Blocking STAT3/5 through direct or upstream kinase targeting in leukemic cutaneous T-cell lymphoma.

Leukemic cutaneous T-cell lymphomas (L-CTCL) are lymphoproliferative disorders of skin-homing mature T-cells causing severe symptoms and high mortality through chronic inflammation, tissue destruction, and serious infections. Despite numerous genomic sequencing efforts, recurrent driver mutations have not been identified, but chromosomal losses and gains are frequent and dominant. We integrated genomic landscape analyses with innovative pharmacologic interference studies to identify key vulnerable nodes in L-CTCL. We detected copy number gains of loci containing the STAT3/5 oncogenes in 74% (n = 17/23) of L-CTCL, which correlated with the increased clonal T-cell count in the blood. Dual inhibition of STAT3/5 using small-molecule degraders and multi-kinase blockers abolished L-CTCL cell growth in vitro and ex vivo, whereby PAK kinase inhibition was specifically selective for L-CTCL patient cells carrying STAT3/5 gains. Importantly, the PAK inhibitor FRAx597 demonstrated encouraging anti-leukemic activity in vivo by inhibiting tumor growth and disease dissemination in intradermally xenografted mice. We conclude that STAT3/5 and PAK kinase interaction represents a new therapeutic node to be further explored in L-CTCL.

The "chicken-leg anastomosis": Low-cost tissue-realistic simulation model for esophageal atresia training in pediatric surgery.

Introduction: Shifting the training from the operating room (OR) to simulation models has been proven effective in enhancing patient safety and reducing the learning time to achieve competency and increase the operative efficiency. Currently the field of pediatric surgery only offers few low-cost trainers for specialized training and these feature predominantly artificial and often unrealistic tissue. The aim of this study was to develop an easy access low-cost tissue-realistic simulation model for open training of esophageal atresia and to evaluate the acceptance in trainees and junior pediatric surgeons. Materials and methods: The model is fashioned using reconfigured chicken skin from a chicken leg. To create a model of esophageal atresia, the chicken skin is dissected off the muscle and reconfigured around a foley catheter balloon to recreate the proximal pouch and a feeding tube to recreate the distal pouch. Surrounding structures such as the tracheo-esophageal fistula and the azygos vein can be easily added, obtaining a realistic esophageal atresia (Type C) prototype. Evaluation of model construction, usage and impact on user were performed by both a self-assessment questionnaire with pre- and post-training questions as well as observer-based variables and a revised Objective Structured Assessment of Technical Skills (OSATS) score. Results: A total of 10 participants were constructing and using the model at two different timepoints. OSATS score for overall performance was significantly higher (p = 0.005, z = -2.78) during the second observational period [median (MD): 4,95% confidence interval CI: 3.4, 5.1] compared to the first (MD: 3, 95% CI 2.4, 4.1). Self-reported boost in confidence after model usage for performing future esophageal atresia (EA) repair and bowel anastomosis (BA) in general was significantly higher (EA: U = 1, z = -2.3, p = 0.021, BA: U = 1, z = -2.41, p = 0.016) in participants with more years in training/attending status (EA MD:5, BA MD: 5.5) compared to less experienced participants (EA MD: 1.5, BA: 1). Conclusion: Our easy access low-cost simulation model represents a feasible and tissue realistic training option to increase surgical performance of pediatric surgical trainees outside the OR.

Is There a Role for Elective Early Upper Gastrointestinal Contrast Study in Neurologically Impaired Children following Laparoscopic Nissen Fundoplication?

Assessment of discomfort as a sign for early postoperative complications in neurologically impaired (NI) children is challenging. The necessity of early routine upper gastrointestinal (UGI) contrast studies following laparoscopic Nissen fundoplication in NI children is unclear. We aimed to evaluate the role of scheduled UGI contrast studies to identify early postoperative complications following laparoscopic Nissen fundoplication in NI children. Data for laparoscopic Nissen fundoplications performed in NI children between January 2004 and June 2021 were reviewed. A total of 103 patients were included, with 60 of these being boys. Mean age at initial operation was 6.51 (0.11-18.41) years. Mean body weight was 16.22 (3.3-62.5) kg. Mean duration of follow up was 4.15 (0.01-16.65 years) years. Thirteen redo fundoplications (12.5%) were performed during the follow up period; eleven had one redo and two had 2 redos. Elective postoperative UGI contrast studies were performed in 94 patients (91%). Early postoperative UGI contrast studies were able to identify only one complication: an intrathoracal wrap herniation on postoperative day five, necessitating a reoperation on day six. The use of early UGI contrast imaging following pediatric laparoscopic Nissen fundoplication is not necessary as it does not identify a significant number of acute postoperative complications requiring re-intervention.

Assessment of sacral ratio in patients with anorectal malformations: Can magnetic resonance imaging replace conventional radiograph?

INTRODUCTION: In patients with anorectal malformations (ARM), the sacral ratio (SR) serves as an established predictive marker for functional prognosis and is derived from conventional radiographs. More recently, magnetic resonance imaging (MRI) has emerged as a diagnostic alternative for preoperative/baseline assessment of patients with ARM. With this study we aimed to evaluate if the SR could be reliable be measured from MRI images and if it correlated to SR measurements obtained from radiographs. METHODS: Two raters analyzed MRI data and conventional radiographs from thirty-one subjects (n = 17 with ARM; n = 14 controls). We calculated intra-class correlation coefficients (ICCs) to test inter-rater reliability and applied paired t-tests to examine if SR parameters from MRI were comparable with those from pelvic radiograph. We further computed Pearson's correlation coefficients to test the linear relationship between SR calculated from MRI and conventional radiographs. RESULTS: The ARM and control groups did not statistically differ in their age and weight on the day of the MRI scan. Reliability analysis revealed an excellent inter-rater agreement for SR from radiograph parameters with an intraclass correlation coefficient (ICC) of 0.94, respectively of 0.86 for MRI (frontal plane), and of 0.84 for MRI (sagittal plane). The correlation coefficient between SR calculated from the sagittal MRI and SR calculated from radiograph images was significant and high (r = 0.80, P < 0.001). The SRs from MRI images did not significantly differ from SRs from radiographs, but were also not statistically equivalent. CONCLUSION: Our results demonstrate that the SR can be derived from MRI images with good inter-rater reliability. The SR value is marginal higher when calculated on MRI, presumably due to inclusion of cartilaginous yet unossified structures.

The Effect of Pediatric Colorectal Short-Term Medical Service Trips on Self-Reported Confidence in Patient Care in Volunteers in the Home Country.

Introduction: Short-term international medical service trips (MST) are established means to access specialized medical aid in resource-limited areas. The field of pediatric colorectal surgery is a subspecialty in pediatric surgery that mainly treats anorectal malformations (ARM) and Hirschsprung disease (HD). This study aimed to investigate the impact of MST on the donors' perception of competency concomitantly to the impact on patients in the donors' home country. We also wanted to investigate whether the donors' pre-existing experience in the field of ARM and HD affects the experience they gain during the MST, and the subjective perception in treating patients in their base country. Methods: We created a questionnaire for the international medical staff participating in MSTs on the unique topic of pediatric colorectal diseases. The questionnaire was split into three parts: essential experience (1) in the field of colorectal surgery of the participant, the experience and impact on patient care in the home country during and after the MST in ARM (2), and in HD (3). Results: We collected data from 20 participants (6 female, 14 male). The majority of them had prior experience with the MST program (75%) and came from institutions specialized in the treatment of pediatric colorectal disorders (80%). Participants felt that MST improved patient care in both the host country (p < 0.001) and their home country (p < 0.001). Experienced and less experienced participants did not differ in the overall MST evaluation (ps > 0.08). They reported that their competencies to treat ARM and HD improved significantly in response to the MST (ps < 0.001). Improvements in ARM and HD treatment were associated with the number of supervised HD surgeries during MST, while the other forms of participation were unrelated to the improvements. Conclusion: The results of our questionnaire indicate that participation in MST in the specialized field of pediatric colorectal surgery helps to improve confidence in the care and treatment of affected patients in both the host and donor countries, independent of previous surgical experience.

Joint Attention in a Laparoscopic Simulation-Based Training: A Pilot Study on Camera Work, Gaze Behavior, and Surgical Performance in Laparoscopic Surgery.

Introduction: Training in laparoscopic surgery seems to be an important aspect in gaining and maintaining professional competency. In experimental settings, camera navigation skills improved after simulation-based training, but the effect of camera work on the surgeon's performance is not well studied. The aim of this study was to investigate whether a fixed camera or an operated camera, as well as the experience of the camera operator has an effect on the performance of the surgeon. Materials and Methods: The study was performed on the LapSim laparoscopic training system. The task was to tie an intracorporal knot in a static surgical environment with three different camera conditions: fixed camera, camera operated by an inexperienced person (inexpert camera), and camera operated by an experienced surgeon (expert camera). The camera conditions were counterbalanced across trials. Performance variables were completion time in seconds and the extend of movements in path length and angular pathway. Gaze behavior was measured with eye-tracking glasses worn by the surgeon as well as the camera operator and was evaluated for performance-harming effects. Results: Completion time varied across conditions, with participants performing significantly longer in the fixed camera condition than in the expert or the inexpert condition. The expert and inexpert conditions did not differ. The performance-harming effect of non-focusing on the tissue was especially visible in the fixed camera condition but disappeared in the expert camera condition. Neither the camera operators' gaze behavior nor the surgeon-camera operator fixation agreement predicted task performance. Discussion: A camera operator can potentially eliminate performance-harming effects of maladaptive gaze behavior and promote optimal visual behavior of a surgeon. In our experimental task, there was no significant difference in whether the camera operator had previous training in laparoscopic surgery or not.

Impact of Capnoperitoneum on Renal Perfusion and Urine Production in Infant and Adolescent Pigs: Crystalloid versus Colloid Fluid Resuscitation.

BACKGROUND: Infants are likely to develop anuria during laparoscopy which is uncommon in older patients. The reason for this susceptibility remains unknown. We compared the impact of CO2 pneumoperitoneum on renal perfusion and urine production in piglets compared with adolescent pigs. We furthermore investigated the effects of different resuscitation strategies. MATERIALS AND METHODS: Male piglets (n = 21) were divided into four groups: (a) infant controls (n = 5), (b) infants with crystalloid restitution (n = 6), (c) infants with colloidal restitution (n = 5), and (d) adolescents with crystalloid restitution (n = 5). Animals were ventilated, the central vessels and ureters were cannulated, and the animals were subjected to a 3-hour, 10 mm Hg CO2 pneumoperitoneum followed by 2-hour resuscitation. Renal perfusion was assessed by fluorescent microspheres and the rate of urine flow was measured. RESULTS: Urine production significantly decreased after insufflation only in the infant crystalloid and adolescent group, but not in controls or infants treated with colloids. In the infant crystalloid group, urine production remained at levels below 20% of baseline throughout the experiment. In this group, the renal perfusion dropped significantly after the beginning of the capnoperitoneum and remained significantly reduced throughout the experiment. CONCLUSION: Our data indicates that capnoperitoneum impairs renal perfusion and urine production in infants. In moderate-pressure capnoperitoneum, this effect cannot be compensated by application of crystalloids but with colloids.

Interleukin-6 serum levels predict surgical intervention in infants with necrotizing enterocolitis.

BACKGROUND: Symptoms at suspicion of necrotizing enterocolitis (NEC) are often nonspecific and several biomarkers have been evaluated for their discriminative power to both diagnose and predict the course from NEC suspicion to complicated disease requiring surgical intervention. Thus, we aimed to assess the utility of interleukin-6 (IL-6) to predict surgical intervention in infants suffering from NEC and, furthermore, to discriminate infants with starting NEC or late-onset sepsis (LOS). METHODS: IL-6 serum levels at disease onset were retrospectively analyzed in 24 infants suffering from NEC as well as 16 neonates with LOS. RESULTS: IL-6 serum levels at disease onset were significantly higher in infants suffering from NEC necessitating surgical intervention in the disease course compared to infants with medical NEC (5000 [785-5000] vs. 370 [78-4716] pg/ml, p = 0.0008) as well as gram-positive LOS (5000 [785-5000] vs. 84 [12-269] pg/ml, p = 0.0001). Infants suffering from gram-negative LOS exhibited elevated IL-6 serum levels at disease onset comparable to infants with surgical NEC (5000 [1919-5000] vs. 5000 [785-5000] pg/ml, p = 1.00). CONCLUSION: The proinflammatory cytokine IL-6 appears to be a promising marker to distinguish surgical NEC from medical NEC at the onset of disease but cannot discriminate between surgical NEC and gram-negative LOS. LEVEL OF EVIDENCE: II.

Bladder augmentation in children: current problems and experimental strategies for reconstruction.

Bladder augmentation is a demanding surgical procedure and exclusively offered for selected children and has only a small spectrum of indications. Paediatric bladder voiding dysfunction occurs either on a basis of neurological dysfunction caused by congenital neural tube defects or on a basis of rare congenital anatomic malformations. Neurogenic bladder dysfunction often responds well to a combination of specific drugs and/or intermittent self-catheterization. However, selected patients with spinal dysraphism and children with congenital malformations like bladder exstrophy and resulting small bladder capacity might require bladder augmentation. Ileocystoplasty is the preferred method of bladder augmentation to date. Because of the substantial long-and short-term morbidity of augmentation cystoplasty, recent studies have tried to incorporate new techniques and technologies, such as the use of biomaterials to overcome or reduce the adverse effects. In this regard, homografts and allografts have been implemented in bladder augmentation with varying results, but recent studies have shown promising data in terms of proliferation of urothelium and muscle cells by using biological silk grafts.

Using pediatric liver grafts (≤ 6 yr) for adult recipients: A considerable option?

In LT, the common policy is to allocate pediatric liver grafts to pediatric recipients. Pediatric organs are also offered to adults if there is no pediatric recipient. However, they are rarely accepted for adult recipients. So far, there is no information available reporting outcome of LT in adult recipients using pediatric livers from donors ≤ 6 yr. In this study, we included nine adult recipients (seven females and two males) who received grafts from children ≤ 6 yr from January 2008 to December 2013. We evaluated the graft quality, the GBWR and analyzed the recipients' perioperative course. Laboratory samples and graft perfusion were analyzed. Nine adults with a median age of 49 yr (range: 25-65) and a median weight of 60 kg (range: 48-64) underwent LT with a pediatric donor graft. Median donor age was five yr (range: 3-6). Median GBWR was 1.02 (range: 0.86-1.45). After a median follow-up of 3.9 yr (range: 11 months-6.6 yr), patient survival was 100%; graft survival was 89%. One patient needed re-transplantation on the second postoperative day due to PNF. Eight recipients were discharged from the ICU after 2-9 days with a regular graft function. Doppler scans revealed regular flow patterns at any time. Only if denied for pediatric recipients, the use of pediatric livers from donors ≤ 6 yr for adult recipients is a considerable option.

First case studies of successful ABO-incompatible living-related liver transplantation in infants in Germany.

AIM: A series study mainly from Asia suggests that ABO-incompatible (ABOi) living-related liver transplantation (LRLT) for pediatric recipients is associated with excellent short- and long-term graft and patient survival. Until now, ABOi LRLT has been rarely performed in Europe. The aim of this study was to analyze the safety and early results of an ABOi LRLT in a German high-volume pediatric liver transplant center. METHODS: Six consecutive pediatric patients (four males and two females) were included in this prospective study from January, 2010 to January, 2013 with a median age of 13 months (range, 6-30 months) receiving ABOi LRLT and were matched with six patients receiving ABO-compatible LRLT in the same period. In the ABOi group, titers of IgG and IgM isoagglutinins against the donor's blood group were determined at day 14 before the transplantation and from day 1 to 14 after the transplantation, and then twice a week for another 8 weeks. The titer results were determined as the reciprocal number of the highest serum dilution that caused macroscopical reaction. RESULTS: The patients receiving ABOi and those receiving ABO-compatible LRLT were comparable regarding the recipient's preoperative pediatric end-stage liver disease (PELD), age, gender, and technical aspects of transplantation. The median follow-up was 2.6 years (range, 1-4.5 years). At the time of operation, the mean body weight was 7.7 kg (range, 5.7-16 kg) in ABO-compatible LRLT recipients and 8.8 kg (range, 5.5-18 kg) in ABOi LRLT recipients. In each group, the median PELD score was 28 (range, 28-35), respectively. All recipients received tacrolimus plus mycophenolate mofetil-based standard immunosuppression and four ABOi transplanted patients received intravenous immunoglobulins at days 1, 3, and 5 after liver transplantation. Patient and graft survival in this group was 83%. One female patient died within 24 hours due to fulminant gram-negative sepsis. Another patient developed acute cellular rejection at the 8th postoperative day, which responded to steroid treatment. No further complications occurred. In the ABO-compatible group, patient survival was 100% and graft survival was 83%; one patient in this group received retransplantation after 4 days. During follow-up, two patients of the ABOi group had maximum alloantibody titers of four against the donor's blood group; all other patients had titers below four. CONCLUSION: ABOi LRLT seems to be safe without an escalation of immunosuppression and should be considered as an additional option to timely facilitate the transplantation.

Awake caudals and epidurals should be used more frequently in neonates and infants.

The current literature provides fundamental insights regarding the neurotoxic potency of various general anesthetic drugs in neonates and small infants. Therefore, considerations to minimize the use of general anesthetic drugs in this age group are required. The use of caudal and epidural anesthesia under sedation is one possibility to minimize the use of general anesthetic drugs. A large number of surgical procedures can be managed with this anesthetic concept. Training, practical hand skills, good infrastructure, a well-defined indication, and a team approach including the entire operation room staff are the major prerequisites to implement these techniques in the daily clinical practice. This review article discusses all present aspects and possible future evolutions of caudal and epidural anesthesia under sedation.

Spectrum of pathogens in native liver, bile, and blood during pediatric liver transplantation.

During LTX, there may be a risk that pathogens of the native liver are released into the systemic circulation. No investigations on incidence/spectrum of pathogens in native livers have been published. We hypothesized that pathogens are found in the native liver of a large proportion of pediatric patients during LTX and investigated the microbiology of native livers. These data may help optimize antibiotic therapy. Twenty-two consecutive pediatric patients (median age 14 months, range, 5 months-15 yr) receiving LTX in our department from October 2010 to October 2011 were included in this prospective study. Tissue and bile were collected from the explanted liver and were cultivated on different media. All liver tissues were investigated using a broad-range PCR (SepsiTest(®)). In 16 patients, blood cultures were collected post-transplantation. Eleven patients (50%) had at least one pathogen detected; nine of these patients had an underlying diagnosis of biliary atresia. SepsiTest(®) was positive in seven patients. In four patients it was the only test detecting any pathogen. In detail, the positivity rate for liver tissue in all patients was 41% (n = 9); for bile 25% (n = 3); and for blood 25% (n = 4). Thirteen different pathogens (69% bacterial, 31% fungal) were isolated. A highly-sensitive broad-range PCR appears to be an effective method to detect pathogens in native livers of patients undergoing LTX. A high number and variety of microbes, including a high proportion of fungal pathogens, were detected.

Implementation of fast-track pediatric surgery in a German nonacademic institution without previous fast-track experience.

Fast-track concepts in pediatric surgery were established in a university hospital in consecutive studies within several years. They significantly reduced the length of hospitalization compared with German institutions without fast-track protocols. The aim of this study was to assess the implementation process of fast-track in a German nonacademic department of pediatric surgery without previous fast-track experience. All patients undergoing four types of operations (appendectomy, hypospadias repair, pyloromyotomy, and fundoplication) from February 2011 to January 2012 were included in this prospective study. Fast-track included detailed clinical pathways and specific pain treatment protocols using validated pain scales according to age. Mobilization and oral nutrition were started 2 hours postoperatively and documented with established scores. The length of hospital stay was compared with data from other hospitals with conventional treatment using information from the German reimbursement system (German diagnosis-related groups [G-DRG]) and with the hospital stay of patients from the corresponding university hospital undergoing fast-track treatment for the same procedures during the same study period. Two weeks after discharge, a questionnaire was completed by the patients/parents. A total of 143 patients with a mean age of 7.9 ± 5.0 years underwent fast-track treatment. The mean pain intensity during the immediate postoperative period was 1.7 ± 2.1 in patients < 4 years and 2.3 ± 2.1 in patients ≥ 4 years on a 10-point scale. Full mobilization was reached after a mean duration of 2.3 ± 2.0 days while full oral nutrition was completed after a mean duration of 1.8 ± 1.4 days. There were no complications associated with fast-track. The mean hospital stay was 5.8 ± 3.4 days which was not significantly different compared with G-DRG data from other hospitals without fast-track. This was in contrast to the mean hospital stay of patients from the corresponding university hospital (5.6 ± 3.0 days vs. G-DRG 6.9 ± 3.2 days, p < 0.05). After 2 weeks, patients/parents were highly satisfied with fast-track (mean score of 8.6 ± 1.4 on a 1-10-point scale) and 95.2% claimed that they would choose it again. Fast-track concepts can be applied in a nonacademic department of pediatric surgery without previous fast-track experience and with excellent patient/parent satisfaction. However, the G-DRG system interferes with concepts of early discharge of patients. Modifications of the reimbursement modalities within the German health care system seem to be mandatory.

Current status of laparoscopic appendectomy in children: a nation wide survey in Germany.

INTRODUCTION: Management of appendicitis in children has changed remarkably over the last decade. The proven benefits of laparoscopic appendectomy (LA) over the open operation have made LA increasingly popular for pediatric patients. To date, no national clinical practice guideline is available for pediatric LA in Germany and the operation is not standardized. Thus, the aim of our study was to evaluate the current status of pediatric LA in Germany. MATERIALS AND METHODS: An internet-based survey was conducted on pediatric LA among all 98 registered pediatric surgical units in Germany, comprising 22 questions with regard to utilization and subjective appraisal of LA, technical standards, perioperative treatment, and training aspects. RESULTS: The survey was completed by 71 of the 98 units (72%). Technical infrastructure for LA was provided in all units, but only in 79% of the units was LA, the standard approach for appendectomy. Overall quality of LA was rated better compared with open appendectomy by 52% units, equivalent by 38% and worse by 3%. The three-port technique was used by 90% of the units; 10% used a single-port approach. Dissection of the mesoappendix was done with bipolar coagulation in 55%, monopolar coagulation in 24%, harmonic knife in 6%, and endostaplers in 11% of the units. Closure of the appendiceal stump was performed using endoloops in 57%, ligations in 3%, endostaplers in 39%, and harmonic knife in 1%. Removal of the appendix was done through the port by 79%, using a retrieval bag by 18%, whereas in 3% it was removed directly through laparotomy. In case of appendiceal perforation, an intra-abdominal drain was placed in 65%. Perioperative antibiotic treatment for nonperforated appendicitis was given as a single shot in 33% of the units, for 24 hours in 17%, for 3 days in 39%, and for 5 to 7 days in 11%. LA was performed by a trainee under supervision in 87%, by a board approved pediatric surgeon in 2%, by an attending pediatric surgeon in 7%, and by the surgeon-in-chief in 4% of the units. For 93% of the sample, LA was an essential part of pediatric surgical training. CONCLUSION: LA is the favored surgical method for pediatric appendectomy in Germany. However, technical details, perioperative therapy and implementation into training programs remain inconsistent. An effort has to be made to establish national clinical practice guidelines to achieve standardization of LA.

General practitioners assessment highlights excellent patient satisfaction following bar removal after Nuss procedure in children and adolescents.

BACKGROUND: We recently demonstrated that minimally invasive repair of pectus excavatum (MIRPE) achieves a lasting patient satisfaction after bar removal. This correlated with parent ratings. It has been postulated that patient ratings may be biased by high preoperative patient expectations. The aim of this study was to compare patient self-assessment with general practitioners (GPs) assessment. METHODS: Of the 39 patients who underwent bar removal after MIRPE between 2002 and 2006, 39 GPs were asked to answer a modified version of a former single-step questionnaire to evaluate their opinion on psychosocial and physical well-being of their patients. The subjective patient ratings were compared with the GP ratings. RESULTS: Of the 39 GPs, 22 (56%) completed a questionnaire and assessed the outcome of the Nuss procedure. There was a highly significant correlation between GP and patient ratings (p<0.001; correlation coefficient=0.437). Mean total scores obtained from GPs were similar to patient scores (63.4±2.6 SEM vs. 67.5±2.4 SEM; not significant [NS]). Detailed analysis revealed that GPs scored several items differently to their patients: GPs scored social activity (p<0.05) and preoperative self-esteem (p<0.05) significantly lower, but pain episodes (p<0.05) and impairment of daily activities (p<0.05) during the period with the implanted bar significantly higher than their patients. Comparison of the 17 nonassessed cases, with the self-assessment of 22 patients with GP assessment, revealed no significant difference, making an analytical bias unlikely (67.5±2.4 SEM vs. 67.3±2.8 SEM; NS). CONCLUSION: GPs found a higher impairment of patient well-being during the period with an implanted bar, which might be related to the high patient motivation to cope with bar impairment. However, the all over GP and patient satisfaction was similar and excellent.

Thoracoscopic resection of congenital pulmonary malformations in infants: is the feasibility related to the size of the lesion?

BACKGROUND: The size of congenital pulmonary malformation (CPM) in infants might interfere with the feasibility of thoracoscopic resection. This study was undertaken to evaluate the impact of the size of CPM on the applicability of video-assisted thoracic surgery (VATS) in infants. METHODS: Twenty-two infants were operated on for CPM from November 2000 to June 2009. The intra- and postoperative course was analyzed retrospectively from patient charts. Preoperative scans were evaluated blindly by a radiologist to calculate the relation between the maximum size of the lesion and the thoracic diameter in VATS and open procedures. RESULTS: VATS was performed in 14 (64%) of the 22 patients and thoracotomy in 8. VATS was successfully performed in 11 (79%) of the 14 patients, whereas VATS was converted to thoracotomy due to lack of overview in 3 (21%). The mean relative size of CPM at preoperative imaging was 0.34 ± 0.05 (range: 0.3-0.4) in patients who received successful VATS, 0.57 ± 0.06 (range: 0.5-0.6) in converted cases, and 0.68 ± 0.10 (range: 0.5-0.8) in infants who underwent thoracotomy. The relative CPM size was significantly lower in successful VATS than in cases of conversion (P<0.01) and thoracotomy (P<0.01). CONCLUSIONS: The relative size of CPM at preoperative imaging might be useful information for a decision-making on the use of VATS in infants. A relative CPM size below 0.5, which is less than half of the thoracic diameter, indicates a good feasibility for thoracoscopic resection of CPM. A larger size may indicate that VATS might be technically difficult.

The role of laparoscopic techniques in children with suspected post-transplantation lymphoproliferative disorders.

AIM: To assess the role of minimally invasive surgery (MIS) to diagnose post-transplantation lymphoproliferative disorder (PTLD) in pediatric patients. METHODS: Thirty-four patients (20 male, 14 female) underwent organ transplantation (14 liver, 14 kidney, 3 heart, 2 lung, 1 heart-lung) from May 1992 to November 2008 (mean age at transplantation, 66 months; range, 5-277), in whom a biopsy was performed for suspected PTLD from May 1993 to September 2009. The time point of onset, type of PTLD, rate of intraabdominal manifestations with need of MIS, and its accuracy were assessed. RESULTS: Twenty-four of 34 patients (70%) had biopsies of superficial lymph nodes (9), oropharyngeal biopsy (5), gastrointestinal endoscopy or bronchoscopy (5), ultrasound-guided biopsies (3), biopsy of the bone marrow (1), or of the orbita (1). Data of the technique used were unavailable in 3 (9%). Due to lack of superficially located lesions, 6 of 34 patients (18%) had laparoscopic biopsy, of which 4 had abdominal organ graft. Laparoscopic biopsy was successful in 5 of 6 cases (83%). Abscess formation at area of transplanted kidney led to conversion in 1. Tumor extension to the abdominal wall led to a primary biopsy via a mini-laparotomy in another case. One patient with abdominal Burkitt's lymphoma developed a trocar metastasis, successfully treated by systemic chemotherapy. No other complications were observed after MIS. Accuracy of MIS biopsies was 100%. The onset of PTLD was significantly later diagnosed in cases of explicit intraabdominal PTLD (81 ± 6.3 versus 28 ± 5.3 months; P < .001). Morbidity and mortality were not influenced by biopsy technique or time point of PTLD onset. CONCLUSIONS: In 20% of pediatric PTLD cases an intraabdominal biopsy is required due to explicit intraabdominal manifestation. As laparoscopic surgery was even feasible in patients after prior abdominal organ transplantation, we suggest laparoscopic biopsy as a safe tool for diagnosing PTLD.

Rigid NOTES: the transurethral approach in female piglets.

BACKGROUND: Natural orifice transluminal endoscopic surgery (NOTES) was introduced to reduce scars and the surgical trauma. The feasibility of this technique in children is unknown. Our study was designed to determine the feasibility of various procedures via a transurethral-assisted approach in an animal model. MATERIALS AND METHODS: Specially designed Aesculap-Braun (Tuttlingen, Germany) instruments and Endo-Ligasure (Valleylab, Boulder, CO) were used in 12 female piglets (mean weight, 15.2 kg; range, 14-17). A modified 12-mm device, including a 0-degree optic and a working channel, was used for the umbilical approach and for CO(2) insufflation (8 mm Hg, flow 5L/min). A 3-mm trocar, including a 2-mm optic, was introduced via the urethra and the urinary bladder dome into the abdominal cavity. The end-point of the study was the feasibility of nephroureterectomy (n = 8) and bilateral tuboovariectomy (n = 4). RESULTS: All nephroureterectomies and bilateral tuboovariectomies were performed successfully. Closure of the urinary bladder was safely performed with Endoloops (Ethicon Endosurgery, Cincinnati, OH) via the umbilical "two in one system." Intracorporal suturing, knotting, and placement of Endoclips (Ethicon Endosurgery) during nephrectomy were time-consuming due to the restricted motion of the two in one system. The use of a vessel-sealing device allowed a safe, fast, and easy nephroureterectomy. CONCLUSIONS: Modifications of instruments and approaches are mandatory for NOTES and must be tested in animal models before being used in infants and children. We showed that nephroureterectomy and tuboovariectomy can be performed safely via a transurethral and umbilical approach in female piglets. The use of vessel-sealing devices is essential in two in one systems with limited view and range of motion.

Prior thoracic surgery has a limited impact on the feasibility of consecutive thoracoscopy in children: a prospective study on 228 procedures.

BACKGROUND: This study aimed to determine the impact of prior thoracic surgery on consecutive ipsilateral thoracoscopic surgery in children. METHODS: We prospectively analyzed 228 thoracic procedures, which were performed in 190 children (99 male,91 female; mean age, 5.1 years; range, 1 day to 18 years) over a 7-year period (January 2000 to August 2007).Of these, 137 were thoracoscopies and 91 conventional operations. A panel of pediatric pulmonologists, anesthetists,and pediatric surgeons decided whether a thoracoscopy or a conventional approach was indicated. The endpoints were conversion rate, intraoperative events, and complications in subsequent thoracoscopies with regard to the type of prior thoracic surgery. In addition, the reasons for exclusion from thorascopy of those patients,who had a previous thoracic operation, should be identified. RESULTS: Thirty-two patients (14%) had prior ipsilateral thoracic surgery; 20 of these underwent thoracoscopy,12 after prior thoracotomy and 8 after prior thoracoscopy. The type of initial approach had no significant impact on the conversion rate of subsequent thoracoscopy (1/12 after thoracotomy vs. 0/8 after thoracoscopy; not significant). The conversion rate was not significantly different in patients with or without prior surgery (1/20 vs. 19/117; not significant). However, there was a higher number of reconstructive procedures in patients without prior surgery, which was reflected in conversions due to lack of overview (n 12), bleeding (n 3), tension during reconstruction of a diaphragmatic defect (n 2) and esophageal atresia (n 2), and intraoperative respiratory problems (n 1). Twelve patients with a prior operation underwent thoracotomy due to limited respiratory capacity (n 5), advanced tumor stage, prior sternotomy (n 6), and limited visibility, leading to conversion during initial thoracoscopy (n 1). CONCLUSIONS: Prior thoracic operation has, independent of the initial approach, a limited impact on the feasibility of ipsilateral consecutive thoracoscopic surgery in children. The feasibility of thoracoscopy after prior operation is excellent.