Arterioportal shunting, splanchnic capillary perfusion, and the effects of colloids during capnoperitoneum in neonatal and adolescent pigs.

BACKGROUND: Clinical and experimental data indicate that neonates are sensitive to the CO2 pneumoperitoneum. An impaired splanchnic perfusion during laparoscopy in adults has been reported. We recently confirmed that intravenous colloids improve macrocirculatory function in neonates. We aimed to determine the impact of CO2 pneumoperitoneum on the perfusion of splanchnic organs in the young including effects of colloid application. METHODS: Male piglets (n = 25) were divided into four groups: (1) neonatal controls, (2) neonates with crystalloid restitution, (3) neonates with colloidal restitution, and (4) adolescents with crystalloid restitution. Animals were ventilated and subjected to a 3-h, 10 mmHg CO2 pneumoperitoneum followed by 2 h resuscitation. Hepatic, splanchnic, and arteriovenous shunt perfusion was assessed via central and portal venous catheters. Capillary organ flow was detected by fluorescent microspheres. The rate of bile flow was measured. RESULTS: The neonatal crystalloid group showed a significant decrease in the intestinal capillary perfusion at the end of the recovery period. This was not detectable in the adolescent and colloid group. There was a significant increase in microcirculatory arterioportal shunt flow during the CO2 pneumoperitoneum in both neonatal groups but not in the sham and adolescent groups (p < 0.05). Hepatic arterial perfusion increased after insufflation in all groups and dropped during capnoperitoneum to levels of about 70% baseline. There was no significant impairment of splanchnic perfusion or bile flow as a result of the pneumoperitoneum in all groups. CONCLUSIONS: Capillary perfusion of the abdominal organs was stable during capnoperitoneum and recovery in adolescents and neonates with colloid restitution, but not with crystalloid restitution. Significant arterioportal shunting during capnoperitoneum could affect hepatic microcirculation in neonates. Our data confirm that moderate pressure capnoperitoneum has no major effect on the perfusion of abdominal organs in neonates with adequate substitution.

Development and pilot-testing of a condition-specific instrument to assess the quality-of-life in children and adolescents born with esophageal atresia.

The survival rate of children with esophageal atresia has today reached 95%. However, children are at risk of chronic morbidity related to esophageal and respiratory dysfunction, and associated anomalies. This study describes the pilot testing of a condition-specific health-related quality-of-life instrument for children with esophageal atresia in Sweden and Germany, using a patient-derived development approach consistent with international guidelines. Following a literature review, standardized focus groups were conducted with 30 Swedish families of children with esophageal atresia aged 2-17 years. The results were used for item generation of two age-specific pilot questionnaire versions. These were then translated from Swedish into German with considerations of linguistic and semantical perspectives. The 30-item pilot questionnaire for children aged 2-7 years was completed by 34 families (parent report), and the 50-item pilot questionnaire for children aged 8-17 years was completed by 52 families (51 child report, 52 parent report), with an overall response rate of 96% in the total sample. Based on predefined psychometric criteria, poorly performing items were removed, resulting in an 18-item version with three domains (Eating, Physical health and treatment, Social isolation and stress,) for children aged 2-7 years and a 26-item version with four domains (Eating, Social relationships, Body perception, and Health and well-being) for children aged 8-17 years. Both versions demonstrated good internal consistency reliability and acceptable convergent and known-groups validity for the total scores. The study identified specific health-related quality-of-life domains for pediatric patients with esophageal atresia, highlighting issues that are important for follow-up care. After field testing in a larger patient sample, this instrument can be used to enhance the evaluation of pediatric surgical care.

Appendectomy in the pediatric population-a German nationwide cohort analysis.

BACKGROUND: Meta-analyses indicate advantages of laparoscopic compared to open appendectomy. Nationwide analyses on results of laparoscopic appendectomy are scarce and studies from Germany are not available. This observational cohort study based on a nationwide insurance database was performed to analyze results of pediatric laparoscopic versus open appendectomy in general use. METHODS: Data were extracted from the largest German statutory health insurance TK (∼9 million clients) in a 3-year period (2010-2012). All patients aged 4-17 years with International Classification of Procedures in Medicine (ICPM) code "appendectomy" were included. Logistic regression analysis for the risk of a surgical complication within 180 postoperative days was performed. RESULTS: Appendectomy was performed in 8110 patients (52.6 % male; 47.4 % female) and conducted laparoscopically in 75.0 % of the patients (conversion rate = 1.2 %). Laparoscopic compared to open surgery was associated with a shorter length of hospital stay in both uncomplicated and complicated appendicitis. Patients with complicated appendicitis had lower readmission rates for surgical complications after laparoscopic appendectomy and logistic regression analysis confirmed a significantly lower risk of readmission for surgical complications after laparoscopic compared to open operation in adolescents. Pediatric surgeons operated 23.9 % and general surgeons 76.1 % of patients. Laparoscopy was less frequently used and the conversion rate was significantly higher in pediatric surgical departments. CONCLUSION: This first nationwide German cohort study confirms that laparoscopic appendectomy is associated with a less complicated postoperative course compared to open appendectomy, particularly in patients with complicated appendicitis. Pediatric surgeons used laparoscopy less frequently compared to general surgeons. Laparoscopic appendectomy should therefore be further promoted in pediatric surgical centers in Germany.

Early complications after esophageal atresia repair: analysis of a German health insurance database covering a population of 8 million.

The treatment of esophageal atresia is not centralized in Germany. Therefore, high numbers of departments are involved. Data on the results of esophageal atresia repair from Germany are lacking. The aim of this study was to evaluate the early postoperative results after repair of esophageal atresia based on unbiased data of a German health insurance. We aimed to determine whether characteristics of the departments had an impact on outcome and compared the results from this study with the literature data from centers with a high caseload. Data of a German health insurance covering ∼10% of the population were analyzed. All patients who had undergone esophageal atresia repair from January 2007 to August 2012 were included. Follow-up data of 1 year postoperatively were analyzed. The potential impact of various characteristics of the treating surgical institutions was assessed. Results were compared with the latest international literature. Seventy-five patients with esophageal atresia underwent reconstructive surgery in 37 departments. The incidences of anastomotic leak (3%) and recurrent tracheoesophageal fistula (7%) were comparable with the literature (both 2-8%). Anastomotic stricture required dilatation in 57% of patients (mean 5.1 ± 5.6 dilatations) comparing unfavorably to most, but not all international reports. During 1-year follow-up, 93% of the patients were readmitted at least once (mean 3.9 ± 3.1 admissions). The incidence of complications did not correlate with any of the characteristics of the treating institutions such as academic affiliation, the number of consultants, beds, and preterm infants treated per year (all P > 0.05). Based on unbiased data, postoperative results after repair of esophageal atresia in Germany are comparable with recently published reports from international single centers. A correlation between the complication rate and characteristics of the treating institutions was not identified.

Comparison of environmental risk factors for esophageal atresia, anorectal malformations, and the combined phenotype in 263 German families.

Esophageal atresia with or without tracheoesophageal fistula (EA/TEF) and anorectal malformations (ARM) represent the severe ends of the fore- and hindgut malformation spectra. Previous research suggests that environmental factors are implicated in their etiology. These risk factors might indicate the influence of specific etiological mechanisms on distinct developmental processes (e.g. fore- vs. hindgut malformation). The present study compared environmental factors in patients with isolated EA/TEF, isolated ARM, and the combined phenotype during the periconceptional period and the first trimester of pregnancy in order to investigate the hypothesis that fore- and hindgut malformations involve differing environmental factors. Patients with isolated EA/TEF (n = 98), isolated ARM (n = 123), and the combined phenotype (n = 42) were included. Families were recruited within the context of two German multicenter studies of the genetic and environmental causes of EA/TEF (great consortium) and ARM (CURE-Net). Exposures of interest were ascertained using an epidemiological questionnaire. Chi-square, Fisher's exact, and Mann-Whitney U-tests were used to assess differences between the three phenotypes. Newborns with isolated EA/TEF and the combined phenotype had significantly lower birth weights than newborns with isolated ARM (P = 0.001 and P < 0.0001, respectively). Mothers of isolated EA/TEF consumed more alcohol periconceptional (80%) than mothers of isolated ARM or the combined phenotype (each 67%). Parental smoking (P = 0.003) and artificial reproductive techniques (P = 0.03) were associated with isolated ARM. Unexpectedly, maternal periconceptional multivitamin supplementation was most frequent among patients with the most severe form of disorder, i.e. the combined phenotype (19%). Significant differences in birth weight were apparent between the three phenotype groups. This might be attributable to the limited ability of EA/TEF fetuses to swallow amniotic fluid, thus depriving them of its nutritive properties. Furthermore, the present data suggest that fore- and hindgut malformations involve differing environmental factors. Maternal periconceptional multivitamin supplementation was highest among patients with the combined phenotype. This latter finding is contrary to expectation, and warrants further analysis in large prospective epidemiological studies.

Neonatal murine macrophages show enhanced chemotactic capacity upon toll-like receptor stimulation.

BACKGROUND: The neonatal surgical patient is threatened by exuberant inflammatory reactions. Neonatal macrophages are key players in this process. We investigated the ability of neonatal macrophages to initiate a local inflammatory reaction upon exposure to different bacterial or viral ligands to toll-like receptors (TLRs). METHODS: Peritoneal wash outs from neonatal (<24 h) and adult (42 days) C57BL/6J mice were gained by peritoneal lavages. In a first set of experiments, macrophages were purified and stimulated for 6 h by four different TLR ligands. mRNA was extracted for transcriptome analysis. In a second set of experiments, lipopolysaccharide was applied into peritoneal cavities. After 6 h of incubation, the cellular composition of the inflamed cavities was evaluated by cytological staining as well as chipcytometry. RESULTS: Neonatal murine peritoneal macrophages differed significantly in the expression of pro- and anti-chemotactic genes. Functional assignment of these genes revealed enhanced chemotactic potential of neonatal macrophages and was confirmed by a higher influx of pro-inflammatory cells into neonatal peritoneal cavities. CONCLUSION: Neonatal peritoneal macrophages demonstrated an enhanced chemotactic potential upon stimulation with four TLR ligands. This was associated with an increased influx of inflammatory cells to the peritoneal cavity. This might contribute to the strong inflammatory responses of neonates and preterms.

[Ethical conflicts in pediatric surgery: high-performance medicine and the economical environment]. / Ethische Konflikte in der Kinderchirurgie : Hochleistungsmedizin und ökonomische Rahmenbedingungen.

BACKGROUND: Healthcare is increasingly influenced by economical constraints which can lead to ethical conflicts for surgeons. The aim of the study was to investigate the incidence of these conflicts and the coping strategies of surgeons. METHODS: A prospective, standardized staff survey in an academic pediatric surgical department was performed over a period of 4 weeks. The types of conflict and solution strategies were determined. The agreement with given statements was determined using a 5-point Likert scale. RESULTS: In 155 returned questionnaires 74 ethical conflicts were identified. Most conflicts concerned decisions relating to diagnosis-related groups (DRG) which were economically based. To resolve the ethical conflict surgeons decided to the detriment of patients in 73  % and to the economical benefit in 72 %. In 8  % a medical disadvantage for the patient was noted and in 62  % a disadvantage for patient comfort was seen. Surgeons were highly dissatisfied with the conflict solutions (2.3/5). CONCLUSIONS: Economical considerations cause ethical conflicts in the daily routine in pediatric surgery. Decisions are made to the benefit of the hospital and cause a decrease in patient comfort. Political solutions for this problem are required in the interest of all those involved.

Thoracic wall reconstruction for primary malignancies in children: short- and long-term results.

AIM: Primary thoracic wall malignancy is a rare and diverse entity in children. Surgical treatment commonly involves major chest wall resection causing large defects requiring complex reconstruction. In adults, the use of alloplastic and/or xenogenic materials and muscle flap repair is well established. However, literature provides only little information on procedures in children. We report our experience in 8 consecutive children who underwent chest wall resection and reconstruction with regard to surgical treatment and outcome. PATIENTS AND METHODS: Retrospective study of all children with primary malignant chest wall tumors requiring rib resection and reconstruction with prosthetic material performed in our institution between November 2002 and April 2010. Endpoints were postoperative complications and long-term results, focusing on scoliosis defined radiologically by the Cobb angle. RESULTS: 8 children (7 male, 1 female) with a median age of 10.6 (4.1-18.9) years underwent resection of thoracic wall tumors. A mean number of 3 (1-5) ribs were resected. Stability was obtained using rigid prosthetic material (STRATOS™ titanium bar) in 2 patients and/or non-rigid prosthetic material (Goretex® patch in 6 patients, Vicryl® patch in 3 patients, Tutopatch® in 1 patient). A muscular flap was added in 5 patients. Postoperative complications included superficial wound infection (n = 2) and dislocation of a titanium bar necessitating removal in 1 patient. No infections of the prosthetic material were observed. No perioperative mortality occurred. At a mean follow-up of 37.5 (4-97) months, 6 patients were alive. 2 patients died due to early tumor recurrence. Mild scoliosis (Cobb angle 10-20°) was detected in 2 of the surviving patients (33%). CONCLUSION: Surgical reconstruction after resection of malignant thoracic wall tumors using non-rigid prosthetic material is safe and effective in pediatric patients, whereas rigid prosthetic material might dislocate. Scoliosis represents a long-term complication after chest wall reconstruction and should be monitored during routine follow-up.

Our experience with single lung ventilation in thoracoscopic paediatric surgery.

INTRODUCTION: Data on the feasibility and effects of single lung ventilation (SLV) in children are scarce. We conducted a retrospective study on the feasibility of SLV during video-assisted thoracoscopic surgery (VATS) in children and adolescents undergoing major thoracic procedures. METHODS: A retrospective chart review of all records from patients who underwent VATS at our institution from 2000 to 2010 was done. Patients receiving SLV were analysed in detail. Endpoints of the analysis were conversion to open thoracotomy (frequency and reasons), postoperative duration of ventilation, and pulmonary complications such as radiologically confirmed atelectasis and pneumonia. RESULTS: 74 out of 305 patients (24%, 43 boys, 31 girls) with a mean age of 9.4 years (56 days-18 years) and mean weight of 34 kg (4.5-76 kg) had SLV. Lung resection was done in 43 (58%), pleural surgery in 17 (23%), a combination of both in 7 (9%), and mediastinal procedures in 7 (9%). 11 patients (15%) required conversion of VATS to open surgery, mostly because of problems with exposure of the operative field (73%). 32 patients (43%) were extubated immediately after the operation, whereas 8 (11%) required ventilation for more than 24 h. The mean intensive care unit stay was 1.6 days. 18 patients (24%) developed radiologically confirmed atelectasis, and 1 patient (1%) required bronchoscopic clearance. Pneumonia occurred in 1 case (1%) and was successfully treated with antibiotics. CONCLUSION: SLV is feasible in children and adolescents undergoing VATS for a broad spectrum of procedures. However, despite SLV, the conversion rate in our series was 15%. The main reason for conversion was problems with exposure of the operative field. The complication rate for SLV was low. Atelectasis developed in every fourth patient but usually resolved spontaneously, and intervention to achieve ventilation was rarely indicated.

Feasibility of fast-track elements in pediatric surgery.

BACKGROUND: We recently showed that fast-track pathways could be applied to only one third of patients undergoing routine pediatric surgery. The aim of this study was to investigate various fast-track elements in various procedure types irrespective of the applicability of a whole fast-track pathway. METHODS: Patients undergoing routine surgical procedures from April 2009 to April 2010 were included in the study. 11 groups of procedures were differentiated and quality criteria were established for 8 fast-track elements: analgesia, postoperative nutrition, postoperative mobilization, applicability of minimally invasive surgery when appropriate, hospital stay, postoperative symptoms, complications, and parental evaluation. A fast-track element was considered as successfully applied if used in at least 75% of patients. The hospital stay was compared with data from the German reimbursement system (G-DRG). RESULTS: A total of 203 patients were included. Optimal analgesia was achieved in all procedure types except in oncologic surgery (58%) and ureteral reimplantation (71%). Significant nausea and vomiting occurred only after Kasai operation and "other laparoscopic procedures". Early nutrition was achieved in all procedures except after fundoplication (67%) and Kasai operation (62%). Early postoperative mobilization was not successful after hypospadias repair (40%) and ureteral reimplantation (43%). Minimally invasive techniques could not be applied in 48% of thoracic procedures and in 58% of oncological patients. There were no fast-track associated complications. In 4 of 11 procedure types, the mean hospital stay was significantly reduced compared to G-DRG data. There were 4 readmissions (2%). 2 weeks after discharge 94% of interviewed parents evaluated fast-track treatment as excellent. CONCLUSION: Fast-track elements in pediatric surgery increase patient comfort, reduce hospital stay, and achieve a high patient satisfaction. We wish to emphasize the benefits of using fast-track elements irrespective of whether a whole fast-track protocol is applicable.

Failure to report ethical approval and informed consent in paediatric surgical publications.

INTRODUCTION: Medical research involving human subjects must follow ethical standards as outlined in the Declaration of Helsinki of the World Medical Association. The 3 journals J Ped Surg, Eur J Pediatr Surg and Pediatr Surg Int all require authors' statements regarding ethical approval and the patient or guardian informed consent for studies involving human subjects. It has previously been reported that ethical approval and informed consent is not documented in a considerable proportion of publications in other journals. The aim of this study was to investigate whether ethical approval and informed consent was documented in a consecutive series of publications involving human subjects in the 3 paediatric surgical journals. MATERIAL AND METHODS: All articles involving human subjects or material published in the print and online issues of J Ped Surg, Eur J Pediatr Surg and Pediatr Surg Int in 2010 were systematically reviewed as to whether ethics committee or institutional review board approval and patient or guardian consent to participate in the study was reported. Publications were categorised into prospective studies, retrospective studies, description of new methods and case reports. RESULTS: 579 articles were included in the study (324 J Ped Surg, 103 Eur J Pediatr Surg and 153 Pediatr Surg Int). In case reports (n=142), the lowest level of documentation of ethical approval (1.4%) and informed consent (1%) was observed. The remaining 437 original articles reported ethical approval in 54% of publications (prospective studies 66%, retrospective studies 59%, new methods 27%). Informed consent was documented in 16% of the original articles (prospective studies 50%, retrospective studies 17%, new methods 14%). Detailed investigation of the different journals revealed the highest rate of reporting of ethical approval for J Pediatr Surg (71%), followed by Eur J Pediatr Surg (43%), and Pediatr Surg Int (24%). Patient or guardian informed consent was reported in 15% of the publications in J Pediatr Surg and Pediatr Surg Int, respectively, and in 24% of the papers published in Eur J Pediatr Surg. CONCLUSION: Adherence to ethical principles in paediatric surgical research should be improved. Information on ethical approval and informed consent should be included in all manuscripts accepted for publication. Editors should consider establishing a specific online template asking authors for the necessary information during the submission process.

Portal venous gas detected by ultrasound differentiates surgical NEC from other acquired neonatal intestinal diseases.

BACKGROUND: The definite clinical diagnosis of acquired neonatal intestinal diseases (ANID) is a challenge, usually met by applying Bell's or, more recently, Gordon's classification. Both classifications incorporate radiological pneumatosis intestinalis (PI) as a cornerstone of the NEC diagnosis. However, PI may be absent or difficult to identify by abdominal X-ray. Portal venous gas detected by ultrasound (PVG-US) has been proposed as another characteristic of NEC, but its incidence in other entities of ANID remains unknown. OBJECTIVE: To determine whether PVG-US and Gordon's classification can help to differentiate between NEC and other ANID, especially SIP. METHODS: Retrospective analysis of the data of 83 infants, who underwent laparotomy for a clinical diagnosis of ANID was performed. The results of PVG-US and other markers of ANID were compared with the operative result, defined as the gold standard for diagnosis. RESULTS: The NEC diagnosis was confirmed in 28/83 infants and PVG-US was present in 23 (82%) of those patients prior to operation. PVG-US was detected in 2 patients without NEC (one volvulus, one SIP), resulting in an 82% sensitivity and a 96% specificity. The sensitivity and specificity of radiological PI for patients with NEC was lower (75 and 91%), but the combination of PVG-US and radiological PI increased the sensitivity for NEC detection to 89%. Gordon's classification had a sensitivity of 93% and a specificity of 92% for NEC diagnosis. CONCLUSION: Screening for PVG-US and Gordon's classification are valid tools to differentiate between NEC and other ANID including SIP. Although an effect of these proposed diagnostic tools on treatment regimen and operative management has yet to be verified, the improvement in diagnosing ANID is certainly valuable.

Biliary atresia: lessons learned from the voluntary German registry.

INTRODUCTION: Aim of the study was to carry out a 5-year survey of German patients with biliary atresia (BA) and to launch a discussion regarding the feasibility of voluntary registries in unregulated healthcare systems. METHODS: A retrospective analysis of German BA patients born between 2001 and 2005, based on data collected from the voluntary European Biliary Atresia Registry (EBAR), was carried out and supplemented by data from all BA patients who underwent liver transplantation at the only 4 pediatric transplantation centers (pLTx) in Germany which are so far not registered at EBAR. Survival rates were calculated using Kaplan-Meier analysis and compared by Cox regression to determine the predictive value of age at surgery and the influence of the center size (fewer or more than 5 patients/study period) on overall survival and survival with native liver. RESULTS: A critical review of the 148 German EBAR charts revealed that 11 patients (7.4%) had no biliary atresia. The remaining 137 patients from EBAR together with 46 BA patients who underwent LTx without prior registration at EBAR were evaluated with a median follow-up of 39 months (range: 25-85 months). 29 hospitals performed a total of 159 Kasai procedures, but only 7 centers treated 5 or more patients (116 patients, range: 5-68), and 22 hospitals performed less than 5 KP (43 patients, range: 1-4). Primary LTx was performed in 21 patients (11.5%) and 3 patients died without surgical intervention. 16 patients were lost to follow-up (8.7%). Overall survival after 2 years was 83.3% (139 patients), including 105 patients (63%) who had undergone LTx and 34 patients (20.3%) with native liver. 28 patients died (16.7%), 8 after LTx (5.8%). The experience of the center was the only factor with a significant predictive value for jaundice-free survival with native liver (p=0.001). CONCLUSION: 25% of all German BA patients were not registered at EBAR, and 29 clinics were involved in the surgical management of BA patients. Therefore a new approach consisting of an internet-based decentralized registry for rare neonatal liver diseases is outlined which could improve the future management of patients with BA. The centralization of such patients at experienced centers with higher caseloads is necessary in Germany and would improve the outcome of patients with biliary atresia.

Microdebrider-assisted versus radiofrequency-assisted inferior turbinoplasty: a prospective study with objective and subjective outcome measures.

In order to relieve the symptoms of nasal obstruction in patients with inferior turbinate hypertrophy, various surgical methods have been used. Aim of this study was to compare post-operative outcome between radiofrequency and microdebrider-assisted partial turbinoplasty. A prospective study was performed in 268 patients with nasal obstruction and hypertrophied turbinate mucosa refractory to medical treatment, from December 2000 to December 2005. Overall, 124 patients were treated with microdebrider (Group 1) and 144 patients with radiofrequency (Group 2). Post-operative changes in the degree of nasal obstruction, nasal discharge, hyposmia and headache were evaluated prospectively on the 7(th) day, 1(st), and 3(rd) months after the procedure. Rhinomanometric evaluation was also performed for objective comparison. Both procedures were perfectly tolerated by the patients. The nasal obstruction scale improved significantly in Group 1 on day 7, and within the periods of 1(st) and 3(rd) months after surgery, while the significant improvement took place in Group 2 only in the 1(st) and 3(rd) months after surgery. The comparison between the two groups showed that symptom improvement was statistically significant in Group 1 on the 7(th) day, 1(st) and 3(rd) months after surgery. Severity of nasal discharge, headache and hyposmia grades improved significantly in the first week after the operation both in the microdebrider and radiofrequency group and persisted during the 1(st) and 3(rd) months after the operation. Since microdebrider can effectively widen the nasal airway, the rhinomanometric measurements of these patients were found to be lower than in the radiofrequency group. Moreover, patient satisfaction in the microdebrider group was higher than that in the radiofrequency group. In conclusion, this study suggests that microdebrider-assisted partial turbinoplasty is more effective and satisfactory in relieving nasal obstruction.

CO2 modulates the inflammatory cytokine release of primary human pleural macrophages.

BACKGROUND: It is well known that CO (2) used during laparoscopy affects the peritoneal surface and local inflammatory response, including the inflammatory reactivity of peritoneal macrophages. However, little is known about the local effects of CO (2) during thoracoscopy. In a previous study we have shown that in healthy adolescents, macrophages are the dominant cell population on the pleural surface. Therefore, we examined the effects of CO (2) on the inflammatory response of primary human pleural macrophages. METHODS: Human primary macrophages were harvested lavage from healthy adolescents undergoing elective surgery for pectus bar correction (n=8). After purification and 24 h resting, cells were incubated for 2 h in 100% CO (2), 5% CO (2) or 95% inert helium with 5% CO (2) as hypoxic control. After incubation cells were stimulated with LPS for 4 h and 24 h. The release of TNF-alpha, IL-8, IL-6, IL-10 and IL-1 beta were determined by ELISA. RESULTS: CO (2), but not hypoxia, induced a significant reduction in the release of TNF-alpha and IL-8 as well as a significant increase in the release of IL-10 and IL-1 beta within the first 4 h after incubation. The levels of IL-6 and the release of cytokines at 24 h after incubation were not significantly affected. CONCLUSIONS: CO (2) directly modulates the immediate inflammatory response of pleural macrophages. Therefore, CO (2) insufflation during thoracoscopy could lower the local stress response, but does not appear to have a lasting effect.

[Minimally invasive pediatric surgery]. / Minimal-invasive Kinderchirurgie.

In recent years minimally invasive surgical techniques in children have made substantial progress. The feasibility and safety of a wide spectrum of laparoscopic and thoracoscopic procedures have been confirmed in numerous studies. Moreover, it was reported that minimally invasive pediatric surgery is associated with lower morbidity, a shorter hospital stay, lower costs, better cosmetics and clinical results similar to those achieved by open surgery. The present article reviews information on established as well as feasible but not yet established surgical procedures. The discussion of potential hemodynamic, respiratory and organ perfusion effects of the CO(2) pneumoperitoneum and the notation of special logistic aspects should support the reader in the process of decision-making to schedule infants and children for minimally invasive surgery.