Comparison of laparoscopic and open ileocecal resection for Crohn's disease in children.

PURPOSE: Ileocecal resection (ICR) is the most frequently performed surgery in paediatric Crohn's disease (CD) patients. The aim of the study was to compare laparoscopic-assisted and open ICR. METHODS: Retrospective review of consecutive CD patients undergoing ICR between March 2014 and December 2021 was performed. The patients were divided into open (OG) and laparoscopic (LG) groups. Compared parameters included patients' demographics, clinical characteristics, surgery, duration of hospitalisation and follow-up. Complications were classified according to the Clavien-Dindo classification (CDc). Risk factors were identified using multivariable analysis. RESULTS: Sixty-two patients (29 females, 46.7%) were included in the analysis, forty-two patients in OG. The median duration of surgery was 130 in OG versus 148 in LG (p = 0.065) minutes. Postoperative complications were reported in 4 patients (12.1%). There was no significant difference in postoperative complications according to CDc (OG 7.14 vs LG 5%, p = 1). The median length of hospitalisation was 8 in OG and 7 days in LG (p = 0.0005). The median length of follow-up was 21.5 months. CONCLUSION: The laparoscopic-assisted approach had shorter hospital stay and was not associated with increased risk of 30-day postoperative complications. Laparoscopic surgery should be considered the preferred surgical approach for primary ICR.

Treatment of the congenital thoracic deformity pectus excavatum.

Pectus excavatum is the most common chest wall deformity in the Czech Republic. This chest deformity is typically characterized by a wall depression with sternal rotation. If the excavation of the chest wall does not cause any physical or psychological problems, the patient does not need any specific treatment. However, if the deformity is painful, affects the function of the lungs, heart or results in psychological problems, we can propose an appropriate treatment for the specific age category of the patient. Up to 10 years, we choose a procedure that includes targeted exercises and rehabilitation; in the age group of 10-15 years, we can add to the exercises the vacuum bell therapy according to the patient's wishes and compliance; and in the age category of 16 years and above, the patient can be offered a surgical solution. The Nuss operation (so-called MIRPE - minimally invasive repair of pectus excavatum) is the gold standard in surgical treatment; during this surgery, a patient-shaped bar is inserted retrosternally into the patient's chest under thoracoscopic control and is left for 3 years. The aim of this article is to describe the most common modern methods used in the treatment of patients with pectus excavatum, supplemented by a historical overview.

Surgical treatment of Crohns disease in children in the era of biological treatment.

INTRODUCTION: The incidence of Crohns disease in the paediatric population has been increasing and requires surgical treatment in addition to conservative therapy. While surgical treatment used to be the last step after the failure of all conservative therapies, nowadays it is a standard part of complex treatment. Surgery can enter the treatment process at any stage of the disease and, with a proper indication, timing and preoperative optimization, it can induce immediate remission in patients. On the other hand, with inadequate or improper preoperative preparation and indication, surgical treatment can cause serious or even life-threatening complications. The spectrum of patients undergoing surgery is changing in the era of biological therapy. The aim of this review was to summarize the current knowledge of the impact of biological (anti-TNF alpha) therapy on the development of postoperative complications in children and adolescents operated for Crohns disease. METHODS: We present a review based on literature available in MEDLINE-PubMed and Embase databases. CONCLUSION: According to current knowledge, no association was found between biological treatment in the preoperative period and the development of postoperative complications in paediatric patients. Surgical treatment of paediatric patients with Crohns disease is one of standard treatment modalities.

Initial experience with single incision laparoscopic appendectomy.

INTRODUCTION: Within the development of laparoscopy, the single incision laparoscopy method has been recently introduced in paediatric surgery. The aim of this study was to evaluate the initial experience with single incision laparoscopic appendectomy at the Department of Paediatric Surgery, 2nd Faculty of Medicine, Charles University and Motol University Hospital, Prague. METHODS: A consecutive cohort of paediatric patients (18 years) undergoing laparoscopic single incision surgery for uncomplicated appendicitis between 4/30/2019 and 4/30/2021 was retrospectively evaluated. The following parameters were monitored: patients demographic characteristics, perioperative course, surgery duration, number and method of surgery conversions, length of postoperative hospitalization, postoperative complications classified according to Clavien-Dindo classification, occurrence of incisional hernias, and length of follow-up. RESULTS: In all, 160 patients (72 (45%) females) with uncomplicated appendicitis were included in the study. The median age at the time of surgery was 12 (IQR: 9.914.9) years. The median duration of surgery was 50 (IQR: 3860) minutes. Only one conversion to multiport laparoscopy and no conversion to open surgery were reported. The median postoperative hospital stay was 2 (IQR: 23) days. We observed 5 intra-abdominal and 9 wound complications. CONCLUSION: Single incision laparoscopic appendectomy is a safe, effective and rapidly adoptable method for the treatment of uncomplicated appendicitis in children.

Robotic pyeloplasty in children - a pilot study.

INTRODUCTION: Pyeloplasty for congenital hydronephrosis (pyeloureteral junction obstruction, PUJO) can be performed as an open, laparoscopic or robotic procedure in children. The aim of this study was to analyze a pilot cohort of pediatric patients operated robotically. METHODS: A retrospective analysis of the cohort of patients 3 to 18 years of age who underwent primary robotic pyeloplasty between December 2018 (which is when the robotic program was launched at the University Hospital Motol) and June 2021. Patients already operated on for PUJO in the past were excluded. The indication criteria, clinical symptoms, operation time, hospitalization length and complications were evaluated from the medical records. RESULTS: During this period, we operated on 28 children aged 3 to 17 years (median 8); 2 patients were excluded. Of the 26 children analyzed, 6 (23%) were asymptomatic before surgery, 17 (65%) reported pain, 2 (8%) had acute pyelonephritis before the surgery, and 1 (4%) suffered from nephrogenic hypertension. The most common etiology of PUJO was an aberrant vessel in 22 (85%) patients. The time from incision to skin closure was 106 to 201 minutes (median 142 minutes). Patients were hospitalized for 3 to 5 days (median 4) after the surgery and followed up for 1 to 30 months (median 6). Twenty-four of the 26 patients showed regression of the pelvic dilatation according to the postoperative ultrasound scan and no symptoms of PUJO. Seven (27%) had postoperative complications requiring a procedure under general anesthesia (all Clavien-Dindo 3b); of these, 2 were re-operated. CONCLUSION: Robotic pyeloplasty is an alternative to laparoscopic and open surgery. It is a safe and successful (92%) method. We believe that the higher rate of complications (27%) in our cohort is due to the fact that this is a new technique and more experience is needed.

CT findings predicting lung resection in children with complicated community-acquired pneumonia.

PURPOSE: To investigate computed tomography (CT) features which predict lung resection in children with complicated community-acquired pneumonia. METHODS: A retrospective study of CT findings of patients with complicated pneumonia treated between January 2010 and December 2019. Fisher's exact test and ROC curves were used for statistical analysis. RESULTS: The study cohort consisted of 84 patients who underwent chest CT for complicated pneumonia. Lung resection was performed in 36 patients, 3 patients were treated by lung decortication, 45 patients were cured conservatively. Seven CT features were found statistically significant among the patients who underwent lung resection. 80.5% of patients from the resection group had two or more of these features on the initial CT scan, 64% had three or more. According to ROC analysis, simultaneous occurrence of multiple cavities equal to or greater than 3 cm and lung abscess predicted a pulmonary resection. CONCLUSION: The combination of CT features which clearly predict lung resection are the simultaneous occurrence of multiple cavities ≥ 3 cm and lung abscess. The most common triple combination of CT signs in the resected group of patients were multiple cavities ≥ 3 cm, consolidation of lung tissue and pleural effusion < 3 cm.

Management of ileocolic intussusception in the Czech Republic.

INTRODUCTION: Ileocolic intussusception is one of the most frequent causes of acute abdomen in infants and toddlers. The purpose of this study was to evaluate the treatment of ileocolic intussusception in the Czech Republic in 2019. METHODS: Fourteen departments of paediatric surgery participated in this multicentre retrospective study. A SurveyMonkey Inc. questionnaire was used for anonymous data collection of patients with ileocolic intussusception. RESULTS: In 2019, ileocolic intussusception was diagnosed in 162 patients; median age was 30 months (3 months to 9.5 years). Contrast enema was indicated in 133 patients, primary surgery in 14 patients and spontaneous reduction was found in 15 patients. All departments using contrast enema had a success rate of 89.5%; 12 departments approached the contrast enema procedure under general anaesthesia (including myorelaxation at 7 departments) and 2 departments under sedation. Contrast enema under general anaesthesia with/without myorelaxation was significantly more successful than contrast enema under sedation (108/113, 95.6% vs 11/20, 55%; p.

Laparoscopic inguinal hernia repair in children via PIRS (percutaneous internal ring suturing).

INTRODUCTION: The miniinvasive approach is a trend in pediatric surgery nowadays. The new surgical technique called percutaneous internal ring suturing (PIRS) is a promising method bringing all the benefits of miniinvasive surgery. METHODS: Prospective study of patients operated on using the PIRS technique from 01 January 2018 to 01 January 2020 at the Department of Pediatric Surgery, 2nd Faculty of Medicine, Charles University, University Hospital Motol. RESULTS: 73 patients (25 boys and 48 girls) were operated on using PIRS. The median age was 68 months. 90 % of operations were performed by the same team of surgeons. During the procedure there were found 53 right-sided and 38 left-sided inguinal hernias. In 18 cases the hernia was bilateral, but only in 13 cases was this diagnosis made before the operation. A non-absorbable stitch was used in 57 cases to close the internal ring of the inguinal canal, and a non-absorbable monofilament in 16. The median operating time was 34 minutes. There were 3 recurrences (3.3 %) in our study.  Conclusion: In our initial study, the PIRS technique proved to be a safe alternative method to the open inguinal hernia surgery. This method provides the benefit of allowing to revise the contralateral inguinal canal as a prevention of a metachronous inguinal hernia. The cosmetic results were excellent.

Sacrococcygeal teratoma.

OBJECTIVE: Description of newborn with early prenatal diagnosis of sacrococcygeal teratomia. Desing: Case report. SETTING: Department of Obstetrics and Gynecology, 2nd Faculty of Medicine and Faculty Hospital Motol Prague. CASE REPORT: In this case report a term neonate with a massive sacrococcygeal teratoma was delivered by a cesarean section (approach by Geppert) with an intrapartal relieving punction of the tumor. It was a type II SCT with both pelvic end extracorporal component with a size of 60×35 centimeters. The tumor was completely resected during the first day of life and was followed by a normal function of lower extremities, normal bowel function and only transitional urinary tract symptoms. CONCLUSION: A sacrococcygeal teratoma (SCT) is the most common congenital tumor in newborns with reported incidence of 1:35000-40000 live births affecting more frequently females (4:1). This germinal tumor is either benign (mature) or malignant (immature), mature types are more common in neonates. A SCT is usually diagnosed by prenatal ultrasound, magnetic resonance is performed to characterize its size and content, type of tumor (type I-IV Altman classification) and relation to surrounding tissues. Preemptive early delivery by cesarean section is recommended when the tumor exceeds the diameter of 5 centimeters to avoid complications during vaginal delivery (rupture, bleeding etc.). The primary treatment of SCT is an early surgical resection with a complete resection of the coccyx („en bloc“ resection), malignant tumors are indicated for adjuvant chemotherapy. Long term complications can be urinary tract or bowel dysfunctions, lower extremity muscle weakness or paralysis and recurrence of the tumor with potential malignancy.

Extraperitoneal pocket splenopexy is a suitable solution for wandering spleen in children and adolescents - case report.

INTRODUCTION: Wandering spleen is a rare cause of recurrent abdominal pain in children that is difficult to diagnose. Splenopexy should be preferred to splenectomy. CASE REPORT: The patient, a 4 years old girl on growth hormone therapy, was referred to the Department of Paediatric Surgery for an assessment of episodes of abdominal colic and frequent vomiting. Sonography did not indicate any pathology, gastrointestinal contrast study showed an altered shape of the gastric outlet, and upper endoscopy diagnosed a prepyloric membrane. Open surgery was indicated based on these examinations, revealing a large wandering spleen and dilated stomach and small bowel loops oppressed by the long splenic suspensory ligaments. Pyloroplasty was performed with the antral membrane excision and shortening of the long gastrosplenic ligament and placement of the spleen into the left hypochondrium. No complications occurred in the postoperative period. Four months later the patient was hospitalised again for abdominal colic pain. Surgical revision of the abdomen revealed the wandering spleen in the mesogastrium. Even though the spleen was the cause of the second surgery, we decided to preserve the spleen. Partial splenectomy was done, fixing the large spleen into an extraperitoneal pocket in the left hypochondrium. The postoperative course was uneventful. Blood flow to the spleen is regularly monitored by Doppler ultrasound. Vaccination was indicated at the office of haematology according to the scheme for splenectomy patients; however, prophylactic antibiotic therapy was not needed given the good function of the preserved part of the spleen. CONCLUSION: Extraperitoneal fixation of the spleen seems to be a good choice for patients with a wandering spleen, particularly for children and adolescents.

[Prediction of bowel damage in patients with gastroschisis]. / Predikce poskození streva u pacientu s gastroschízou.

INTRODUCTION: Gastroschisis is the most common malformation among abdominal wall defects with the incidence of 1:45000 live birth neonates. Postoperative care for these patients is very difficult due to the risk of abdominal compartment syndrome. The identification of markers that correlate with bowel damage in gastroschisis may prevent this serious postoperative complication. METHODS: Review of the literature. CONCLUSION: Prenatal ultrasound prediction of bowel damage followed by an appropriate surgical strategy is a possibility of optimizing care and outcomes in gastroschisis patients. The dynamics of I-FABP is a promising biomarker for the elimination of abdominal compartment syndrome during postoperative care.Key words: gastroschisis preformed silo intraabdominal dilatation I-FABP.

[Multidisciplinary approach to surgical disorders of the pancreas in children]. / Multidisciplinární prístup k chirurgickému onemocnení pankreatu v detském veku.

INTRODUCTION: Surgical diseases of the pancreas in children are not common and may be associated with significant morbidity and potential mortality. A multidisciplinary approach is essential for correct diagnosis, surgical strategy and postoperative as well as follow-up care. METHOD: Retrospective analysis of patients operated on due to a pathological lesion of the pancreas focused on diagnostics, operating procedures, postoperative complications, and long-term results. Between 1991 and 2016, eighty-nine children were treated in our department for a pathologic lesion of the pancreas. 39 of them were boys and 50 were girls. RESULTS: Mean age of the patients was 9.3 years (1 month-18.4 years). Patients were followed from the operation to the age of 19, after which they were referred for follow-up to adult specialists. The indications for surgery were trauma in 34 children, solid pseudopapillary tumor in 23 children, biopsy in 10, hyperinsulinism in 8, chronic pancreatitis in 4, pancreatic cyst in 3, insulinoma in 3, carcinoma in 2, and serous cystadenoma and pancreas divisum in one patient. The most frequent procedures performed on the pancreas were distal pancreatectomy in 35 cases, the duodenum-preserving pancreatic head resection in 23 cases, pseudocystogastroanastomosis in 11 cases, 9095% pancreatic resection in 5 cases, Whipple operation in two cases, Puestow procedure in one case, tumor enucleation in one case, and tumor biopsy for cancer in one case. In 5 patients after major pancreatic injury, ERCP and papillotomy with insertion of a stent into the pancreatic duct was performed. 3 patients died, one after a polytrauma with severe pancreatic injury and two patients with pancreatic cancer. CONCLUSION: Pancreatic surgery in children is not a common operation, and individual as well as institutional experience remains limited. After more than 20 years of experience with pancreatic surgery, we believe that close cooperation with surgeons, pediatric gastroenterologists, radiologists, anesthesiologists, intensivist, pathologists and ERCP specialists is necessary for successful diagnosis and treatment of pancreatic disease in children.Key words: pancreas pancreatic surgery in children duodenum preserving head resection of the pancreas.

[Chest injuries in polytraumatized children]. / Poranení hrudníku u detí s polytraumatem.

Chest injuries in children are part of polytrauma resulting from high-energy violence, most often caused by traffic accidents. Blunt chest injuries (95%) are significantly more frequent than penetrating injuries (5%). Lung contusion, rib fracture, pneumothorax or haemothorax, are the more common injuries, but tracheobronchial rupture, cardiac or diaphragmatic injuries may also occur. The anterior X-ray image remains the basic examination method for isolated chest injuries. CT trauma scan with a contrast medium is done in polytraumatized children. Blunt injuries of intra-thoracic organs in haemodynamically stable children are treated mostly conservatively (85%) under full monitoring at the ICU. Surgical treatment is necessary in a minority of patients. Mortality and morbidity of patients with chest injury depend on the actual combination of multiple body systems injury. The severity of total injury can be predicted using objective scoring systems (Abbreviated Injury Scale=AIS; Injury Severity Score=ISS). Overall mortality ranges from 6 to 20%. Mortality is high but this is mainly due to associated head injuries.Key words: multiple trauma thoracic trauma - paediatric lung contusion Injury Severity Score=ISS.

Selective lung intubation during paediatric thoracic surgeries.

Selective lung intubation is a necessary prerequisite for the completion of most interventions comprising thoracotomy and thoracoscopy. In paediatric care, our site uses Univent tubes for children up to the age of three years and double-lumen tubes (DLT) for children from 6-8 years of age. In younger children, we usually use regular endotracheal intubation, with the lung being held in the hemithorax position being operated on using a surgical retractor. The article presents the analysis of 860 thoracic surgeries, of which 491 comprised selective intubation (Univent 57 cases, DLT 434 cases). The use of the aforementioned devices is connected with certain complications. Univent tube can be connected with intraoperative dislocation of the obturating balloon (29.8%) and balloon perforation (5.2%). DLT insertion may be connected with failure of tube fitting. In 84 cases we had to repeat DLT insertion (20.6%). In 8 cases we were not able to insert DLT at all (1.8%). Standard use of selective intubation methods in paediatric patients from two years of age improved the conditions for surgical interventions (Tab. 2, Fig. 2, Ref. 19).

[Surgical technique changes in the repair of pectus excavatum between 1991 and 2012]. / Zmeny chirurgické techniky pri resení Pectus excavatum v letech 1991-2012.

INTRODUCTION: The aim of this article is a retrospective analysis of the results of three methods used for the repair of pectus excavatum between 1991 and 2012. MATERIAL AND METHODS: 508 patients were operated on at the Department of Paediatric Surgery of the Second Faculty of Medicine, Charles University, and the Teaching Hospital in Motol between 1991 and 2012. 16 patients were older than 19 years (19-28 years). The average age of paediatric and adolescent patients was 14.2 years (5-19 years range). Boys (408) prevailed over girls (82), the ratio being 4.9:1. Open Holcomb technique was used to operate on 87 patients (17%), the Welch method was applied in 208 patients (41%). Minimally invasive repair of pectus excavatum (MIRPE) was used in 213 patients (42%) during the entire period of time. RESULTS: As for the 295 patients operated on by the open Holcomb and Welch method, the outcome was excellent in 239 (81%) of them. A favourable result with a small deformity remaining occurred in 44 patients (15%). Unfavourable result was found in 7 patients (2.5%): in these children, a deep excavation occurred 3-5 years postoperatively. In 5 patients (1.5%) we evaluated the result as recurrent chest wall deformity. The minimally invasive method (MIRPE) produced an excellent result in 182 out of 213 patients (85%). A favourable outcome was observed in 27 (22%), unfavourable result in 1 (0.5%) patient. CONCLUSION: In the last 15 years, minimally invasive repair of pectus excavatum has become popular worldwide. Due to very favourable cosmetic results and a relatively small, gradually decreasing number of complications, the proportion of patients requiring surgery to correct their deformity has risen sharply.

Defect-diaphragmatic ratio: a new parameter for assessment of defect size in neonates with congenital diaphragmatic hernia.

AIM: The aim of our study is to introduce a new objective method of perioperative evaluation of the size of diaphragmatic defect to enable comparison of results among various centres and methods used for diaphragmatic reconstruction. MATERIALS AND METHODS: Prospective observational study of neonates with congenital diaphragmatic hernia (CDH) and respiratory distress within 24 h of birth operated on from January 2009 to December 2011. Weight, length, thoracic shape and the diameters of diaphragmatic defect were measured. To determine the relative size of the defect, a defect-diaphragmatic ratio (DDR = defect area:diaphragm area × 100) was calculated. The measured and calculated data were subsequently compared between Gore-Tex patch group (GT) and primary repair group (PR). Mann-Whitney U test was used for statistical analysis. RESULTS: Forty-seven patients with CDH were admitted during study period. The overall survival rate was 79 % (37/47). Preoperative stabilization was achieved in 85 % (40/47). Survival of operated neonates was 93 % (37/40). Diaphragmatic reconstruction with Gore-Tex patch was used in 7 neonates (17 %), and primary repair in 33 (83 %). Mortality in Gore-Tex group was 29 %; mortality in primary repair group was 3 %. Data of anthropometric measurement were complete in 34 children (5 GT and 29 PR). Significant differences were found between GT group and PR group in the size of diaphragmatic defect with the transverse and sagittal diameters of defect (48.0 ± 5.7 vs. 30.1 ± 5.9, P < 0.00061; 34.0 ± 12.5 vs. 16.0 ± 7.3, P < 0.0022) and DDR (18.29 ± 4.60 vs. 5.77 ± 3.28, P < 0.0005), respectively. CONCLUSION: The value of DDR as an objective criterion of the extent of diaphragmatic defect was confirmed by the close correlation between DDR and feasibility of primary repair in the study group. This objective assessment of defect size may improve comparing various surgical techniques and results of different centres, and thus facilitates sharing experience with management of neonates with CDH.

Large diaphragmatic defect: are skeletal deformities preventable?

PURPOSE: The aim of study was to compare growth, nutritional status and incidence of chest wall deformities and scoliosis in survivors of large congenital diaphragmatic hernia (CDH) defect (Gore-Tex patch reconstruction) with survivors with smaller defects and primary reconstruction. MATERIALS AND METHODS: An anthropometric study of 53 children who underwent CDH repair in neonatal period was carried out. Weight, height, and skin-fold thickness were measured, scoliosis and chest wall deformity were evaluated. Body mass index (BMI) and thoracic index (TI) were calculated using standard rules. The measured data were compared with national population standard with the use of standard deviation score (SDS). According to the type of diaphragmatic reconstruction, the patients were divided into two groups [Gore-Tex patch (10) versus primary repair (43)]. Student t test and Fisher exact tests were used for statistical analysis. RESULTS: Pectus excavatum was found in 25 (47%) patients, poor posture in 33% and significant scoliosis in 5%. Compared with the population norm, CDH children had a significantly lower body height SDS (mean -0.39, p < 0.05), weight SDS (mean -0.75, p < 0.001), BMI (mean SDS -0.68, p < 0.001) and lower TI (mean SDS -0.62, p < 0.01). Gore-Tex versus primary repair group significantly differed in incidence of pectus excavatum and BMI (PE: p = 0.027, BMI SDS: p = 0.016). A majority of anthropometric parameters (weight, height, thoracic index, and thorax circumference) and incidence of scoliosis and poor posture in children after Gore-Tex patch reconstruction did not significantly differ from children after primary repair. CONCLUSION: The differences in some anthropometric parameters (weight, BMI, and TI) and in the skeletal deformity suggest that the CDH not only disturbs normal lung growth, but also seems to have implications on some other aspects of somatic development. Whether these changes could be related to the type of diaphragmatic reconstruction or rather to the size of the defect remains uncertain.

[Liver transplantations in children using reduced grafts]. / Transplantace jater u detí redukovaným stepem.

AIM: Liver transplantation is a life-saving procedure in patients with end stage liver disease. Five-year survival in patients indicated for transplantation based on standard indication criteria, has reached a rate over 80%. Shortage of suitable grafts remains the main problem in these procedures. While the situation in adult patients is relatively satisfactory, liver transplantations in children, mainly in the low-weight categories, remain a worldwide problem because of the absolute lack of suitable donors. In order to reduce mortality in the youngest patients on the waiting list, a concept of reduction of the adult graft for pediatric use was introduced in the early 1990s. Recent introduction of novel methods, such as split transplantations or transplantations between relatives, has resulted in lower mortality rates in the youngest recipients on the waiting lists. The author assesses a group of patients below 18 years of age, who underwent reduced liver graft transplantations in the Czech Republic. MATERIAL AND METHODS: From 1995 to 2009, a total of 43 patients below 18 years of age underwent transplantations, using 48 liver grafts. Further 17 children were sent abroad for transplantations, where a total of 23 liver grafts were used. Only patients who underwent transplantations using the liver grafts adjusted in IKEM were assessed in the patient group, i.e. 14 patients, resp. 16 liver grafts. Reduction was performed in 13 subjects. One subjects underwent transplantation between relatives and a liver split was used in two subjects. In the lowest weight category up to 10 kgs, 5 liver reductions were performed. OUTCOMES: Out of the total (n = 16), 4 grafts failed (2 were early postoperative failures, ie. within 2 postoperative days and 2 grafts failed in Month 5). The mean graft survival was 65 months. Within the youngest recipient age group (n = 5), no graft failure was recorded. The mean survival time is 26 months. CONCLUSION: Since 2007, the Czech Republic has been providing a program for all patients, including the lowest weight-category pediatric patients. To date data are satisfactory. No graft failure has been recorded in the category of the smallest (up to 10 kgs) pediatric patients.

Diagnostic efficacy of ERCP in cholestatic infants and neonates--a retrospective study on a large series.

BACKGROUND AND STUDY AIMS: Cholestatic jaundice in infants is a serious condition, requiring timely and accurate diagnostic evaluation. Our aim was to determine the safety and diagnostic efficacy of endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis of cholestatic liver disease in neonates and infants. PATIENTS AND METHODS: ERCP procedures in cholestatic infants performed in our endoscopy unit between December 1998 and March 2008 were reviewed retrospectively (n = 104 children, 48 boys, 56 girls; mean age 7 weeks, range 3 - 25 weeks; mean weight 4.05 kg, range 1.5 - 4.8 kg). Endoscopic findings were compared with final diagnoses. Statistical analysis was performed and sensitivity, specificity, positive (PPV) and negative (NPV) predictive values of ERCP were calculated both separately for each diagnosis and on aggregate. RESULTS: Cannulation of the papilla was successful in 95 of 104 patients (success rate 91.3 %). Biliary atresia of any type was found in 51 children (53.7 %), with a sensitivity of 86 %, a specificity of 94 %, a PPV of 96 %, and a NPV of 100 %. Choledochal cysts were found in seven children (7.4 %), with a sensitivity of 100 %, a specificity of 90 %, PPV of 86 %, and NPV of 100 %. Biliary stones were found in seven patients (7.4 %). Other structural pathology was found in six patients, and no abnormality was seen in 24 patients. No severe complications occurred during or after ERCP. CONCLUSIONS: ERCP in cholestatic infants, when performed in an expert center, is a safe and reliable procedure that can detect biliary tract abnormalities (e. g. biliary atresia, bile duct stones or choledochal cysts) with high sensitivity and specificity. Laparotomies can be prevented in infants by demonstrating normal patency of the biliary tract by ERCP or by magnetic resonance cholangiography if improvements in this technique are made.

Duodenum-sparing technique of head resection in solid pseudopapillary tumor of the pancreas in children.

AIM OF STUDY: Aim of the study was to assess the complications and long-term results in children operated on for solid pseudopapillary tumor of the pancreas (SPTP) between 1993-2008 at the authors' institution with a focus on a novel duodenum-sparing technique to treat tumors of the head of the pancreas. METHODS: Retrospective analysis was performed of patient data including demographics, diagnostic measures, the operative technique focusing on tumor of the head of the pancreas, complications and long-term results. RESULTS: There were 13 patients (12 girls and one boy) with an average age of 14 years (9-17.5 years) at operation. In 7 patients the tumor was localized in the head of the pancreas, in 4 patients in the tail, and in 2 patients both the body and tail were involved. Patients with body and tail involvement underwent distal pancreatic resection. In 6 patients with head involvement a duodenum-sparing resection of the head and end-to-end anastomosis of the excluded jejunal loop either to the corpus or tail of the pancreas were performed. One girl underwent a modified Whipple operation. She developed a biliary fistula which closed after three weeks with endoscopic stenting. One patient with head resection developed a biliary fistula which closed after two weeks of stenting. One patient who underwent resection of the pancreatic head complained of recurrent abdominal pain one year postoperatively. All patients are alive without tumor recurrence at 6 months to 16 years after operation. CONCLUSION: SPTP is a rare pancreatic tumor with a low degree of malignancy. No perioperative chemotherapy is necessary. Therefore duodenal resection in cases of SPTP in the head of the gland seems too invasive and mutilating. The authors consider the duodenum-sparing technique to be more appropriate for the developing organism of a child. Favorable short and long-term results support this opinion.