Expanding safety boundaries in pediatric robotic-assisted laparoscopic surgery: are we protecting our children?

Little is known about the effects of CO2 insufflation (CDI) on cerebral oxygen saturation (CrSO2) during laparoscopy in the pediatric population. In children undergoing robotic-assisted laparoscopic pyeloplasty (RALP), we prospectively assessed the effects of CDI using standard monitoring and cerebral near-infrared spectroscopy (NIRS). We also explored whether a correlation existed between CrSO2 and parameters known to affect cerebral blood flow. Between January 2021 and September 2023, a cohort of consecutive children older than 2 years underwent RALP at Necker-Enfants Malades Hospital in Paris. A ventilation protocol aimed to prevent hypercarbia was implemented. Data collected included standard monitoring parameters and CrSO2 by NIRS. Thirty patients (16 females), mean age 5.5 ± 3.9 (2.0-9.5) years, were included. Twenty-three patients underwent a retroperitoneal approach. The mean baseline CrSO2 value was 83.0 ± 9.8. Mean CrSO2 decreased during progressive CDI, never below baseline values, while standard-monitoring parameters did not significantly change. No significant correlation was detected between CrSO2 and end tidal CO2, or between CrSO2 and mean arterial pressure, at any operative time. During RALP, a gradual CDI doesn't cause pathological derangements of CrSO2. The lack of correlation between CrSO2 and standard parameters affecting cerebral blood flow suggests the likely presence of cerebral autoregulation in our population.

Effect of retropneumoperitoneum on cerebral and renal oxygen saturation during retroperitoneal robotic-assisted laparoscopic pyeloplasty (R-RALP) in a pediatric population: Preliminary results of a prospective observational study using a dedicated anesthetic protocol and Near-InfraRed Spectroscopy.

BACKGROUND: Retroperitoneal robotic-assisted laparoscopic pyeloplasty (R-RALP) for ureteropelvic junction obstruction (UPJO) has gained growing acceptance among pediatric urologists, and is increasingly performed as day-case surgery, involving smaller children and infants. However, retroperitoneal CO2 insufflation may cause hemodynamic derangements, respiratory changes, and hypercapnia, whose consequences are poorly investigated. We, therefore, decided to prospectively study its effect on regional tissue perfusion and oxygenation in a cohort of pediatric patients undergoing R-RALP, using a dedicated anesthetic protocol and cerebral and renal Near InfraRed Spectroscopy (NIRS). MATERIAL AND METHODS: Between January 2021 and September 2022, a cohort of 21 consecutive children [12 males (9 females), mean age of 7.1 ± 3.8 years and mean body weight of 25.7 ± 12.3 kg] underwent their first elective pyeloplasty for UPJO by R-RALP. The surgical procedure followed a previously described standardized technique and a dedicated anesthetic protocol. In conjunction with the minimal expected standard monitoring, cerebral and renal NIRS were added. Standard monitoring parameters and NIRS values were recorded at preset points throughout the procedures. RESULTS: Standard monitoring and NIRS measurements during R-RALP were not adversely affected by CO2 insufflation, pending a significant increase in respiratory rate, aimed to avoid hypercapnia, while keeping the ventilation pressure within the safety range, preventing lung injury. CONCLUSIONS: R-RALP, using a constant retroperitoneal CO2 insufflation pressure of 12 mmHg with a 5 L.min-1 flow, does not adversely affect respiratory and hemodynamics parameters, pending the implementation of a specifically designed anesthetic protocol aimed to prevent hypercapnia, the most threatening effect of retroperitoneal CO2 insufflation. CLINICAL TRIAL REGISTRATION NUMBER: NCT03274050.

Use of combined cerebral and somatic renal near infrared spectroscopy during noncardiac surgery in children: a proposed algorithm.

Cerebral near infrared spectroscopy (NIRS) monitoring has been extensively applied in neonatology and in cardiac surgery, becoming a standard in many pediatric cardiac centers. However, compensatory physiological mechanisms favor cerebral perfusion to the detriment of peripheral tissue oxygenation. Therefore, simultaneous measurement of cerebral and somatic oxygen saturation has been advocated to ease the differential diagnosis between central and peripheral sources of hypoperfusion, which may go undetected by standard monitoring and not mirrored by cerebral NIRS alone. A clinical algorithm already exists in cardiac surgery, aimed to correct intraoperative cerebral oxygen desaturations. A similar algorithm still lacks in noncardiac pediatric surgery. The goal of this paper is to propose a clinical algorithm for the combined use of cerebral and somatic NIRS monitoring during anesthesia in the pediatric population undergoing noncardiac surgery. A panel of experienced pediatric anesthetists developed the algorithm that is based on the clinical experience and intraoperative observations. It aims to lessen the current variability in interpreting NIRS measurement. Multisite NIRS monitoring was achieved applying one pediatric sensor to the forehead for cerebral tissue perfusion reading and a second one to the decumbent lumbar region for recording somatic renal tissue perfusion. The algorithm describes a sequence of acts aimed to identify the putative cause of intraoperative organ tissue desaturation and suggests clinical interventions expected to restore adequate tissue perfusion. It is composed of two arms: the main arm includes patients with an observed decrease in cerebral perfusion (CrO2), the second one includes those with a stable CrSO2 with declining RrSO2. Described also are five clinical cases of infants and neonates in whom pathological alterations of organ perfusion were detected using intraoperative multisite NIRS monitoring, portrayed in the accompanying figures (Annex).

Cerebral Oxygenation by Near-Infrared Spectroscopy in Infants Undergoing Thoracoscopic Lung Resection.

Background: Thoracoscopic resection is the standard of care for congenital lung malformations (CLMs) in infants. However, there is rising concern that capnothorax may affect cerebral perfusion and oxygenation, carrying potential long-term effects on neurodevelopmental behavior. The aim of our study was to investigate, using near-infrared spectroscopy (NIRS), the regional cerebral oxygenation (CrSO2) in infants undergoing thoracoscopic lung resection; the secondary aim was to assess the relationship between rSO2 and standard monitoring. Methods: In this retrospective study, we reviewed all infants (<1 year old, ASA II) who underwent thoracoscopic CLM resection in double-lung ventilation under fixed capnothorax parameters (5 mmHg of pressure, 1 L/minute flow), standardized anesthetic protocol, standard monitoring, and multisite NIRS in our center. We focused our attention on 8 anesthetic and surgical maneuvers, potentially affecting tissue oxygen saturation. Results: Ten infants met the inclusion criteria. At surgery, median age was 5.5 (4-7) months, median weight 7.2 (6.6-8) kg, median operative time 110 (55-180) minutes, and median capnothorax duration 79 (34-168) minutes. No conversion to open surgery occurred. CrSO2 values remained within clinically accepted values during thoracoscopy, beside a CrSO2 drop >20% of basal value in 1 patient, during capnothorax induction. Renal NIRS added very little to standard monitoring, which appeared generally inadequate to consistently appraise end-organ perfusion. ETCO2 best correlated with CrSO2 variations, suggesting to be able to realistically predict them. Conclusions: The thoracoscopic treatment of CLMs under the given conditions appears well tolerated in infants, pending the continuous adjustment of ventilator settings by an experienced anesthetist, confident with NIRS technology.

The coagulation profile as a marker for acute appendicitis in the paediatric population: Retrospective study.

INTRODUCTION: Appendicitis is the commonest and most frequently misdiagnosed acute abdominal surgical illness in the paediatric population worldwide. The aim of this study is to evaluate the role of coagulation profile in acute appendicitis (AA) in children. MATERIALS AND METHODS: we retrospectively collected data of patients submitted to appendectomy from 2011 to 2017. According to histopathology, patients were divided into three groups: not histologically confirmed AA (NAA), simple AA (SAA) and complicated AA (CAA). White blood cell (WBC) count, relative neutrophilia (Neutr%), C-reactive protein (CRP), prothrombin time ratio (PTratio), activated partial thromboplastin time ratio (APTTratio) and fibrinogen (Fib) were compared among groups. RESULTS: Three hundred and seven patients were included: 57 NAA, 184 SAA and 66 CAA. WBC was significantly different among groups: CAA (mean 16.67 × 103/ml), SAA (14.73 × 103/ml, P= 0.01) and NAA (10.85 × 103/ml, P< 0.0001). Significant differences were found for Neutr% (mean CAA 81.14 vs. SAA 77.03 P= 0.006, vs. NAA 63.86 P< 0.0001) and CRP (mean NAA 2.56, SAA 3.26, CAA 11.58, P< 0.0001). PTratio and Fib increased with the severity of AA receiver operator characteristic curves were similar for CRP (0.739), Fib (0.726), WBC (0.746) and Neutr% (0.754), while for PTratio and aPTTratio were 0.634 and 0.441, respectively. CONCLUSIONS: extrinsic coagulation pathway is altered in AA, especially in CAA. Coagulation can be useful in the diagnostic and perioperative anaesthetic management of AA in children. Fib seems to have the highest accuracy.

Tracheal Diameter and Respiratory Outcome in Infants with Congenital Diaphragmatic Hernia Treated by Fetal Endoscopic Tracheal Occlusion.

AIM: To evaluate tracheal diameters and their clinical impact in patients with congenital diaphragmatic hernia (CDH) after fetal endoscopic tracheal occlusion (FETO). METHODS: Patients born with CDH between January 2012 and August 2016 were divided into two groups: noFETO and FETO. Tracheal diameters at three levels (T1, carina, and maximum tracheal dilation) on chest X-ray at 1, 3, 6, 12, 24, and 36 months of follow-up, requirements of invasive and noninvasive respiratory support, the incidence of respiratory infections, and results of pulmonary function tests (PFT) were compared. RESULTS: A total of 71 patients with CDH were born in the study period, and there were 34/41 survivors in the no-FETO group (82.9%) and 13/30 in the FETO group (43.3%). The maximum tracheal diameter was significantly greater in the FETO group at all ages. No differences were observed in the diameters at T1 and the carina, in the requirements of invasive and noninvasive respiratory support, and in the incidence respiratory infections. At the PFT (6-12 months), the FETO group presented higher respiratory rates (46.1 ± 6.2 vs. 36.5 ± 10.6, p = 0.02). No differences in PFT results were found between the groups after the 1st year of life. CONCLUSIONS: The FETO procedure leads to persistent tracheomegaly. However, the tracheomegaly does not seem to have a significant clinical impact.

Start a Neonatal Extracorporeal Membrane Oxygenation Program: A Multistep Team Training.

Background: Extracorporeal membrane oxygenation (ECMO) is a complex life-saving support for acute cardio-respiratory failure, unresponsive to medical treatment. Emergency events on ECMO are rare but require immediate and proficient management. Multidisciplinary ECMO team members need to acquire and maintain over time cognitive, technical and behavioral skills, to safely face life-threatening clinical scenarios. Methods: A multistep educational program was delivered in a 4-year period to 32 ECMO team members, based on guidelines from the Extracorporeal Life Support Organization. A first traditional module was provided through didactic lectures, hands-on water drills, and laboratory animal training. The second phase consisted of a multi-edition high-fidelity simulation-based training on a modified neonatal mannequin (SimNewB®). In each session, participants were called to face, in small groups, ten critical scenarios, followed by debriefing time. Trainees underwent a pre-test for baseline competency assessment. Once completed the full training program, a post-test was administered. Pre- and post-test scores were compared. Trainees rated the educational program through survey questionnaires. Results: 28 trainees (87.5%) completed the full educational program. ECMO staff skills improved from a median pre-test score of 7.5/18 (IQR = 6-11) to 14/18 (IQR = 14-16) at post-test (P < 0.001, Wilcoxon rank test). All trainees highly rated the educational program and its impact on their practice. They reported high-fidelity simulations to be beneficial to novice learners as it increased self-confidence in ECMO-emergencies (according to 100% of surveyed), theoretical knowledge (61.5%) and team-work/communicative skills (58%). Conclusions: The multistep ECMO team training increased staff' knowledge, technical skills, teamwork, and self-confidence, allowing the successful development of a neonatal respiratory ECMO program. Conventional training was perceived as relevant in the early phase of the program development, while the active learning emerged to be more beneficial to master ECMO knowledge, specific skills, and team performance.

A Single-Center Experience with Very Low Birth Weight Infants and Focal Intestinal Perforation: Comparison of Primary Anastomosis versus Stoma Opening.

INTRODUCTION: We present a single-center experience with very low birth weight (VLBW) infants with focal intestinal perforation (FIP), comparing the results of primary anastomosis (PA) and stoma opening (SO). MATERIALS AND METHODS: Clinical records of VLBW infants with FIP who underwent surgery between 2006 and 2015 were reviewed. Patients were divided into two groups according to the procedure performed: limited bowel resection and PA or SO. Patients with gastric perforation or patients who underwent clip and drop were excluded. Information regarding birth weight (BW), gestational age (GA), weight at surgery (WS), number of abdominal reoperations, duration of parenteral nutrition (PN), and demise was recorded. RESULTS: In this study, 40 patients were included: 22 in PA group and 18 in SO group. BW was 865 g in PA and 778 in SO (p-value: 0.2). GA was 26.1 weeks in PA and 25.6 in SO (p-value: 0.3). WS was 1,014 g in PA and 842 in SO (p-value: 0.09). Duration of surgery was 115 minutes in PA and 122 in SO (p-value: 0.67). Five patients (23%) belonging to PA group developed complications and required SO. Five patients (23%) demised in PA group and six (33%) in SO (p-value: 0.2). Seventeen abdominal reoperations were performed in PA group and 22 in SO group (p-value: 0.08). CONCLUSION: Both procedures appear to be safe. When possible, PA should be performed as it reduces the number of abdominal reinterventions.

Supra-transumbilical laparotomy (STL) approach for small bowel atresia repair: our experience and review of the literature.

BACKGROUND: Supra-Transumbilical Laparotomy (STL) has been used in paediatric surgery for a broad spectrum of abdominal procedures. We report our experience with STL approach for small bowel atresia repair in newborns and review previous published series on the topic. PATIENTS AND METHODS: Fourteen patients with small bowel atresia were treated via STL approach at our Institution over a 5-year period and their charts were retrospectively reviewed. RESULTS: STL procedure was performed at mean age of 3.1 day. No malrotation disorders were detected with pre-operative contrast enema. Eight patients (54.1%) presented jejunal atresia, five (35.7%) ileal atresia, and one (7.1%) multiple ileal and jejunal atresias. Standard repair with primary end-to-back anastomosis was performed in all but one patient. In the newborn with multiple atresia, STL incision was converted in supra-umbilical transverse incision due to difficulty of exposition. After surgery, one patient developed anastomotic stricture, and another developed occlusion due to adhesions: Both infants required second laparotomy. No infections of the umbilical site were recorded, and cosmetic results were excellent in all patients. CONCLUSIONS: Increasing evidence suggests that STL approach for small bowel atresia is feasible, safe and provides adequate exposure for small bowel atresia surgery. When malrotation and colonic/multiple atresia are pre-operatively ruled out, STL procedure can be chosen as first approach.