Publishing trends in Journal of Paediatric Surgery, Pediatric Surgery International and European Journal of Pediatric Surgery over the past three decades.

The aim of this study was an analysis of the changing publication trends over the last three decades in the Journal of Pediatric Surgery (JPS), Pediatric Surgery International (PSI) and European Journal of Pediatric Surgery (EJPS) by studying the bibliometric variables, authorship, collaboration, and citation trends. A previously applied methodology using intermittent years was applied to review the archives of JPS, PSI and EJPS over the last 30 years. Citation data were collected from the Web of Science database. Statistical analysis was performed using SAS 9.4 software. A total of 1917 articles originating from 63 countries met the inclusion criteria. The number of articles published every year increased significantly in the last three decades from 336 in 1987 to 626 in 2017 (P < 0.0001). Multinational papers made up 5% of the total, of which 58% involved more than one continent. A majority of papers (75%) were single institution papers, there was strong evidence of an increase in multi-institution publications over time. There was a statistically significant increase in the number of female first and corresponding author. The publishing landscape of paediatric surgery has evolved to be more inclusive with increased collaboration, female authors and mentors and more publications from developing nations.

Developmental outcome at 3 years of age of infants following surgery for infantile hypertrophic pyloric stenosis.

PURPOSE: The study compared neurodevelopmental outcome at 3 years of age of infants with infantile hypertrophic pyloric stenosis (IHPS) who underwent pyloromyotomy with healthy control infants in New South Wales, Australia. METHODS: Infants with IHPS as well as controls were recruited between August 2006 and July 2008. Developmental assessments were performed using the Bayley scales of infant and toddler development (version III) (BSITD-III) at 1 and 3 years of age. RESULTS: Of the 43 infants originally assessed at 1 year, 39 returned for assessment at 3 years (90%). The majority were term infants (77%). Assessments were also performed on 156 control infants. Infants with IHPS scored significantly lower on four of the five Bayley subsets (cognitive, receptive and expressive language and fine motor) compared to control infants. Analysis of co-variance showed statistically significant results in favour of the control group for these four subsets. CONCLUSION: Compared with the outcomes at 1 year, infants with IHPS at 3 years of age continue to score below controls in four of the BSITD-III subscales. This suggests they should have developmental follow-up with targeted clinical intervention. There is a need for further studies into functional impact and longer term outcomes.

Elevated Preoperative Neutrophil-Lymphocyte Ratio is Predictive of a Poorer Prognosis for Pediatric Patients with Solid Tumors.

BACKGROUND: An elevated neutrophil-lymphocyte ratio (NLR) has been shown to indicate poorer prognosis for adults with solid tumors and potentially represents an independent, universal adjunct prognostic factor. The value of NLR in a pediatric setting has not been evaluated. This study sought to determine the prognostic value of NLR for pediatric patients with solid tumors. METHODS: Pediatric patients with solid tumors undergoing neoadjuvant chemotherapy followed by surgery with curative intent between 2000 and 2014 were eligible for this study. A preoperative peripheral blood count within 1 month of surgery taken after recovery from recent chemotherapy was analyzed in relation to overall survival (OS) and event-free survival (EFS). RESULTS: This retrospective study enrolled 293 patients. The median age at diagnosis was 46.5 months (range 0.1-206.1 months). Males accounted for 58% of the patients. The median OS was 49 months. An NLR cutoff of 2.5 was used in the analysis. In the univariate analysis, a high NLR was associated with low OS (p = 0.001) and low EFS (p = 0.020). Other factors identified in the univariate analysis that affected survival included metastatic disease at diagnosis (p < 0.001) and tumor type (p = 0.012). The multivariate analyses showed that a high NLR was associated with low OS (p = 0.014) but not with EFS (p = 0.270). The multivariate analysis of neuroblastoma patients found that a high NLR was associated with low OS (p = 0.013). CONCLUSIONS: An elevated NLR is prognostic of a poorer outcome for pediatric patients with solid tumors and potentially represents an independent, universal adjunct prognosticator in such cases.

A bibliometric analysis of pediatric liver transplantation publications.

Citation counts can identify landmark papers. The aim of this study was to identify and characterize the top-cited articles in the pediatric liver transplantation literature. A search strategy for the Scopus® database was designed for pediatric liver transplantation publications from 1945 to 2014. The 50 top-cited articles were analyzed. Author co-citation analysis was performed using VOSviewer techniques. There were 2896 articles published between 1969 and 2015. The mean citation count of the top 50 cited articles was 166 (range 95-635). There were three case reports in this top-cited list. There were 15 collaborations in this top-cited list with nine being international. The top-cited publications originated in 12 countries, with the USA and the UK contributing 31 and seven articles, respectively. There were 14 authors with four or more publications in this list. There was a single author with nine publications in the top-cited list. These top-cited papers were found in 16 journals, with three journals collectively publishing over 50% of these publications. Pediatric liver transplantation research is an evolving entity. Surgical techniques and case reports are influential articles. Collaborations at a national and international level produce highly cited articles, which are found in influential journals.

Does Functional Outcome Improve with Time Postsurgery for Hirschsprung Disease?

PURPOSE: Constipation and incontinence are significant problems following pull-through surgery for Hirschsprung disease (HD). There is evidence that these problems improve with time. However, there is also evidence showing no improvements and furthermore, significant long-term data are lacking for the newer endorectal pull-through. We aim to determine if there is clinical evidence that show improvements in functional outcomes with time after an endorectal pull-through surgery for HD. METHODS: We utilized the validated pediatric incontinence and constipation scoring system (PICSS) to score 51 consecutive children 3 months to 15 years posttransabdominal or transanal endorectal pull-through for HD. Cases of total colonic aganglionosis and Down syndrome were excluded. PICSS scores below the age-specific lower limit 95% confidence interval scores represent incomplete continence or constipation, respectively. We performed linear regression to analyze the relationship between PICSS scores and the follow-up duration and then compared the demographics of children with and without incomplete continence and constipation, respectively. Significance was set at p < 0.05. RESULTS: The median age at PICSS interview was 71 months (range, 6-191 months). Incontinence scores obtained from 42 children older than 35 months showed a positive relationship with the follow-up duration (p = 0.03). Constipation scores obtained from 51 children were unrelated to follow-up duration (p = 0.486). When demographics were compared, the continent children had longer follow-up than those with incomplete continence (mean, 111.64 vs. 69.19 months; p = 0.051), however follow-up duration did not differ in the group of constipated children compared with the nonconstipated group (mean, 61.88 vs. 71.80 months; p = 0.321). CONCLUSION: These findings suggest that after an endorectal pull-through, improved continence should be expected with time but constipation often continues to be an ongoing problem.

Pediatric burns research: A history or an evolution?

BACKGROUND/PURPOSE: Pediatric burns research has increasingly been recognized as a sub-specialty of its own. The aim of this study was to assess and analyze the publication patterns of the pediatric burns literature over the last six decades. METHODS: A search strategy for the Web of Science database was designed for pediatric burns publications, with output analyzed between two periods: 1945-1999 (period 1) and 2000-2013 (period 2). RESULTS: There were 1133 and 1194 publications for periods 1 (1945-1999) and 2 (2000-2013), respectively. The mean citation counts of the top 50 publications were 77 (range 45-278) and 49 (range 33-145) for periods 1 and 2, respectively. There were 26 and 20 authors with two or more publications in the top 50 list in periods 1 and 2, respectively. Of these there are two authors that have published 47 papers in both combined time-periods. There were 29 and 9 journals that have published 50% of the publications for time-period 1 and 2 respectively. In period 2, there were two burns journals that have published 37.2% of the total articles. CONCLUSIONS: Pediatric burns research has evolved from an associated, dispersed entity into a consolidated sub-specialty that has been successfully integrated into mainstream burns journals.

Percutaneous endoscopic gastrostomy (PEG) does not worsen vomiting in children.

PURPOSE: We aimed to evaluate the rate and examine potential predictors of subsequent anti-reflux procedures in a population undergoing percutaneous endoscopic gastrostomy (PEG) insertion. MATERIALS: We retrospectively reviewed the pre- and post-operative clinical course of patients undergoing PEG insertion over a 10-year period with respect to indication, underlying co-morbidity, and GER investigation and management. RESULTS: We reviewed data on 170 patients. Neurological disability (e.g., cerebral palsy) was the most common underlying condition in those undergoing PEG insertion (n = 104) followed by cystic fibrosis (n = 29). Oropharyngeal dysphagia and failure to thrive were the commonest indications for PEG. Eight patients (4.7%) reported increased frequency of vomiting after PEG, 6 (75%) of whom had a pre-operative diagnosis of GER. Two (25%) patients from this sub-group subsequently required anti-reflux surgery. Patient's with neurological disease were not at increased risk of new-onset GER or increased vomiting following PEG insertion compared to those with non-neurological conditions (p = 0.259). In total, 8 (4.7%) and 7 (4.1%) patients underwent fundoplication and gastrojejunal tube insertion, respectively. CONCLUSIONS: PEG insertion does not appear to induce symptomatic gastro-oesophageal reflux in the majority of children, suggesting that in the majority of cases, a concurrent anti-reflux procedure is unnecessary. Parents should be counseled accordingly.

The use of the trapdoor incision for access to thoracic inlet pathology in children.

Lesions at the thoracic inlet are difficult to access via a thoracic or cervical approach. The use of the anterior cervico-thoracic trapdoor incision has been reported to give good exposure to the anterior superior mediastinum in adults. We report our experience of four cases where a trapdoor incision was used to gain excellent access and exposure to thoracic inlet pathology in children.

Patterns of internet use by parents of children attending a pediatric surgical service.

PURPOSE: The internet has revolutionised the way we search for information. We determined the level of internet use by parents of children attending general surgical services and identified trends in online information-seeking behaviour. METHODS: A questionnaire based on the work by Boston and Tassone was distributed to parents attending both the day surgical units and surgical outpatients department in a paediatric tertiary referral centre. RESULTS: There were 214 (82.3 %) questionnaires returned, with 82 (38.3 %) of respondents having searched the internet regarding their child's surgical issue. Access to a smartphone, a university education and private health insurance were factors that positively influenced online searching (p < 0.005). Of those respondents who searched the internet, 42 (51 %) felt that information they found online was understandable, while only 14 (17 %) admitted to online sourced information influencing the treatment decisions they had made for their children. When asked to rank information sources on Likert-type scales in terms of importance; parents ranked the surgeon as most important (mean = 4.73), whilst the internet ranked lowest (mean = 3.02). CONCLUSION: We demonstrated significant use of the internet amongst those attending paediatric general surgical services. Clinician sourced information remains important, however we should engage with patients to utilise this vast resource effectively.

Publication patterns on neonatal surgery over 65 years.

BACKGROUND/PURPOSE: Staying abreast of the literature in a given speciality is difficult. The aim of this study is to analyze the publication patterns of the neonatal surgical literature over the last six decades. MATERIALS: A search strategy for the Web of Science database was designed using MeSH defined terms for 10 index neonatal surgical conditions, with output analyzed over two time-periods. RESULTS: There were 6215 and 6144 publications for periods 1 (1945-1994) and 2 (1995-2010), respectively. There were 24 and 546 articles published in 1945 and 2010, respectively. The mean citation counts of the top 50 publications are 228 and 156 for periods 1 and 2, respectively. There were 6 and 11 authors with two or more publications in the top 50 list in periods 1 and 2, respectively. Three of the pediatric surgery journals cumulatively have published 30.9% of the total articles. CONCLUSIONS: Publication patterns for neonatal surgical conditions have changed significantly over time. The majority of articles are published outside of pediatric surgical journals. Pediatric surgeons should not limit their reading to these journals.

Are routine dilatations necessary post pull-through surgery for Hirschsprung disease?

INTRODUCTION: We aim to compare the anastomotic stricture and enterocolitis rates between groups who either had or did not have anal dilatations (AD or NAD) prescribed routinely post pull-through surgery for Hirschsprung disease (HD); by this means, we will evaluate the benefit of routine dilatations. METHODS: A retrospective review of the records of all children operated on for HD between 1997 and 2010 was performed. Associated Down syndrome and total colonic aganglionosis were excluded. Two cohorts were identified; those who had anal dilatation prescribed routinely (AD) and those who did not (NAD). In the latter group, if an anastomotic stricture was subsequently diagnosed, anal dilatations were initiated. The anastomotic stricture and enterocolitis rates between groups were compared. Significance was set at p < 0.05. RESULTS: There were 73 children that met the inclusion criteria (30 AD and 43 NAD). The NAD group had the longer mean follow-up period of 91 versus 59 months (p = 0.026); however, follow-up duration was unrelated to the anastomotic stricture rates (p = 0.575) and enterocolitis rates (p = 0.150). The anastomotic stricture rates were 13% (n = 4) versus 14% (n = 6) (p = 1.000) for the AD and NAD groups, respectively (relative risk [95% confidence interval] RR [95% CI], 0.95 [0.29 to 3.09]; p = 0.94). The mean duration between surgery and stricture occurrence was 348 versus 74 days for the AD and NAD groups, respectively. The enterocolitis rates were 23% (n = 7) versus 28% (n = 12) (p = 0.788) for the AD and NAD groups, respectively (RR [95% CI], 0.84 [0.37 to 1.87]; p = 0.66). CONCLUSION: We have not shown a reduced risk of developing anastomotic strictures or enterocolitis if anal dilatations are prescribed routinely. However, when routine dilatations were prescribed, predominantly late onset strictures of perhaps a different etiology occurred.

Scrotal exploration for acute scrotal pain: a 10-year experience in two tertiary referral paediatric units.

OBJECTIVE: Acute scrotal pain is a common presentation to the paediatric emergency department. Testicular torsion is one of the most common causes of acute scrotal pain. Testicular torsion is a surgical emergency requiring immediate surgical exploration to prevent permanent testicular damage or loss. The aim of this study was to determine the surgical outcome of all scrotal explorations and to assess the use of colour Doppler ultrasound (CDUS) in the assessment of acute scrotal pain in two tertiary referral paediatric units. MATERIAL AND METHODS: A retrospective review of a prospectively maintained database was carried out for all scrotal explorations between 1999 and 2010. RESULTS: In total, 155 scrotal explorations were carried out for acute scrotal pain. The mean age was 9.1 years (range 0-15 years). The pathology in 46.5% (n = 72) was testicular torsion, 30.3% (n = 47) were torsion of a testicular appendage, 16.1% (n = 25) were epididymitis, 3.3% (n = 5) had no obvious pathology identified and other pathology accounted for 4%. There was a significant difference in age of presentation between those with testicular torsion and those with torsion of a testicular appendage (9 vs 10 years, p = 0.0074). CDUS was performed by a trained radiologist on 40 patients. Overall sensitivity, specificity, positive predictive value and negative predictive value for CDUS predicting testicular torsion were 96.9%, 88.9%, 96.9% and 89%, respectively. Overall, 36 patients (23%) with acute scrotal pain (50% of patients in the group with confirmed testicular torsion at exploration) required orchidectomy. CONCLUSION: This study supports the practice of immediate surgical exploration with a clinical suspicion of testicular torsion in a paediatric population.

Comparative review of functional outcomes post surgery for Hirschsprung's disease utilizing the paediatric incontinence and constipation scoring system.

PURPOSE: We aim to analyze differences in functional outcomes in children operated on for Hirschsprung's disease (HD) using the Paediatric incontinence/constipation scoring system (PICSS) validated in a normative group. METHODS: A retrospective review of the records of all children operated on for HD between 1997 and 2010 was performed. Patients had either a Soave or transanal endorectal pull-through. Children with total colonic aganglionosis and Down's syndrome were excluded. Utilizing the PICSS children who scored below their age-specific lower limit 95 % confidence interval PICSS scores were considered to have incomplete continence or constipation. The rates of incomplete continence and constipation were compared between groups. Significance was set at p < 0.05. RESULTS: PICSS analysis could be completed in 51 (Soave 35, transanal 16). The median age at interview was 71 months (range 6-191 months). The rate of incomplete continence was 75 % (n = 21) and 71 % (n = 10) for the Soave and transanal groups, respectively (p = 1.00). The constipation rate was 34 % (n = 12) and 25 % (n = 4) for the Soave and transanal groups, respectively (p = 0.74). The overall rates of incomplete continence and constipation rates were 74 and 31 %, respectively, compared with 14 and 10 %, respectively, when rates were calculated by review of records. CONCLUSION: The PICSS is a sensitive tool for assessing functional outcome post HD surgery. The Soave and transanal procedures have similar functional outcomes.

Urinary incontinence in children: botulinum toxin is a safe and effective treatment option.

PURPOSE: This study's aim was to assess the use of intravesical injection of botulinum neurotoxin type A (BoNT-A) as a treatment of overactive bladder (OAB) in children. METHODS: A 6-year retrospective study of children who received BoNT-A for OAB was performed. Treatment outcome was classified as complete success (CS), partial success (PS) or treatment failure (TF). RESULTS: Of the 57 patients who received BoNT-A treatment for OAB, 35 were males. CS occurred in 74.2% of males and 54.5% of females. PS was achieved in 20% of males and 18.2% of females. TF occurred in 2.9% of males and 22.7% of females. Anticholinergics had previously been used and had been effective in 58.6% and 83.3% of males and females. Significant side effects to medications were experienced in 12 (41.4%) males and 4 (22.2%) females. Of these, BoNT-A achieved CS in seven (53.3%) males and two (50%) females and PS in three (25%) males and one (25%) female. BoNT-A was successful in seven (58.3%) males and two (66.7%) females where anticholinergics were ineffective. CONCLUSIONS: BoNT-A has a role in a carefully selected subgroup of children with overactive bladder symptoms including those with medication side effects and treatment compliance issues. It may have a role in patients who do not respond to conventional therapy.

Serum proteomic profiling reveals that pretreatment complement protein levels are predictive of esophageal cancer patient response to neoadjuvant chemoradiation.

OBJECTIVE: To identify serum-based biomarkers predicting response to neoadjuvant chemoradiotherapy (neo-CRT) in esophageal cancer. PURPOSE: Increasingly, the standard of care for esophageal cancer involves neo-CRT followed by surgery. The identification of biomarkers predicting response to therapy may represent a major advance, enabling clinical trials and improved outcomes. BACKGROUND DATA: Patients with esophageal cancer (n = 31) received a standard neo-CRT regimen. Histopathologic response to therapy was assessed by using the Mandard tumor regression grade (TRG) classification. Serum was collected pretreatment and at 24-hour and 48-hour time points into treatment. Serum samples were analyzed by using Surface-enhanced laser desorption/ionization time-of-flight mass spectrometry and enzyme-linked immunosorbent assay. A leave-one-out cross-validation predictive algorithm assessed the ability of validated biomarkers to correctly predict therapeutic outcome. RESULTS: Fifty-one percent (16) of patients were poor responders (TRG 3-5), whereas 49% (15) responded well (TRG 1-2). On CM10 biochips, serum expression of 9 protein peaks was significantly different between the response groups. Two differential spectrum peaks were identified as complement C4a and C3a and were subsequently analyzed by enzyme-linked immunosorbent assay. Pretreatment serum C4a and C3a levels were significantly higher in poor responders versus good responders. Subdivision of the response groups by TRG indicated an inverse correlation between levels of C4a and C3a and pathological response to neo-CRT. The leave-one-out cross-validation analysis revealed that these serum proteins could predict response to neo-CRT with a sensitivity and specificity of 78.6% and 83.3%, respectively. CONCLUSIONS: This translational application of proteomics technology identifies pretreatment serum levels of C4a and C3a as predictive biomarkers of response. Large validation studies in an independent cohort are merited.

Increased spontaneous apoptosis, but not survivin expression, is associated with histomorphologic response to neoadjuvant chemoradiation in rectal cancer.

PURPOSE: Survivin has been shown to be an important mediator of cellular radioresistance in vitro. This study aims to compare survivin expression and apoptosis to histomorphologic responses to neoadjuvant radiochemotherapy (RCT) in rectal cancer. MATERIALS AND METHODS: Thirty-six pre-treatment biopsies were studied. Survivin mRNA and protein expression plus TUNEL staining for apoptosis was performed. Response to treatment was assessed using a 5-point tumour regression grade. RESULTS: Survivin expression was not found to be predictive of response to RCT (p = NS). In contrast, spontaneous apoptosis was significantly (p = 0.0051) associated with subsequent response to RCT. However, no association between survivin expression and levels of apoptosis could be identified. CONCLUSIONS: This in vivo study failed to support in vitro studies showing an association between survivin and response to chemotherapy and radiation therapy. These results caution against the translation of the in vitro properties of survivin into a clinical setting.