Surgery for Pediatric Ureteropelvic Junction Obstruction-Comparison of Outcomes in Relation to Surgical Technique and Operating Discipline in Germany.

INTRODUCTION: Surgery for ureteropelvic junction obstruction (UPJO) is performed by both pediatric surgeons (PS) and urologists (URO). The aim of this study was to analyze treatment modalities for UPJO and results in relation to the surgical technique and the operating discipline in Germany. MATERIALS AND METHODS: Data of patients aged 0 to 18 years were extracted from a major public health insurance (covering ∼5.7 million clients) during 2009 to 2016 and were analyzed for sociodemographic variables, surgical technique, and treating discipline. Logistic regression analysis was performed for the risk of a complication within the first postoperative year. RESULTS: A total of 229 children (31.0% female) were included. Laparoscopic pyeloplasty (LP) was performed in 58 (25.3%) patients (8.6 ± 6.4 years), and open pyeloplasty (OP) was applied in 171 (74.7%; 4.6 ± 5.9 years). LP was the dominant technique in females (p < 0.02); males preferentially underwent OP (p < 0.02). Length of hospital stay was 4.3 days (p = 0.0005) shorter in LP compared with that in OP, especially in children ≤ 2 years (6.7 days, p = 0.007). PS operated on 162 children (70.7%), and URO performed surgery on 67 patients (29.3%). The mean age of children operated by PS (3.5 ± 4.7 years) was significantly younger compared with that operated by URO (10.8 ± 6.5 years, p < 0.0001). Complication rates were independent of surgical technique or treating specialty. CONCLUSION: In Germany, UPJO was treated by LP in 25.3% of patients, which was associated with a shorter length of stay, especially in children ≤ 2 years. Complication rates were independent of the operating specialty and surgical technique. Therefore, LP should be further promoted for the treatment of UPJO in small children.

[Accident or maltreatment? Radiographic X­ray patterns in non­accidental trauma : The concept of sentinel injuries]. / Unfall oder Misshandlung? Radiologische Befunde beim nichtakzidentiellen Trauma : Das Konzept der "sentinel injuries".

The focus of this review article is on child abuse and the radiographic pattern of X­ray findings. The radiologist should be able to recognize typical injuries resulting from child abuse. In some cases the findings are highly specific for abuse and these include metaphyseal corner fractures of the long bones in children aged up to 24 months. In other cases the fractures are not specific but highly indicative of child abuse: rib fractures, for example can be associated with child abuse in more than 50 % of the cases; however, maltreatment is difficult to diagnose without taking the entire pattern of skeletal findings into consideration so that a radiological screening of the entire skeleton is often necessary. The concept of sentinel injuries might be helpful for deciding in which cases a complete skeletal screening should be performed. In the age group up to 24 months old a complete skeletal status (with some exceptions) is recommended if one of the three sentinel injuries of rib fractures, intracranial bleeding and abdominal trauma is present.

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.

COUP-TFII gene expression is upregulated in embryonic pleuroperitoneal folds in the nitrofen-induced congenital diaphragmatic hernia rat model.

INTRODUCTION: The nitrofen model of congenital diaphragmatic hernia (CDH) creates a Bochdalek-type diaphragmatic defect and has been widely used to investigate the pathogenesis of CDH. However, the exact pathogenesis of the diaphragmatic defect in this model is still poorly understood. Chicken ovalbumin upstream promotor-transcription factor II (COUP-TFII) is expressed in the embryonic pleuroperitoneal folds (PPF) in the early stage of development and in the diaphragm in the late days of gestation. COUP-TFII is known to be a strong repressor of the retinoid signaling pathway (RSP), which plays an important role in diaphragm development. Furthermore, it has been recently shown that COUP-TFII is upregulated during early gestation in the nitrofen-induced hypoplastic lung. We designed this study to investigate the hypothesis that COUP-TFII gene expression is upregulated during early diaphragmatic development in the PPF. MATERIAL AND METHODS: Timed pregnant rats were exposed to either olive oil (Control) or nitrofen (CDH) on day 9 of gestation (D9). Fetuses were sacrificed on D13, D18 or D21. The PPF was dissected from D13 fetuses using laser capture microdissection. Diaphragms were dissected from D18 and D21 fetuses under the dissection microscope. The relative mRNA expression levels of COUP-TFII were determined using real-time PCR. Immunohistochemistry was performed to evaluate diaphragmatic protein expression and the distribution of COUP-TFII.Results On D13, gene expression levels of COUP-TFII in the PPF were significantly increased in the CDH group (82.93 ± 11.85) compared to Controls (46.22 ± 8.09; p < 0.05), whereas there were no differences at later time points. The immunoreactivity of diaphragmatic COUP-TFII was markedly increased in the PPF in the CDH group compared to controls on D13. No difference in immunoreactivity was observed on D18 and D21. CONCLUSION: Upregulation of COUP-II gene expression in the PPF may contribute to the diaphragmatic defect in the nitrofen CDH model by inhibiting the RSP.

Endoloop closure of the urinary bladder is safe and efficient in female piglets undergoing transurethral NOTES nephrectomy.

INTRODUCTION: Recently, we showed that various procedures for rigid Natural Orifice Transluminal Endoscopic Surgery (NOTES) can be successfully performed in piglets. However, the safety and effectiveness of endoscopic closure of the urinary bladder remains to be determined before introducing transurethral NOTES in children. Our study was designed to investigate the safety and impermeability of the urinary bladder after endoscopic closure in transurethrally assisted nephrouretectomy in piglets. MATERIAL AND METHODS: Five female piglets (mean weight 14.5 kg; range: 14-15) underwent right-sided transurethral nephroureterectomy using a hybrid technique with one 15 mm trocar placed umbilically and one 3 mm trocar placed transvesically. Hilar dissection was performed with a 5 mm Endoligasure vessel sealing device. After umbilical retrieval of the resected kidney, the urinary bladder was closed by an Endoloop via an umbilical "two in one system" with the assistance of a 2 mm transurethrally placed endoscopic clamp. Endpoints of the study were total operation time, duration of cystoscopy and transurethral trocar positioning, duration of nephrectomy, duration of bladder closure and determination of bladder impermeability. Intraoperatively, bladder filling was performed with normal saline (ml), while bursting pressure (mmHg) was measured by filling the harvested bladder with air. RESULTS: All nephroureterectomies were successfully performed with negligible blood loss. Mean total operation time was 46 min (range: 35-69). Cystoscopy and transurethral trocar positioning took 14 min (range: 9-23), and nephrectomy took 28 min (range: 18-48). Mean duration of bladder closure was 4 min (range: 2-6). Mean volume of intraoperative bladder filling was 94 ml (range: 80-100), indicating adequate capacity after closure with Endoloops. Post-mortem bladder impermeability was confirmed by a mean air filling bursting pressure of 88 mmHg (range: 70-140) indicating sufficient bladder closure. CONCLUSION: A safe urinary bladder closure is mandatory for transurethral rigid NOTES procedures and can be adequately achieved with Endoloops.