Is There Gender (In)Equality in Pediatric Surgery? An Online Survey on Gender-Related Career Opportunities.

INTRODUCTION: The highest percentage of female surgeons is found in pediatric surgery but most departments are led by men. The aim of this study is to evaluate gender-related career goals, perceived career opportunities, and reasons for differences. MATERIALS AND METHODS: An online questionnaire was created and distributed to pediatric surgeons in Germany, Switzerland, and Austria between July and September 2020. Participants were asked to state current position, career goals, and perceived career opportunities in comparison to a colleague of the opposite gender. Reasons for gender-related differences were asked for as free-text comments. RESULTS: A total of 182 questionnaires were analyzed. The overall gender ratio was balanced but junior positions were predominantly held by women, while there were more men in leading positions. Most women pursued a position as a consultant, while the majority of men aimed for a leading position. Men mostly regard both genders to have the same career opportunities, whereas most women believe the chances of men to be better. From the free-text answers, three following categories for gender-related differences in career chances were derived: (1) absences due to maternity, (2) differing support and bias arising from gender-related stereotypes, and (3) assumed personality traits. CONCLUSION: There are gender-related differences in career opportunities in pediatric surgery. Gender equality is needed not only to overcome injustice but also to maximize team efficiency and collaboration. Career support needs to be gender-independent and (unconscious) bias needs to be recognized and eradicated.

Successful Treatment of a Single Giant Renal Cyst in a Newborn with Drainage and Sclerotherapy.

Simple renal cysts are a scarce entity in pediatric patients and their etiology is unknown in most cases. Usually, they are monitored with ultrasound and regular follow-up of renal function. Surgical treatment is rarely indicated. We report the case of a newborn with a single giant renal cyst that could be treated successfully with drainage and sclerotherapy. Single giant renal cysts require careful investigation and monitoring. In cysts without communication to the pelvico-caliceal system, sclerotherapy by instillation of doxycycline is a therapeutic option.

Thoracoscopic Resection of a Foregut Duplication Cyst with the Use of a 5-mm Stapling Device in an Infant-A Case Report.

Esophageal foregut duplication cysts are a rare congenital anomaly predominantly diagnosed in children. With possible growth foregut duplication cysts may cause compression on thoracic or mediastinal structures, respectively. Due to the presence of ectopic gastric mucosa and its potential malignant alteration resection of foregut duplication cysts is recommended. More recently, the use of a thoracoscopic approach for resection has shown to be an advantageous alternative to a conventional open approach. A case of a complete thoracoscopic resection of an esophageal foregut duplication cyst using a 5-mm stapling device is presented.

A Novel Tool to Predict Postoperative Opioid Need after Laparoscopic Appendectomy in Children: A Step toward Evidence-Based Pain Management.

BACKGROUND: Optimizing postoperative pain treatment is essential to minimize morbidity, lower costs, and ensure patient and parent satisfaction. This study aims at identifying pre- and intraoperative parameters predicting opioid needs after laparoscopic appendectomy to enable timely and adequate postoperative pain control. MATERIALS AND METHODS: A retrospective analysis of patients treated with laparoscopic appendectomy for appendicitis between January 2018 and March 2019 was performed. Multiple logistic regression was applied to identify predictors of opioid demand. RESULTS: Based on our analysis, we developed a prediction tool for opioid requirements after laparoscopic appendectomies in children. The integrated parameters are: presence of turbid fluid, age, white-blood-cell count, symptom duration, and body temperature. CONCLUSION: We developed an algorithm-based predictor tool that has the potential to better anticipate postoperative pain and, thereby, optimize pain management following laparoscopic appendectomies in children. The proposed predictor tool will need validation through further prospective studies.

Complete Resection of a Large Mediastinal Calcifying Fibrous Tumor.

Calcifying fibrous tumor (CFT) is a benign tumor entity which can present in a variety of different sites. Till date, eight cases with a mediastinal manifestation have been published in literature. Surgical removal is the treatment of choice for this often incidentally detected tumor. Surgery of thoracic CFT may be challenging due to its localization within the mediastinum. A 10-year old boy with a right-sided thoracic pectus carinatum-like deformity was referred for further evaluation, incidentally, revealing a mediastinal mass in computed tomography (CT). Laboratory results were all within normal range. Magnetic resonance imaging (MRI) showed a large tumor in the upper anterior mediastinum suggesting expansive but not infiltrative character. The tumor was displacing surrounding structures like the heart and the diaphragm. Lower venous stasis with dilation of the inferior cava vein could be demonstrated. The tumor was considered to be of benign dignity and surgical removal was indicated. Complete tumor resection could be achieved through a sternotomy approach, along with thymectomy. A partial resection of both the pericardium and diaphragm was required due to adhesion with soft tissue at those sites. The specimen's size was 320 mm × 145 mm × 100 mm, histologically confirmed as CFT. The patient showed no residual tumor at 3- and 9-month follow-up. This case is a report on a large mediastinal CFT which underwent successful complete surgical removal. Following tumor resection, prognosis is considered to be good; however, key issue is complete resection to avoid local tumor recurrence.

Applications of Laparoscopic Transperitoneal Surgery of the Pediatric Urinary Tract.

Application of laparoscopy in pediatric urology has evolved over more than 30 years coming from a merely diagnostic use for non-palpable testes to "interventional" laparoscopy to extirpative surgery and finally to the era of reconstructive pediatric laparoscopic urology, when in 1995 Peters described the first laparoscopic pyeloplasty in a child. Laparoscopic surgery in pediatric urology became implemented increasingly in the twenty-first century with now present-day applications including the complete variety of all kind of indications for surgery for pediatric urological pathology. This article aims to provide a comprehensive overview of current indications, techniques, and outcomes of laparoscopic transperitoneal surgery of the upper as well as of the lower urinary tract for urological pathology in the pediatric patient population.

Nonischemic Priapism in Childhood: A Case Series and Review of Literature.

INTRODUCTION: Nonischemic priapism (NIP) in childhood is a very rare affection. In the literature, patients with NIP are described mainly incidental after perineal trauma. Many of them underwent embolization of either internal pudendal artery or bulbocavernosal arteries. PATIENTS AND METHODS: We report on six boys between 4 and 13 years of age with NIP, treated at our institution between 2008 and 2014. Color Doppler ultrasound (CDU) was performed in all patients as emergency diagnostic evaluation. Patients were treated conservatively, including bed rest, local cooling, and perineal compression. History, etiological factors, clinical findings, diagnostics, and follow-up are presented. RESULTS: Out of the six patients, only one boy had a history of perineal injury with subsequent arteriocavernosal fistula, revealed in CDU. Five patients were circumcised, and one of them suffered from thalassemia minor, but no other underlying disease or etiological factors could be found. In all patients, normal to high blood flow velocities were detected in the cavernosal arteries. Detumescence started with nonoperative treatment within 24 hours in five boys and in one patient with recurrent priapism after 1 week. All six patients remained painless without evidence for an ischemic priapism. None of them suffered from relapse and further erections were observed during follow-up from 3 to 87 months. CONCLUSION: In contrast to the literature, five out of six boys developed NIP without a previous perineal trauma. The etiology of idiopathic NIP in childhood remains unclear; however, circumcision may play a role as a conditional factor. One etiological thesis could be the release of the neurotransmitter nitric oxide after stimulation of the corpora cavernosa. Conservative treatment proved to be successful in all six patients. During a median follow-up of 55 months (3-87 months), none of the patients showed signs of erectile dysfunction.

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.

Weight-adapted surgical approach for laparoendoscopic single-site surgery in pediatric patients using low-cost reusable instrumentation: a prospective analysis.

OBJECTIVES: Laparoendoscopic single-site surgery (LESS) in pediatric patients has emerged as a viable alternative to standard laparoscopy. The aim of our investigation was to assess different surgical approaches for LESS, stratifying by weight. SUBJECTS AND METHODS: From March 2010 to April 2012 LESS was performed in 42 children. Children weighing below 10 kg underwent LESS through an umbilical incision using two 3-mm trocars and one 5-mm trocar. Patients above 10 kg were operated on using a metal multiuse single-site single port (X-Cone; Karl Storz Endoskope, Tuttlingen, Germany). Conventional straight laparoscopic instruments were used in all cases. RESULTS: Mean age at operation was 100 months (range, 0.25-207 months), and mean weight was 27 kg (range, 3.1-82 kg). Median operating time was 74 minutes (range, 36-300 minutes). Eighteen children underwent LESS using two 3-mm trocars and one 5-mm trocar; 1 case required two 5-mm trocars and one 10-mm trocar. Twenty-three patients were operated on with the multiuse device. All operations were carried out safely in a standard laparoscopic transperitoneal technique with full achievement of the surgical target. In none of the patients was an intraoperative complication noticed. Postoperatively two complications were noted, which resolved spontaneously. CONCLUSIONS: LESS for pediatric patients can be done safely and efficiently with even less trauma than in conventional laparoscopy irrespective of age and weight. However, different surgical approaches have to be considered as disposable single-site ports are not available for infants and small children. To decrease operative expenses, conventional multiuse trocars and a multiuse single-site port were used with conventional laparoscopic instruments.

Surgical treatment of inspissated bile syndrome using a 2-stage pure laparoscopic approach: a case report.

We describe a 99-day old girl with inspissated bile syndrome (IBS) unresponsive to treatment with oral ursodeoxycholic acid. We performed a pure laparoscopic 2-stage procedure, consisting of cholecystostomy and insertion of an indwelling balloon catheter for local ursodeoxycholic acid flushing for 13 consecutive days. Subsequently, the cholecystostomy was removed, preserving the gallbladder using the same laparoscopical approach when bilirubin values returned to normal and bile duct obstruction was no longer detectable radiologically. This is the first report of an exclusively laparoscopic management of IBS.

Perioperative outcome of patients with congenital diaphragmatic hernia undergoing open versus minimally invasive surgery.

PURPOSE: The aim of this study was to evaluate outcome of patients with congenital diaphragmatic hernia (CDH) undergoing open versus minimally invasive surgery. SUBJECTS AND METHODS: Patient records of 33 children undergoing surgery for CDH between March 2002 and September 2008 were reviewed. Patient data were compared regarding operating time, intraoperative maximum CO(2) partial pressure (pCO(2 max)) values, postoperative ventilation time, complications, and recurrences. RESULTS: Median age at time of operation was 4 days (range, 0-1017 days), and median weight was 3800 g (range, 2000-13,200 g). Laparotomy was performed in 12 children. Seventeen patients underwent thoracoscopic repair, and four children had a laparoscopic approach. Operating time was significantly longer (P=.004) in the minimally invasive group. Median values of pCO(2 max) during operation were not significantly different (P=.25) in the minimally invasive surgery group. The pCO(2 max) values in the postoperative course were significantly lower (P=.013) in the minimally invasive group, whereas median ventilation times postoperatively were significantly longer (P=.024) in the open surgery group. CONCLUSIONS: Median values of pCO(2 max) in the postoperative course were significantly lower in the minimally invasive surgery group. In addition, postoperative ventilation time was shorter when children underwent minimally invasive surgery. In conclusion, minimally invasive surgery seems to offer advantages for selected patients with CDH.

Perioperative outcome of patients with esophageal atresia and tracheo-esophageal fistula undergoing open versus thoracoscopic surgery.

INTRODUCTION: Thoracoscopic approach for repair of esophageal atresia (EA) and tracheo-esophageal fistula (TEF) has become a standard procedure in many pediatric surgical centers. Thoracoscopic surgery in a newborn is demanding from both the surgeon and the patient. The potential benefits for the newborn are still discussed by neonatologists, pediatric intensive care physicians, and also parents. The aim of our investigation was to clearly define perioperative outcome and complication rates in children undergoing thoracoscopic versus open surgery for EA and TEF repair. PATIENTS AND METHODS: We reviewed the records of 68 newborns undergoing surgery for EA and TEF between March 2002 and February 2010. Patient data of open versus thoracoscopic approach were compared regarding operating time, intraoperative as well as postoperative pCO(2)max values, postoperative ventilation time, and complications. Specific patient data are reported with the median and range. Data analysis was done with the JMP(®) 7.0.2 statistical software (SAS Institute, Cary, NC). RESULTS: For the 68 patients, the mean gestational age was 35 weeks (28-41), the median birth weight was 2720 g (1500-3510 g) in the thoracoscopic group and 2090 g (780-3340 g) in the open group. There were 36 girls and 32 boys. Thirty-two children had associated anomalies. Twenty-five children were undergoing a thoracoscopic procedure. In 8 cases, the operation was converted to open thoracotomy. Another 32 children received a thoracotomy. In 11 newborns, a cervical esophagostomy was performed because of long-gap EA and these patients were excluded from the study. Operating time was 141 minutes (77-201 minutes) in the thoracoscopic group and 106 minutes (48-264 minutes) in the thoracotomy group, with significant difference (P=.014). Values of pCO(2)max during operation were 62 mm Hg (34-101 mm Hg) in the thoracoscopic group and 48 mm Hg (28-89 mm Hg) in the open group, with significant difference (P=.014). Postoperative ventilation time was 3 days (1-51 days) in all groups, with no significant difference (P=.79). Early complications were noticed in 9 children undergoing thoracoscopy and in 8 patients of the thoracotomy group, again with no significant difference (P>.05). CONCLUSION: Thoracoscopic repair of EA with TEF is justified because of a comparable perioperative outcome to open surgery, competitive operating times, decreased trauma to the thoracic cavity, and improved cosmesis despite skeptical considerations. Complication rates are not higher than in children operated on through a thoracotomy. However, a learning curve has to be taken into account and large experience in minimal invasive surgery is mandatory for this procedure. Larger series have to be expected for a more objective evaluation of perioperative as well as long-term outcomes. To our opinion, the thoracoscopic approach appears to be favorable and could be a future standard.

Laparoscopic Roux-en-Y hepaticojejunostomy in children with long common pancreaticobiliary channel: surgical technique and functional outcome.

BACKGROUND: In patients with maljunction of pancreatic and common bile duct (CBD)-defined as a long common pancreaticobiliary channel (LCPC)-a resection of the CBD and a hepaticojejunostomy is recommended. To date, this operation is usually performed through an open approach. In this article, we report on our experience with minimally invasive surgery (MIS) for LCPC in children. PATIENTS AND METHODS: From 2004 to 2008, 7 children underwent MIS for LCPC. Mean age at operation was 46 months. Two patients had a choledochal cyst (Todani type IV) additionally. Diagnosis was made preoperatively by magnetic resonance cholangiopancreaticography, in 5 children confirmed by endoscopic retrograde cholangio-pancreaticography. A four-trocar technique was used for the laparoscopic approach. Follow-up examinations included laboratory tests, ultrasound, and scintigraphy. RESULTS: A Roux-en-Y hepaticojejunostomy was performed in all patients-in 6 children completely by laparoscopy. In 1 child, the operation was converted to open after CBD diversion due to a large, vulnerable liver. In 2 children with extended choledochal cyst, additionally, a reconstruction of the separated hepatic ducts was performed. Reresection of a CBD stump was carried out by laparoscopy in another patient. A leakage of the anastomosis occurred in 1 child. CONCLUSIONS: The laparoscopic approach for pathology of pancreaticobiliary ducts might be a new alternative for surgical treatment in infants and children. It can also be performed in cases with choledochal cyst involving the hepatic ducts and for reresection of remnants of CBD.

Functional outcome after laparoscopic dismembered pyeloplasty in children.

OBJECTIVE: Laparoscopic or retroperitoneoscopic pyeloplasty for ureteropelvic junction obstruction in children has become a routine procedure. The aim of this study was to evaluate functional outcome for patients who had undergone a laparoscopic dismembered pyeloplasty. PATIENTS AND METHODS: Seventy children underwent a laparoscopic dismembered pyeloplasty. Median follow up was 24 months (1-48). We reviewed differential renal function (DRF) and tracer clearance with diuretic renography before as well as 3 and 12 months after operation. Ultrasound was used to determine the grade of hydronephrosis pre- and postoperatively. RESULTS: Median age at operation was 20 months (1-178). Median operating time was 140 min (95-220). Mean DRF could be preserved with no significant difference (P>0.05). All patients showed a significant improvement in tracer clearance on diuretic renography postoperatively (P<0.0001). Ultrasound examinations postoperatively showed a diminished grade of hydronephrosis without significance (P=0.657). CONCLUSION: In terms of preservation of DRF the laparoscopic approach is as effective as open surgery. Tracer clearance is significantly improving. Operating times for laparoscopic pyeloplasty are competitive. We conclude that laparoscopic pyeloplasty requires extensive experience in laparoscopic pediatric urology but might replace the open surgical procedure as gold standard in the operative treatment of ureteropelvic junction obstruction.

Impact of pedicle clamping in pediatric liver resection.

BACKGROUND: Vascular clamping techniques are commonly used but so far the impact on pediatric liver surgery has not been investigated. The purpose of this study was to analyze pedicle clamping during pediatric liver resection in terms of hepato-cellular injury and blood loss. METHODS: Sixty-seven children undergoing liver resection were analyzed retrospectively. Vascular clamping was used in 28 cases (PC group), in 39 the resection was performed without clamping (NPC group). Major hepatectomies (resection of more than three segments) were carried out in 88%, minor hepatectomies (resection of three and less segments) in 12% of patients. Twenty-six children underwent extended liver resection. Patient data, liver function tests (LFTs) and blood loss were analyzed statistically. RESULTS: There were no significant differences in patient preoperative and postoperative data and LFTs between the groups. Within the NPC group the amount of administered fresh frozen plasma (FFP) in total and per kilogram (FFP/kg) was significantly higher (p=0.023 and 0.028) than in the PC group. For patients with extended liver resection, operation times were significantly longer (p=0.016) in the group without vascular clamping (NPCext). In the NPCext group significantly more children required packed red cells, FFP and FFP/kg. LFTs showed no significant differences in all children regardless of vascular clamping. CONCLUSIONS: For children undergoing liver resection, vascular clamping offers a blood saving surgical technique. Postoperative LFTs were not statistically different, regardless of vascular clamping. Pedicle clamping proved to be a safe method, not associated with an increase in perioperative complications.

Thoracoscopic repair of a right-sided congenital diaphragmatic hernia.

The presentation of a congenital diaphragmatic hernia (CDH) beyond infancy is rare, as it is a common cause for severe respiratory distress in the newborn. In contrast to the newborn period, delayed diagnosis of right-sided congenital diaphragmatic hernia (RCDH) is known as it causes less severe symptoms than left-sided CDH. A case of an 8-month-old girl is reported. Chest x-ray and ultrasound examination of the diaphragm for symptoms of pneumonia revealed an RCDH. Thoracoscopic repair could be performed. The further course was uneventful. Thoracoscopic repair of a RCDH proved in this case to be feasible and safe beyond the newborn period. It avoided the morbidity of a major thoracotomy or laparotomy and provided an excellent cosmetic result. To our knowledge, this is the first report of thoracoscopic repair of RCDH.

Colon atresia, facial hemiaplasia, and anophthalmia: a case report.

A case of a newborn with atresia of the transverse colon and right facial hemiaplasia, anophthalmia, and cerebral dysfunction is reported. Colon atresia is a rare cause of congenital bowel obstruction and often associated with other malformations such as abdominal wall defects, gastrointestinal, cardiac, urogenital, and musculosceletal lesions. Facial hemiaplasia may arise in frame of chromosomal defects or as a result of neurovascular compromise caused by congenital amniotic bands. However, the combination of colon atresia and facial hemiaplasia has not been reported before.