=98; 24.7%) primary or staged closure (N.=17; 4.3%). The most frequent complication was sepsis (N.=52). There were 90 (22.7%) lethal outcomes, 6 lethal outcomes in neonates even before final closure could be achieved and 12 in prematures. Leading cause of mortality was sepsis (N.=51; 56.6%), the cause of lethal outcome was not reported in 8 cases. CONCLUSIONS: Giant-omphaloceles have a lethal outcome in one-fifth of neonates. Predictors of mortality included pulmonary hypoplasia and respiratory failure with prematurity and ruptured sacs implicated within this group. Sepsis was the independent iatrogenic factor in mortality.

Activated Notch signaling cascade is correlated with stem cell differentiation toward absorptive progenitors after massive small bowel resection in a rat.

Notch signaling is thought to act to drive cell versification in the lining of the small intestine. The purpose of the present study was to evaluate the role of the Notch signaling pathway in stem cell differentiation in the late stages of intestinal adaptation after massive small bowel resection in a rat. Male Sprague-Dawley rats were randomly assigned to one of two experimental groups of eight rats each: Sham rats underwent bowel transection and reanastomosis, while SBS rats underwent 75% small bowel resection. Rats were euthanized on day 14 Illumina's Digital Gene Expression (DGE) analysis was used to determine Notch signaling gene expression profiling. Notch-related gene and protein expression was determined using real-time PCR, Western blot analysis, and immunohistochemistry. From seven investigated Notch-related (by DGE analysis) genes, six genes were upregulated in SBS vs. control animals with a relative change in gene expression level of 20% or more. A significant upregulation of Notch signaling-related genes in resected animals was accompanied by a significant increase in Notch-1 protein levels (Western blot analysis) and a significant increase in the number of Notch1 and Hes1 (target gene)-positive cells (immunohistochemistry) compared with sham animals. Evaluation of cell differentiation has shown a strong increase in total number of absorptive cells (unchanged secretory cells) compared with control rats. In conclusion, 2 wk after bowel resection in rats, stimulated Notch signaling directs the crypt cell population toward absorptive progenitors.NEW & NOTEWORTHY This study provides novel insight into the mechanisms of cell proliferation following massive small bowel resection. We show that 2 wk after bowel resection in rats, enhanced stem cell activity was associated with stimulated Notch signaling pathway. We demonstrate that activated Notch signaling cascade directs the crypt cell population toward absorptive progenitors.

Histopathological and Immunohistochemical Findings in Congenital Pouch Colon: A Prospective Study.

BACKGROUND: There is a paucity of literature on the histopathological aspects of congenital pouch colon (CPC) and immunohistochemical (IHC) assessment has not been reported. So we planned to study the histopathological and IHC findings within the spectrum of CPC and compare the findings with the normal colon. METHODS: This is a descriptive prospective study on CPC patients. There were 49 cases of CPC (42 males and 7 females) and 13 controls. Histological examination was done using hematoxylin and eosin and Masson trichrome stain. IHC analysis was done with actin, myosin, and desmin antibodies, and neuron-specific enolase and S100 markers for counting ganglionic cells. RESULTS: Histologically, congestion, edema and hemorrhage were seen in mucosa, submucosa, and serosa. Muscle layers were disrupted and divided into bands. An additional muscle coat inside of the muscularis propria was seen in CPC types 1 and 2. Mature ganglionic cells were reduced and muscle layers showed reduced and patchy positivity for smooth muscle actin, myosin, and desmin compared to a normal colon. CONCLUSIONS: Histopathological and IHC findings suggest that CPC has distinct defects in the neuromusculature.

Minimally invasive resection of adrenal masses in infants and children: results of a European multi-center survey.

BACKGROUND: Minimal access adrenal surgery (MAAS) for adrenal pathologies is the standard for many pediatric surgical centers. However, the literature offers few reports and minimal evidence from small case series. The aim of this study was to evaluate the outcomes of pediatric MAAS through a multi-center data analysis. METHOD: Pediatric patients who underwent MAAS between January 2002 and December 2013 were retrospectively included. Data analysis was conducted using Spss software (Welch's t-test, X-square, Fisher tests, multiple regression model). RESULTS: Six European centers participated, 68 patients were included with mean age of 5.2 years (2 months-16 years). Lesion volume was of 18.1 cc (0.78-145.6), with a mean diameter of 2.8 cm (1.1-6.5). Localization was 50% left-sided masses, 45.6% right-side masses, and 4.4% bilateral. Histological examination revealed 36 neuroblastomas, 15 adenomas, nine pheochromocytomas, three ganglioneuromas, two ganglioneuroblastomas, one bilateral hyperplasia, one adrenocortical carcinoma, an alveolar sarcoma, and a calcification. Surgical access was transperitoneal in 63 (92.6%) and retroperitoneal in 5 (7.4%). Mean operative time was 170 ± 87 min (285 ± 30 min for bilateral lesions). Mean hospital stay was 4.2 ± 2.5 days. Complications included blood loss requiring transfusion in five patients (7.4%) and a diaphragmatic tear. Infiltration of surrounding structures correlated with intraoperative complication rate (p = 0.027) and operative time (p < 0.01). No mass rupture, conversion, or post-operative complications were observed. Median follow-up was 52 months (1-161). Two recurrences occurred in patients with pheochromocytoma. Age, weight, symptoms, characteristics at imaging, chemistry, volume, or histology, did not influence operative time, hospital stays, or complication rate. CONCLUSIONS: Pediatric MAAS was safe adopted for masses up to 145.6 cc, with a very low rate of complication. Conversion to open is not necessary even in the presence of infiltrations. MAAS should represent the first-line treatment for selected cases in centers experienced in laparoscopy.

Laparoscopic Repair of Duodenal Atresia: Systematic Review and Meta-Analysis.

PURPOSE: To investigate the outcome of laparoscopic repair of duodenal atresia (LRDA) in relation to different approaches with regard to suture material and anastomosis technique. To identify evidence for the safety and efficacy of LRDA compared with the conventional open repair. METHODS: Systematic search was performed for all studies on LRDA, excluding case reports, and all comparative studies between LRDA and open repair. Chi-square was used to assess associations between complications or conversions rates and different LRDA approaches (suture material, suturing technique). Meta-analysis was employed to compare LRDA and open repair. RESULTS: The complications and conversions rates of LRDA were not affected by the different suture materials (Silk, Vicryl, PDS; p = 0.51) or suturing technique (interrupted, continuous; p = 0.46). The meta-analysis did not show significant differences between LRDA and open repair in overall complications rate (p = 0.88), time to feeds (p = 0.12) and hospitalization time (p = 0.28), although it revealed longer operative time with LRDA (p < 0.0001). CONCLUSIONS: LRDA shows comparable safety and efficacy with the open repair, although it is associated with significantly longer operative time. There is no evidence that the type of the suture material or anastomotic technique affects the outcome of LRDA.

Proton pump inhibitors for reflux therapy in infants: effectiveness determined by impedance pH monitoring.

PURPOSE: To evaluate the influence of proton pump inhibitors (PPI) in predominantly milk-fed infants with symptoms of GERD by 24-h pH-multichannel intraluminal impedance (24-h pH-MII). METHODS: Ten infants (8 males and 2 females) with a mean gestational age of 39 weeks (28-40) were included. 24-h pH-MII was performed before prescription and during intake of PPI. Total acid exposure time, bolus exposure time (acidic/non-acidic/total) and the number of refluxes (acidic/non-acidic/total) were determined. Clinical symptoms were recorded and used to calculate the Reflux Symptom Index (RSI) and the Symptom Severity Index (SSI). RESULTS: There was a significant decrease in the number of acidic refluxes, total acid exposure and acidic bolus exposure time. However, this went along with a significant increase in non-acidic bolus exposure time. The total number of refluxes and the total bolus exposure time remained unchanged. Under PPI, a decrease of SSI and RSI for pain-related symptoms could be observed. For respiratory symptoms and vomiting however no significant changes could be demonstrated. CONCLUSIONS: Under PPI, an improvement of pain-related symptoms could be shown. The decrease of acid exposure went along with an increase of non-acidic refluxes resulting in almost constant total reflux numbers. This finding is interpreted as main reason for some persisting symptoms despite adequate PPI dosage. Concluding from our data PPI therapy should only be indicated in case of pain, but has no effect in case of vomiting or recurrent respiratory symptoms.

Surgical management of pediatric multiple magnet ingestions in the past two decades of minimal access surgery- systematic review of operative approaches.

BACKGROUND: Multiple magnet ingestion is increasingly reported in paediatrics and can cause significant morbidity. Various surgical approaches exist, though minimal literature compares outcomes between techniques. This review evaluates laparoscopic, laparoscopic-assisted, and open surgery with regard to outcomes. METHOD: Systematic review across MEDLINE, Embase, Scopus, and Web of Science identified reports of paediatric multiple magnet ingestion managed surgically between 2002 and 2022. RESULTS: Ninety-nine studies were included, reporting data from 136 cases. Of these, 82 (60%) underwent laparotomy, 43 (32%) laparoscopic surgery, and 11 (8%) laparoscopic-assisted procedures. Sixteen laparoscopic cases were converted to open, often due to intraoperative findings including necrosis/perforation, or grossly dilated bowel. Bowel perforation occurred in 108 (79%); 47 (35%) required bowel resection, and 3 had temporary stoma formation. Postoperative recovery was uneventful in 118 (86%). Complications were reported following 15 (18%) open and 3 (7%) laparoscopic surgeries. No complications occurred following laparoscopic-assisted surgery. All post-laparoscopic complications were Clavien-Dindo (CD) Grade I. Following open surgery, 5 complications were CD grade I, 6 were CD grade II, and 4 were CD grade IIIb, requiring re-laparotomy. Median length of stay for open and laparoscopic-assisted procedures was 7 days, and for laparoscopic was 5 days (p < 0.001). CONCLUSION: Surgical management of multiple magnet ingestion often achieved uncomplicated recovery and no long-term sequelae. Whilst open laparotomy was the more common approach, laparoscopic surgery was associated with reduced length of stay and postoperative complications. Therefore, in experienced hands, laparoscopic surgery should be considered first-line, with the possibility of conversion to open if required.