Postoperative ileus after digestive surgery: Network meta-analysis of pharmacological intervention.

AIMS: Several medicinal treatments for avoiding postoperative ileus (POI) after abdominal surgery have been evaluated in randomized controlled trials (RCTs). This network meta-analysis aimed to explore the relative effectiveness of these different treatments on ileus outcome measures. METHODS: A systematic literature review was performed to identify RCTs comparing treatments for POI following abdominal surgery. A Bayesian network meta-analysis was performed. Direct and indirect comparisons of all regimens were simultaneously compared using random-effects network meta-analysis. RESULTS: A total of 38 RCTs were included in this network meta-analysis reporting on 6371 patients. Our network meta-analysis shows that prokinetics significantly reduce the duration of first gas (mean difference [MD] = 16 h; credible interval -30, -3.1; surface under the cumulative ranking curve [SUCRA] 0.418), duration of first bowel movements (MD = 25 h; credible interval -39, -11; SUCRA 0.25) and duration of postoperative hospitalization (MD -1.9 h; credible interval -3.8, -0.040; SUCRA 0.34). Opioid antagonists are the only treatment that significantly improve the duration of food recovery (MD -19 h; credible interval -26, -14; SUCRA 0.163). CONCLUSION: Based on our meta-analysis, the 2 most consistent pharmacological treatments able to effectively reduce POI after abdominal surgery are prokinetics and opioid antagonists. The absence of clear superiority of 1 treatment over another highlights the limits of the pharmacological principles available.

Postoperative surgical complications after pediatric kidney transplantation in low weight recipients (<15 kg): a systematic review.

PURPOSE OF REVIEW: Kidney transplantation in low-weight recipients (<15 kg) is a challenging surgery with special characteristics. We proposed to perform a systematic review to determine the postoperative complication rate and the type of complications after kidney transplantation in low-weight recipients (<15 kg). The secondary objectives were to determine graft survival, functional outcomes, and patient survival after kidney transplantation in low-weight recipients. METHODS: A systematic review was performed according to preferred reporting items for systematic reviews and meta-analyses. Medline and Embase databases were searched to identify all studies reporting outcomes on kidney transplantation in low-weight recipients (<15 kg). RESULTS: A total of 1254 patients in 23 studies were included. The median postoperative complications rate was 20.0%, while 87.5% of those were major complications (Clavien ≥3). Further, urological and vascular complications rates were 6.3% (2.0-11.9) and 5.0% (3.0-10.0), whereas the rate of venous thrombosis ranged from 0 to 5.6%. Median 10-year graft and patient survival were 76 and 91.0%. SUMMARY: Kidney transplantation in low-weight recipients is a challenging procedure complicated by a high rate of morbidity. Finally, pediatric kidney transplantation should be performed in centers with expertise and multidisciplinary pediatric teams.

Boot camp approach to surgical residency preparation: feedback from a French university hospital.

INTRODUCTION: The transition from medical student to surgical resident is not a simple one. The aim of this study was to report the experience of a university hospital in the organization of the induction course for future surgical residents and the contribution of a video support in the learning of the suture. MATERIAL AND METHOD: We were able to study two consecutive years of students (October 2020 and 2021). Concerning the practical and technical workshops (learning suture) we carried out a comparative study between two groups of students. A group that had video support for learning suture (video group) and a group without video (control group). The evaluation of the suture was performed in a blinded manner by two supervising surgeons. The other practical workshop was drain fixation; the students did not have a video for this workshop. A comparative study was also performed for the drain fixation workshop between the two groups (video group and control group). A program of theoretical courses was also set up. This program is established according to the different future functions of the residents by integrating medico-legal notions and teamwork. Satisfaction questionnaires were given to the students and the answers were given two months after taking up their duties in the hospital (6 questions with Likert scale and 4 free questions). RESULTS: The cohort consisted of 58 students (29 each in 2020 and 29 in 2021). Comparative analyses of the evaluation of the suture workshops showed better performance in the video group compared with the group without video. The comparison of these two groups did not show significant differences in the drain fixation workshop. The theoretical teaching was broken down according to the students' future tasks and each speaker was a specialist in his or her field of expertise. The results of the questionnaires showed a desire on the part of the students to increase the time spent on practical workshops and theoretical forensic teaching. CONCLUSION: We were able to show through these two years of a program that we were able to offer a surgical resident preparation course. In addition, we have highlighted the contribution of a video support in the learning curve of the suture.

Pancreatic fracture: a rare complication following scoliosis surgery.

STUDY DESIGN: Grand Round case report. OBJECTIVE: We report a pancreatic fracture associated with Wirsung duct disruption, following a scoliosis surgery in a cerebral palsy adolescent. Spinal fusion surgery is the standard treatment for severe neuromuscular scoliosis. Many complications such as digestive ones account for its complexity. Postoperative acute pancreatitis is well described, although its pathophysiology remains unclear. To our knowledge, pancreatic fracture following scoliosis correction has never been described to date. Clinical presentation is not specific, and management is not consensual. CASE REPORT: A 14-year-old adolescent had posterior spinal fusion for neuromuscular scoliosis due to cerebral palsy. During the postoperative course, she developed progressive nonspecific abdominal symptoms. The abdominal CT scan demonstrated a pancreatic fracture and a surgical exploration was decided as perforations of the bowel were highly suspected. Drains were placed around the pancreatic area as the retrogastric region was out of reach due to local inflammation. Conservative management led to the occurrence of a pseudocyst in the following weeks as the pancreatic leakage progressively dropped. DISCUSSION: Two hypotheses have been proposed: direct iatrogenic trauma from lumbar pedicle screws and pancreatic rupture related to the correction of the spinal deformity. As the latter seems the most likely, spinal surgeons should be aware of this occurrence following severe scoliosis correction. CONCLUSION: Spinal fusion for severe neuromuscular scoliosis is a difficult procedure, with a high rate of complications. Among them, pancreatic fracture should be considered when abdominal pain persists in the postoperative period. Conservative management is advocated especially in case of a poor general condition.

Wilms tumor, pleuropulmonary blastoma, and DICER1: case report and literature review.

BACKGROUND: Pleuroblastoma (PPB) is a rare pediatric tumor which, in 30% of cases, is associated with cystic nephroma. It has been recently linked to the DICER1 mutation as part of a predisposition syndrome for various tumors. However, if DICER 1 anomalies have been reported in patients with Wilms tumor (WT), to date, no cases of PPB, WT, and DICER1 mutations have been reported in the same patient. CASE PRESENTATION: We report the case of a 3-year-old patient, initially managed for metastatic WT. During his clinical course, the diagnosis of a PPB was made after detecting the DICER1 mutation and subsequent management was therefore modified. CONCLUSION: This case highlights that in case of simultaneous discovery of a renal tumor and a pulmonary lesion in a child, the DICER 1 mutations should be looked for as these could help adapt management and schedule the surgical procedures.

Comparison between pediatric and adult adipose mesenchymal stromal cells.

BACKGROUND: Adipose-derived mesenchymalstromal cells (ASC) are currently tested in regenerative medicine to promote tissue reconstruction after injury. Regardingautologous purpose, the possible loss of therapeutic function and cell properties during aging have been questioned in adults. To date no reliable information is available concerning ASC from pediatric patients and a better knowledge is required for clinical applications. METHODS: Subcutaneous adipose tissue was collected from 27 donors (0-1 years old) and 50 donors (1-12 years old) and compared with adult ASC for in vitro characteristics. ASC were then tested in a mouse model of limb ischemia. RESULTS: Cells from the stromal vascular fraction (SVF) and subsequent cultured ASC were prepared. Only a greater amount in SVF cell number and ASC proliferative rate were found. Cell phenotype, colony formingunit-fibroblast (CFU-F) content, immunomodulation effect and adipogenic, osteoblastic and angiogenic potentials were not significantly different. In vivo, pediatric ASC induced an increase in microangiographic score in a mouse model of limb ischemia, even though improvement in vascular density was not significantly correlated to limb rescue. Finally messengerRNA (mRNA) analysis using a microarray approach identified that only 305 genes were differentially expressed (217 down- and 88 up-regulated) in pediatric versus adult ASC, confirming that ASC from both age groups shared very close intrinsic properties. CONCLUSION: This is the first study reporting a comparative analysis of ASC from a large number of donors and showing that their in vitro and in vivo properties were similar and maintained during aging.

Non-contrast-enhanced MR angiography using time-spin labelling inversion pulse technique for detecting crossing renal vessels in children with symptomatic ureteropelvic junction obstruction: comparison with surgical findings.

OBJECTIVES: Investigate the feasibility and evaluate the accuracy of non-contrast-enhanced MR angiography (NC-MRA) using time-spin labelling inversion pulse (time-SLIP)to identify crossing renal vessels (CRVs) in children requiring surgical treatment of ureteropelvic junction (UPJ) obstructionand compare to laparoscopic findings. MATERIALS AND METHODS: Nineteen children ranging from 6 to 16 years of age underwent NC-MRA using the time-SLIP technique before surgery. Two independent readers analysed the MRA images. Number of renal arteries and presence or absence of CRVs were identified and compared with surgicalfindings. Image quality was assessed, as well as the presence of CRVs and measurement of renal pelvis diameter. Intra and inter-reader agreement was calculated using Cohen's kappa coefficient and Bland-Altman plots. RESULTS: The overall image quality was fair or good in 88% of cases. NC-MRA demonstrated CRVs at the level of the obstruction in 10 children and no CRV in 9 children. All were confirmed intra-operatively except in one of the nine children. Sensitivity, specificity, NPV, PPV for predicting CRVs were 92%, 100%, 100% and 87.5%, respectively, for both readers. CONCLUSION: NC-MRA is a good alternative to contrast-enhanced MRA and CT scanning for identifying CRVs in children with symptomatic UPJ. KEY POINTS: • Time-SLIP technique offers acceptable imaging quality for identifying crossing renal vessel. • Time-SLIP technique is easy to apply to the renal MRA examination. • Time-SLIP technique is an alternative to contrast-enhanced MRA and CT scanning.

Prenatal diagnosis of right-sided diaphragmatic hernia and ipsilateral intrathoracic kidney in a female fetus: a rare observation.

Congenital diaphragmatic hernia is a rare congenital malformation, as well as kidney ectopia. Among kidney ectopias, the intrathoracic one is the rarest. Those malformations concern more frequently boys, and affected more the left than the right side. Their association is poorly reported in the literature. We report the rare case of an early sonographic prenatal diagnosis of intrathoracic kidney at 22 weeks of gestation in a female fetus, completed on the follow-up by the diagnosis of an associated diaphragmatic hernia at 33 weeks of gestation. If chest mass is diagnosed prenatally or in neonate, ITK should be considered in a differential diagnosis, all the more if the ipsilateral renal fossa is empty. An associated DH should be searched if ITK is confirmed. Isolated ITK usually requires no specific treatment, in contrast with ITK associated with DH.

Bilateral anterior sternothoracotomy (clamshell incision): a suitable alternative for bilateral lung sarcoma metastasis in children.

BACKGROUND: The aim of our study was to assess the postoperative course of bilateral anterior sternothoracotomy (BAT) in children with sarcoma metastases, in a curative care perspective. METHODS: We reviewed the records of seven patients younger than 18 years old, who underwent surgical procedures for sarcoma metastasis to the lung between 2000 and 2012. We compared the postoperative course of the BAT group with that of patients who underwent unilateral posterolateral thoracotomies (PLTs) for the same etiology. RESULTS: Of 17 surgical procedures, there were seven BAT and 10 unilateral PLT. Mean ages at the time of the procedures were 12.9 ± 5.4 years old for BAT, and 17.4 ± 1.9 years old for PLT. Mean operative time was 173 ± 37 minutes in the BAT group, and 145 ± 39 minutes in the PLT group (P = 0.19). Patients received epidural analgesia in all cases; this was for a mean time of 3.8 ± 1.3 days in the BAT group, and 3.21 ± 4 days in the PLT group (P = 0.36). Chest tubes were removed after 3.6 ± 1.3 days in the BAT group, and 3 ± 1.2 days in the PLT group (P = 0.69). Total hospital stay was 7.7 ± 6.6 days in the BAT group, and 7 ± 1.2 days in the PLT group (P = 0.72). CONCLUSION: In our experience, BAT seems suitable and shows outcomes similar to those of PLT for sarcoma metastasis resection. The BAT procedure allows the manual exploration of both lungs during a single surgical intervention, and so reduces the delay of further therapies.

Necrotizing pneumonia in children: Report of 25 cases between 2008 and 2018 at a French tertiary care center.

BACKGROUND: Necrotizing pneumonia (NP) is a serious and rare disease in children. Pediatric data on NP are limited and the impact of the 13-valent pneumococcal conjugate vaccine has been very poorly evaluated. PATIENTS AND METHODS: We conducted a retrospective study at Toulouse University Hospital between 2008 and 2018. Children who presented with thin-walled cavities in the areas of parenchymal consolidation on imaging were included in the study. RESULTS: The incidence of NP did not decrease during this period. Bacterial identification occurred in 56% of cases (14/25) and included six cases of Streptococcus pneumoniae, five of Staphylococcus aureus, two of Streptococcus pyogenes, and one of Streptococcus viridans. Streptococcus pneumoniae NP are more frequently associated with empyema/parapneumonic effusion compared to S. aureus NP (p = 0.02). Patients with S. pyogenes NP more often required volume expansion than did S. pneumoniae cases (p = 0.03). When comparing children born before and after implementation of the 13-valent pneumococcal conjugate vaccine, we identified a relative modification of the bacterial epidemiology, with an increase in the proportion of S. pyogenes NP and S. aureus NP and a decrease in the proportion of NP caused by S. pneumoniae. CONCLUSION: Future studies are needed to assess the epidemiology of NP in children. Continued surveillance of identified pneumococcal serotypes is essential to document epidemiological changes in the coming years.

Osteosarcoma metastasis causing ileo-ileal intussusception.

Osteosarcoma metastasis causing intussusception is a very rare entity, with a pejorative prognosis. Based on a case, we performed a literature review in order to better assess this situation. We conclude that, in patients with a history of osteosarcoma lung metastasis, echographic and/or computed tomography scan evidence of a small bowel obstruction with intussusception should lead to an open surgical procedure if the laparoscopic approach does not allow to accurately explore and resect the lesion, in order to prevent misdiagnosis and to avoid further delay in the management.

Non-operative treatment of acute appendicitis in children: clinical efficacy of amoxicillin-clavulanic acid in a retrospective single-centre study.

BACKGROUND: The success rate of non-operative treatment (NOT) of acute uncomplicated appendicitis (AUA) in children varies from 65% to 95%. There are no recommendations on the appropriate antibiotic therapy. OBJECTIVE: To determine the clinical efficacy of amoxicillin-clavulanic acid for NOT of AUA in children. METHODS: Design: Cross-sectional study in a single medical centre. SETTINGS: Emergency department and Paediatric Visceral Surgery department of the Children Hospital in Toulouse, France. PATIENTS: Patients 5-15 years old who were diagnosed with appendicitis, (1) With abdominal pain and a first episode of acute appendicitis, (2) With no radiological or ultrasound evidence of appendicolith, appendiceal perforation, pelvic abscess nor peritonitis, and (3) With non-septic general aspect, were included. INTERVENTIONS: NOT consisted of hospital admission. The antibiotic treatment was a combination of amoxicillin and clavulanic acid (80 mg/kg/day of amoxicillin): intravenous regimen during 48 hours followed by oral route during 7 days. MAIN OUTCOME MEASURE: Success rate of amoxicillin-clavulanic acid NOT in children with AUA at 2 years. RESULTS: The initial success rate of amoxicillin-clavulanic acid NOT in children with AUA was 100% (104/104 patients). The success rate at 2 years was 85.6% (89/104) at discharge. None of the 15 patients who underwent surgery after recurrence of appendicitis presented with peritonitis, appendiceal perforation nor pelvic abscess. CONCLUSION: Narrowed antibiotic therapy with amoxicillin and clavulanic acid seems to be an alternative to surgery in children with AUA. It is necessary to wait for the results of ongoing studies to confirm these results.

Robotic pyeloplasty learning curve for a pediatric surgeon without previous laparoscopic pyeloplasty experience.

Robotic pyeloplasty has become a technique of choice for pyelo-ureteral junction syndrome treatment in children. Less invasive than open surgery, robotic pyeloplasty also has a lower learning curve than laparoscopic pyeloplasty. This is how a new generation of surgeons without previous laparoscopic pyeloplasty experience has begun training in robotics. To assess the robotic assisted pyeloplasty learning curve for a pediatric surgeon only trained in open pyeloplasty, and to investigate if that mode of practice is safe and effective. Data were collected from all children operated on for pyelo-ureteral junction syndrome by the same surgeon in our center between 2015 and 2021. Cases were divided into 4 groups of 14 consecutive procedures to analyze the learning curve. Fifty-six patients were operated on, with a median (IQR) age, weight, and hospital stay of 9 years and 1 month old (3.5), 29 kg (17.3), and 3 days (2), respectively. The mean ± SD operative times were 146.5 ± 39.3, 123.2 ± 48.1, 103.1 ± 29.5, and 141.7 ± 25.0 min, with a unique significant difference between groups 1 and 3 (p = 0.007**). Only two intraoperative and nine postoperative complications were observed. The surgery was successful in 98% cases. Our study shows that a significant improvement in surgical time could be achieved in the first 30 cases, safely and efficiently even without previous laparoscopic pyeloplasty experience.Level of evidence: III.

Pediatric Mini-Invasive Splenectomy Comparing Laparoscopy With or Without Robotic Approach: A Single-Center Study.

Background: The introduction of splenectomy in pediatric robotic surgery programs remains controversial. The aim of this study is to evaluate the feasibility and safety of robotic assisted splenectomy (RAS) in children and compare its outcomes with the laparoscopic splenectomy (LAS). Method: A single institution retrospective study was performed (2011-2020). We used the minimally invasive splenectomy score described by Giza et al. to measure the level of technical difficulty. The data collected for each procedure included its duration, the need for blood transfusion, complications, analgesic use, and the length of hospital stay. A standard univariate analysis is applied. Results: We recorded 41 cases (26 LAS and 15 RAS). The mean age was 11 years [7.00; 13.5]. The operating time was 97 minutes [85.5-108] for LAS and 223 minutes [190-280] for RAS (P < .001). The length of stay was 6.50 days [5.00-8.00] for LAS and 5 days [5.00-5.50] for RAS (P = .055). The cumulative use of level III analgesic was not statically different (P = .29). Two cases of difficult splenectomy were found in each group with comparable performances. In the RAS, we demonstrated the improved outcomes with the progression of the learning curve of a single surgeon. Conclusions: In our experience (as in the literature), RAS remains safe, but offers no additional advantage compared to laparoscopy as the cost and the operating time are higher. Our study has the advantages of having a 9 years long evolving experience, including broad indications in comparison to other pediatric studies.

Successful Elective Thoracoscopic Resection of Complicate Extralobar Bronchopulmonary Sequestration after Intrafoetal Vascular Laser Ablation: The Paediatric Surgeon's Point of View.

Few reports of laser coagulation for foetal bronchopulmonary sequestration (BPS), a rare congenital malformation characterised by the absence of tracheobronchial connection and the presence of a systemic feeding artery, have been published. Additionally, very few of them focus also on the postnatal management, with results limited and controversial. Postnatal treatment of residual malformation remains debated, hence the need to share our experience of a combined pre- and postnatal approach to complicated extra-lobar BPS. We report the case of a female foetus with the diagnosis of a pulmonary lesion. Due to mediastinal shift, unilateral compressive hydrothorax, ascites, and hydrops, a foetal treatment with ultrasound-guided laser coagulation of the anomalous vessel was performed. At birth, due to the persistence of the malformation, an elective delayed thoracoscopical surgery was performed. Prenatal laser ablation for complicated BPS is a life-saving procedure not always resulting in lesion disappearance. Thoracoscopical surgical exploration in case of persistent lesions at birth offers the possibility of a minimally invasive sequestrectomy feasible and safe.

Prenatal diagnosis of an adrenal mature teratoma mimicking a neuroblastoma.

Teratomas are defined by the presence of cell types from different germ layers, they typically involve the gonads or the sacrococcygeal region and are rarely retroperitoneal. Prenatally detected adrenal teratomas are extremely uncommon. Aim of this paper is to share our experience with an adrenal antenatal mass initially diagnosed as a left adrenal neuroblastoma that turned out to be a mature teratoma after microscopical examination. We present the case of a male fetus with antenatal diagnosis of a left adrenal cystic image at the 22nd week of amenorrhea. The fetal magnetic resonance imaging showed a non-calcified cystic mass of the left adrenal gland, compatible with a neuroblastoma. At birth an ultrasound confirmed the presence of an anechogenic lesion of the left adrenal gland. The infant was closely monitored during his first year and in the absence of significant regression of the adrenal mass, it was decided to perform a laparoscopic left adrenalectomy. Unexpectedly, the final pathological diagnosis was mature cystic adrenal teratoma. In conclusion, an adrenal mass diagnosed antenatally is generally a hemorrhage or a neuroblastoma. Adrenal teratomas are very rare and those diagnosed antenatally even more. At present, we have no clinical, biological, or radiological evidence to suspect them before surgical removal. There are only two other cases of unexpected adrenal teratoma in infants described in Literature.

Robotic approach to the uretero-vesical junction in children: An international multicentric retrospective study.

BACKGROUND: Robot-assisted approach to UVJ is getting more and more used in pediatric patients. METHODS: In this retrospective study 26 patients affected by nephro-urological malformations, robotic-surgically treated from 2016 and 2021 at 3 Pediatric Surgery Department were included: 3 (11.5%) primary obstructive megaureter, 2 (7.7%) dysplastic kidneys, 3 (11.5%) duplex collecting system, 18 (69.2%) primary vescico-ureteral reflux (VUR). RESULTS: Mean age at surgery was 6 years old. 22 (84.6%) underwent Lich Gregoire extravesical ureteral reimplantation, 4 (15.4%) total nephroureterectomy. Mean operative time was 230 min. No conversions or intraoperative complications. Median hospital stay was 4 days. There were 4 (15.38%) postoperative complications: 3 (11.54%) persistent VUR and 1 (3.84%) refluxing megaureter. 2 (7.7%) redo-surgery. CONCLUSIONS: Robotic Surgery should be considered a safe and effective technique for treatment of UVJ anomalies in children, because it firstly allows surgeons to approach both upper and lower ureteral ends without modifying trocars' placement.

Thoracoscopy for Pediatric Thoracic Neurogenic Tumors-A European Multi-Center Study.

OBJECTIVES: To assess the efficacy of thoracoscopy and the outcome for children with thoracic neurogenic tumors. METHODS: We performed a retrospective review of 15 European centers between 2000 and 2020 with patients who underwent thoracoscopy for a neurogenic mediastinal tumor. We assessed preoperative data, complications, and outcomes. Results were expressed with the median and range values. RESULTS: We identified 119 patients with a median age of 4 years old (3 months-17 years). The diameter was 5.7 cm (1.1-15). INRG stage was L1 n = 46, L2 n = 56, MS n = 5, M n = 12. Of 69 patients with image-defined risk factors (IDRF), 29 had only (T9-T12) locations. Twenty-three out of 34 patients with preoperative chemotherapy had an 18 mm (7-24) decrease in diameter. Seven out of 31 patients lost their IDRF after chemotherapy. Fourteen had a conversion to thoracotomy. The length of the hospital stay was 4 days (0-46). The main complications included chylothorax (n = 7) and pneumothorax (n = 5). Long-term complications included Horner's syndrome (n = 5), back pain, and scoliosis (n = 5). Pathology was 53 neuroblastomas, 36 ganglioneuromas, and 30 ganglioneuroblastomas. Fourteen had a postoperative residue. With a median follow-up of 21 months (4-195), 9 patients had a recurrence, and 5 died of disease. Relapses were associated with tumor biology, histology, and the need for chemotherapy (p = 0.034, <0.001, and 0.015, respectively). Residues were associated with preoperative IDRF (excluding T9-T12 only) and the need for preoperative chemotherapy (p = 0.04 and 0.020). CONCLUSION: Our results show that thoracoscopy is safe, with good outcomes for thoracic neurogenic tumors in selected cases. Surgical outcomes are related to the IDRFs, whereas oncologic outcomes are related to tumor histology and biology.