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.

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.

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.