Use of Temporary Double-J Stent Placement for Children With Congenital Hydronephrosis: A Long-Term Single-Center Cohort Study.

OBJECTIVE: To evaluate the utilization of double-J stents in children with congenital hydronephrosis in order to avoid or postpone more invasive surgical intervention. Numerous studies have demonstrated that congenital hydronephrosis caused by ureteropelvic junction obstruction (UPJO) or primary obstructive megaureter (POM) may require a surgical correction in up to 20% of cases. METHODS: All infants with severe hydronephrosis and/or an obstructive pattern on renal scintigraphy that received double-J stent placement between 2010 to 2015 in our center were analyzed. Children were followed regularly with ultrasound and received antibiotic metaphylaxis. Urinary tract infection (UTI) and double-J dislocation were defined as complications. Treatment success was defined as avoidance of surgery and reduction of hydronephrosis to grade 1 or 0 during the observation period. RESULTS: 29 children were included, in these, 34 (23 UPJO, 7 POM, 4 UPJO and POM) treatment attempts were performed. Stent implantation failed in six cases, resulting in 28 double-J stent treatments, of which 19 (69%) were successful within the follow-up period of 20 to 104 months. The most common complications were febrile UTI in 6 of29 cases and double-J dislocation in 3 of 29 cases. CONCLUSION: During the observation period, the success rate of temporary double-J in urodynamically relevant obstruction was relatively high. However, urinary tract infections and a complex disease course due to renal stent dislocation, as well as the need for repeated anesthesia and radiation exposure, should be taken into account. Hence, we do not recommend double-J stents placement in all children with congenital hydronephrosis; it may be useful in selected cases.

Case Report: 2-Year-Old Boy with Grade 4 Avulsion Injury of the Hand Caused by a Conveyor Belt System. / Case report: 2-jähriger Junge mit viertgradiger Avulsionsverletzung der Hand durch Einklemmung in ein Förderband.

In the western world, mutilating hand injuries such as amputations and severe avulsions are more common in the working population than in children (Pomares G et al. Orthop Traumatol Surg Res 2018; 104: 273­276). An epidemiologic retrospective study from France identified 1715 traumatic upper-limb amputations over a 10-years period with the majority of cases involving middle-aged men (Pomares G et al. Orthop Traumatol Surg Res 2018; 104: 273­276). Systematic literature search using Pubmed on conveyor belt system injuries found few articles. A recent study analyses occupational traumatic injuries in offshore seafood processors in Alaska. Processing equipment and machinery were among the leading causes of injuries, accounting for 28% of traumata (Syron et al. J Safety Res 2018; 66: 169­178). Tiwari et al. describe a collective of six children who sustained motorized machine belt entrapment injuries (Tiwari P et al. Indian Pediatr 2020; 57: 66­68). Overall mortality and paraplegia rate were 33.3% each. Those accidents mainly occured in rural areas in India. The children were caught in the belt by their clothes while their parents were working nearby. Five patients were pulled through their torso, those with involved head were dead at the time of arrival. Only one had only his limbs involved. If a conveyor belt involves the hand, severe avulsion or crush injuries result. The outcome of reconstructive surgery in hand avulsion injuries depends mainly on the initial degree of injury (Kay et al. J Hand Surg 1989; 14: 204­213). Finger avulsion injuries are classified according to Kay's classification. In class I injuries, tissue perfusion is still normal. Kay II injuries already show inadequate blood flow but no fracture is present. In class III injuries, perfusion is restricted and there is either an associated fracture or a joint injury. Kay IV injuries cover complete digital deglovings or amputations (Kay et al. J Hand Surg 1989; 14: 204­213). Generally, replantations for sharp injuries show higher success rates than for avulsion or crush injuries (Goodman et al. J Hand Surg Am 2017;42:456­463). In general, the age of pediatric patients is critical to the feasibility and success rate of finger replantations and reconstructive hand surgery.

Long-Term Evaluation of Gastroesophageal Reflux in Neonates with and without Preventive Anti-reflux Surgery at the Time of Congenital Diaphragmatic Hernia Repair.

One potential comorbidity after congenital diaphragmatic hernia (CDH) is gastroesophageal reflux (GER), which can have a substantial effect on patients' quality of life, thriving, and complications later in life. Efforts have been made to reduce gastroesophageal reflux with a preventive anti-reflux procedure at the time of CDH repair. In this follow-up study of neonates participating in a primary RCT study on preventive anti-reflux surgery, symptoms of GER were assessed longitudinally. Long-term data with a median follow-up time of ten years was available in 66 patients. Thirty-one neonates received an initial fundoplication. Secondary anti-reflux surgery was necessary in 18% and only in patients with large defects. It was required significantly more often in patients with intrathoracic herniation of liver (p = 0.015) and stomach (p = 0.019) and patch repair (p = 0.03). Liver herniation was the only independent risk factor identified in multivariate regression analysis. Primary fundopexy and hemifundoplication did not reveal a protective effect regarding the occurrence of GER symptoms, the need for secondary antireflux surgery or the gain of body weight regardless of defect size neither in the short nor in the long term. Symptoms of GER must be assessed carefully especially in children with large defects, as these are prone to require secondary anti-reflux surgery in the long-term. Routine evaluation of GER including endoscopy and impedance measurement should be recommended especially for high-risk patients.

Case Report: 7-Year-Old Boy with Incarcerated Internal Hernia Leading to Extensive Intestinal Necrosis Due to a Large Congenital Mesenteric Defect.

We present a case of a 7-year-old boy with acute abdominal symptoms initially misdiagnosed as constipation. Delayed imaging diagnostics revealed an ileus with contorted small intestine, so laparotomy was indicated. An acute bowel obstruction was found based on an incarcerated internal hernia. Small and large bowel segments were incarcerated into a large mesenteric defect leading to extended intestinal necrosis. About 30 cm of necrotic small bowel and 15 cm of large intestine were resected, two primary anastomoses were performed. The mesenteric defect was closed with two running sutures. The boy's clinical outcome was very good. Two aspects are discussed: the initial clinical misdiagnosis of acute bowel obstruction in a child leading to a delay of diagnostics and therapy on the one hand and the origin of mesenteric defects on the other. In children with abdominal pain, ultrasound must be performed as soon as possible and pediatric surgeons have to be involved early. There should be an awareness of the fact, that mesenteric defects and other congenital malformations can occur more often than we suspect it. In the case of an internal hernia, a misjudgement of the clinical condition may be very harmful for the patient and can lead to a short bowel syndrome or even death.

Case report: Infant with a Fast-growing Soft Tissue Tumor on the Thumb, Revealing a PLAG1-positive Connatal Lipoblastoma.

At the age of 4 months, an infant was presented to us with a nodular subcutaneous tumor on the right thumb measuring 2cm, already seen prenatally via ultrasound. An MRI in sedation performed at the age of 4.5 months had no diagnostic specificity. By a biopsy at the age of 5 months malignancy could be excluded. Finally at the age of 16 months the tumor which had meanwhile grown to a monstrous size (5 cm of diameter) could be entirely removed by microsurgical technique maintaining the integrity of all intrinsic structures. The diagnosis of myxoid lipoblastoma was confirmed. According to literature, Lipoblastomas often present as connatal rapid growing soft tissue tumors and are benign. Total removal is essential for avoiding a local recurrence.