Kono-S anastomosis in Crohn's disease: initial experience in pediatric patients.

PURPOSE: Children diagnosed with Crohn's disease (CD) often undergo ileocecal resection (ICR) during childhood. Anastomotic recurrence is a frequent finding following this procedure. Data addressing the effect of the anastomosis type on disease recurrence are scarce in the pediatric population. The Kono-S anastomosis has shown promise in reducing endoscopic, clinical, and surgical recurrence rates in adults. We aimed to report our experience with Kono-S anastomosis in children, focusing on its feasibility and postoperative complications. METHODS: We retrospectively analyzed pediatric CD patients who underwent ICR with Kono-S anastomosis between August 2022 and May 2023. Data on demographics, clinical characteristics, surgery, hospitalization, and follow-up including colonoscopy were collected. Complications were classified using the Clavien-Dindo classification. RESULTS: Twelve patients (7 females, 58.3%) were included. Six (50%) of the patients had the B3 luminal form of the disease (according to Paris classification). Median surgery duration was 174 (interquartile range [IQR] 161-216) minutes. Anastomosis creation took a median of 62 (IQR, 54.5-71) minutes. Median hospitalization length was 6 (IQR 4-7) days. No short- or mid-term complications were observed. Median follow-up duration was 9.5 (IQR 6.8-12) months. CONCLUSION: According to our results, Kono-S anastomosis is safe and feasible in pediatric CD patients, with no observed postoperative complications. These findings support the potential benefit of using Kono-S anastomosis as a treatment approach in children with CD.

Anastomotic stricture prediction in patients with esophageal atresia with distal fistula.

PURPOSE: To investigate potential early risk factors for anastomotic stricture formation and assess the predictive role of post-operative esophagrams. METHODS: A retrospective study of patients with esophageal atresia with distal fistula (EA/TEF) operated between 2011 and 2020. Fourteen predictive factors were tested for stricture development. Esophagrams were used to calculate early (SI1) and late (SI2) stricture index (SI = anastomosis diameter/upper pouch diameter). RESULTS: Of 185 patients operated for EA/TEF in the 10-year period, 169 patients met the inclusion criteria. Primary anastomosis was performed in 130 patients and delayed anastomosis in 39 patients. Stricture formed in 55 patients (33%) within 1 year from anastomosis. Four risk factors showed strong association with stricture formation in unadjusted models: long gap (p = 0.007), delayed anastomosis (p = 0.042), SI1 (p = 0.013) and SI2 (p < 0.001). A multivariate analysis showed SI1 as significantly predictive of stricture formation (p = 0.035). Cut-off values using a receiver operating characteristic (ROC) curve were 0.275 for SI1 and 0.390 for SI2. The area under the ROC curve demonstrated increasing predictiveness from SI1 (AUC 0.641) to SI2 (AUC 0.877). CONCLUSIONS: This study identified an association between long gap and delayed anastomosis with stricture formation. Early and late stricture indices were predictive of stricture formation.

Gastric tumors in children: single-center study with emphasis on treatment of repeated recurrence.

PURPOSE: Analysis of surgical management and survival of pediatric patients with gastric tumors treated at our institution. METHODS: A retrospective study of patients with primary gastric tumors treated between 1993 and 2018 was conducted. RESULTS: Eight patients, five girls and three boys, were diagnosed with gastric tumors at an average age of 10.4 years (1 day-15.4 years). Surgical management included Billroth type I procedure in five and tumor excision in three patients. Histology revealed gastrointestinal stromal tumor (GIST) in four patients and one of each of schwannoma, myofibroblastic tumor, hamartoma and teratoma. Microscopically clear margins were reported in six patients. Repeated local recurrence occurred in three patients (2 × GIST, 1 × myofibroblastic tumors) who consequently underwent three, four and six reoperations. One of these patients had liver metastases, which were managed with ligation of the hepatic arteries. This patient was also diagnosed with a lung hamartoma, which was treated with a lobectomy. Survival rate was 100% with a median follow-up of 8.6 years (7 months-25.5 years). CONCLUSIONS: Gastric tumors are rare in children and represent a management challenge. Repeated recurrence of GISTs and myofibroblastic tumors remains frequent even after complete resection and may necessitate multiple surgeries, therefore patients require a lifelong follow-up.

Indications and outcomes of duodenum-preserving resection of the pancreatic head in children.

AIM OF STUDY: Duodenum-preserving resection of the pancreatic head (DPRPH) with Roux-en-Y pancreatojejunostomy is a procedure used to remove focal pathological lesions of the pancreatic head. Although predominantly used in adult patients, it is both safe and effective in children. The aim of this study was to review our experience with this procedure, with focus on its indications, complications and long-term outcomes. METHODS: A retrospective analysis of pediatric patients who underwent DPRPH between 1994 and 2015 was performed. Patient files were reviewed for demographic, diagnostic, operative and histological details, postoperative complications. Patients were contacted telephonically and sent questionnaires to determine long-term outcomes. RESULTS: The study cohort consists of 21 patients, 14 girls and 7 boys, with an average age of 11.72 years (range 3 months to 18.6 years), who underwent DPRPH with end-to-end anastomosis of the jejunum to the pancreatic body (Roux-en-Y anastomosis). In four cases the head and also part of the body of the pancreas was resected. In the remaining 17 cases, only the head of the pancreas was resected. Indications for DPRPH were solid pseudopapillary tumor of the pancreas (n = 10), trauma (n = 8), pancreas divisum (n = 1), focal congenital hyperinsulinism (n = 1) and pancreatic cyst (n = 1). The length of follow-up ranged from 1 to 22 years (average 9.66). One patient developed a biliary fistula, which closed spontaneously within 2 weeks after stent insertion. A recurrence of abdominal pain was reported in two patients, occurring at 7 months after the operation in one patient and at 1 year in the other. Pancreatic endocrine insufficiency did not occur in any of the 21 patients. Seven patients currently require a low fat diet, five of which need pancreatic enzyme supplementation. An additional two patients need enzyme supplementation without dietary restriction. CONCLUSION: DPRPH is a safe and effective procedure for the treatment of large focal pathological lesions of the pancreatic head in children. As a less invasive procedure than pancreatoduodenectomy, it is more appropriate for the developing child.

Endoscopic treatment of bile duct post-traumatic and post-operative lesions in children.

BACKGROUND AND STUDY AIMS: The aim of this study was to assess the significance and safety of endoscopic retrograde cholangiopancreatography (ERCP) in diagnosing and treating bile duct injuries in children. PATIENTS AND METHODS: Fourteen pediatric patients, with traumatic or postoperative bile duct injury, in which ERCP was performed, were retrospectively evaluated. RESULTS: We performed 46 ERCP and 12 endoscopic papillotomies in children with suspected bile duct injuries. A bile stent was primarily inserted in 13 patients and there were 20 replacements. Endoscopic treatment of bile leakage without need for bile duct sutures or reconstruction was successful in 85.7%. Post ERCP complications included cholangitis and recurrent bleeding, which occurred only in two patients each. CONCLUSIONS: ERCP and endoscopic bile stent insertion is a highly effective, minimally-invasive treatment for bile duct injury and should be included as part of the therapeutic procedures in pediatric patients with suspected bile duct injury.

What is the role of endoscopic retrograde cholangiopancreatography in assessing traumatic rupture of the pancreatic in children?

BACKGROUND AND STUDY AIMS: Trauma is one of the most common causes of morbidity and mortality in the pediatric population. The diagnosis of pancreatic injury is based on clinical presentation, laboratory and imaging findings, and endoscopic methods. CT scanning is considered the gold standard for diagnosing pancreatic trauma in children. PATIENTS AND METHODS: This retrospective study evaluates data from 25 pediatric patients admitted to the University Hospital Motol, Prague, with blunt pancreatic trauma between January 1999 and June 2013. RESULTS: The exact grade of injury was determined by CT scans in 11 patients (47.8%). All 25 children underwent endoscopic retrograde cholangiopancreatography (ERCP). Distal pancreatic duct injury (grade III) was found in 13 patients (52%). Proximal pancreatic duct injury (grade IV) was found in four patients (16 %). Major contusion without duct injury (grade IIB) was found in six patients (24%). One patient experienced duodeno-gastric abruption not diagnosed on the CT scan. The diagnosis was made endoscopically during ERCP. Grade IIB pancreatic injury was found in this patient. One patient (4%) with pancreatic pseudocyst had a major contusion of pancreas without duct injury (grade IIA). Four patients (16%) with grade IIB, III and IV pancreatic injury were treated exclusively and nonoperatively with a pancreatic stent insertion and somatostatine. Two patients (8%) with a grade IIB injury were treated conservatively only with somatostatine without drainage. Eighteen (72 %) children underwent surgical intervention within 24 h after ERCP. CONCLUSION: ERCP is helpful when there is suspicion of pancreatic duct injury in order to exclude ductal leakage and the possibility of therapeutic intervention. ERCP can speed up diagnosis of higher grade of pancreatic injuries.

Isolated prenatal ultrasound findings predict the postnatal course in gastroschisis.

PURPOSE: The aim of the study was to identify which prenatal ultrasonographic findings in fetuses with gastroschisis correlate with complicated postnatal outcome. METHODS: Ultrasound findings at the 30th week of pregnancy and medical reports were statistically analyzed to identify independent prenatal ultrasonographic predictors of postnatal outcome. RESULTS: Completed prenatal data were gathered from 64 pregnancies. Prenatal intra-abdominal bowel dilatation (cutoff 10 mm) correlated with the presence of atresia (p < 0.01), longer administration of parenteral nutrition, extended hospital stay (median 53 vs. 21 days; 68 vs. 36 days, both p < 0.05), and greater number of additional surgical procedures (p < 0.05). Infants with antenatal presence of thickened bowel wall (greater than or equal to 3 mm) required longer administration of parenteral nutrition (median 34 vs. 20 days; p < 0.01) and prolonged stay (median 44 vs. 37 days; p < 0.05). Presence of oligohydramnion (amniotic fluid index below 8 cm) was connected with longer administration of parenteral nutrition in newborns (median 30 vs. 16 days; p < 0.05). CONCLUSION: The isolated presence of oligohydramnion with amniotic fluid index below 8 cm, thickened bowel wall equal to or more than 3 mm and the prenatal intra-abdominal dilatation with 10 mm cutoff had significant predictive value for the adverse postnatal outcome of patients with gastroschisis.

Technical innovation in minimally invasive repair of pectus excavatum.

The aim of study was to introduce technical innovation of MIRPE which reduces the risk of cardiac injury. Modification of MIRPE method with semiflexible thoracoscope and sternum elevating technique has been used. Volkmann bone hook has been inserted percutaneously to the sternum. The hook elevates the sternum forward and enlarges the retrosternal space for safer passage of thoracoscopically guided introducer. Using semiflexible thoracoscope allows better view from various angles via one site of insertion. During the period 2005-2012, the MIRPE was performed on 29 girls and 151 boys; the mean age at the time of surgery was 15.9 years (range 13-18.7 years). The mean Haller index was 4.7 (range 2.7-20.5). The most common complication was pneumothorax (3.3 %) and the incidence of bar displacement was 2 %. The most serious complication was cardiac perforation when inserting Lorenz introducer. This occurred in a 16-year-old girl; she required urgent sternotomy with right atrial repair and recovered well. External elevation of sternum with the hook was used since this case. Subsequent 113 patients underwent surgery without any serious complications. Technical innovation using semiflexible thoracoscope and hook elevation of the sternum reduces the risk of cardiac injury. The hook opens the anterior mediastinum space effectively and makes the following dissection relatively safe and straightforward.

Perioperative Histologically Controlled Fistula Resection in Patients with Imperforate Anus and Perineal Fistula.

INTRODUCTION: Postoperative constipation (PC) in patients with imperforate anus and perineal fistula (PF) has been reported in up to 60%. Histological studies of PF revealed innervation anomalies which seem to be one of the reasons for PC. Perioperative histologically controlled fistula resection (PHCFR) allows appropriate resection of PF and pull-down normoganglionic rectum at the time of posterior sagittal anorectoplasty (PSARP). MATERIALS AND METHODS: A total of 665 patients with anorectal malformations underwent surgery between 1991 and 2021. Of these, 364 presented PF; 92 out of them (41 F) were studied. Patients with sacral and spinal cord anomalies, neurological disorders, and cut-back anoplasty were excluded. PSARP was done on all patients. Hematoxylin-eosin staining and NADH Tetrazolium-reductase histochemical method were used. Four and more ganglion cells in the myenteric plexus represented a sufficient length of the resection. The continence was scored according to the modified Krickenbeck scoring system. Final scores ranged from 1 to 7 points. Values are given as median. RESULTS: A total of 65 (70.7%) patients presented an aganglionic segment in PF, and 27 patients presented hypoganglionosis. The median length of the resected fistula was 25 mm (interquartile range [IQR]: 20-30). The median total continence score was 7 (IQR: 6-7). Post-op constipation was observed in 6/92 (6.5%) patients. CONCLUSION: PHCFR diminished PC to 6.5% of patients.

Lung Resection in Children with Necrotizing Pneumonia: Outcome and Follow-up.

INTRODUCTION: The number of patients with necrotizing pneumonia has increased in recent years. The aim of this study is to review the incidence, management, and outcome of pediatric necrotizing pneumonia requiring surgical therapy and to prove that lung resection results in favorable development of patients. We hypothesize that overall lung function in children after lung resection does not differ from that of the healthy population. MATERIALS AND METHODS: A retrospective tertiary referral center study with a prospective follow-up spirometric study of patients with necrotizing pneumonia managed between January 2010 and December 2019 was performed. RESULTS: The study cohort consisted of 1,295 patients admitted to the pediatric department for community-acquired pneumonia; 47 patients developed necrotizing pneumonia, 36 of whom underwent parenchymal lung resection. A 5-year rise in the occurrence of necrotizing pneumonia requiring resection was 77%, with a significant increase in the last 3 years (p < 0.05). The median age at the time of surgery was 32.5 (interquartile range [IQR]: 32.25) months. Streptococcus pneumoniae was the most prevalent pathogen (83%), although 53.3% of these patients were vaccinated against the agent. In 67% of patients, preresection procedures were performed: drainage of pneumothorax (17%), drainage of empyema (46%), drainage of empyema with use of alteplase (25%), and thoracoscopic decortication (12%). Surgical procedures included lobectomy (72.2%), wedge resection (13.9%), bilobectomy (8.3%), and pneumonectomy (5.6%). The postoperative complication was bronchopleural fistula in three patients. There were two (5.5%) postoperative deaths due to multiple organ failure. The follow-up spirometry was performed 43.3 (median, IQR 23.8-66.7) months after surgical intervention. Normal lung function was detected in 35 (64.8%) patients, restrictive pattern in 6 (11.1%) patients, obstructive pattern in 11 (20.4%) patients, and combined in 2 (3.7%) patients. CONCLUSION: The number of patients with necrotizing pneumonia requiring resection has increased significantly in the last 3 years (p < 0.05). Aggressive surgical treatment results in significant clinical improvement in most cases and favorable lung function outcome. Long-term follow-up showed normal spirometry in 64.8% of cases.

Initial experience with minimally invasive treatment of pilonidal sinus in children.

INTRODUCTION: Sinus pilonidalis (SP) is an acquired inflammatory disease, which is relatively common in the paediatric population. Surgery is indicated in symptomatic patients. In 2017, minimally invasive pilonidal sinus treatment (EPSiT) was adapted to the paediatric population. AIM: To evaluate the first experience with minimally invasive endoscopic treatment of SP (PEPSiT) in children and adolescents in the Czech Republic. MATERIAL AND METHODS: A retrospective review of all consecutive paediatric patients who underwent PEPSiT from November 2018 to February 2020. The monitored parameters were demographics, perioperative course of the disease, surgery, length of hospitalisation, postoperative complications, healing, disease recurrence, and follow-up. RESULTS: Seventeen patients were enrolled in the study. The median age at surgery was 17.1 years (range: 12.5-18). The subjects comprised 76% males, and the median body mass index was 25.6 kg/m2 (range: 17-30.3 kg/m2). Thirteen patients underwent previous surgical treatment (76%) under local anaesthesia. The median duration of PEPSiT was 50 min (range: 30-85 min). The subjective evaluation of pain by patients on the VAS scale was 0 on the day of discharge. There were no postoperative complications up to the 30th postoperative day. Two disease recurrences were successfully managed by re-PEPSiT. By the end of follow-up, 14/15 patients had healed. Two patients are still within 3 months of surgery, which is too soon to definitively evaluate possible recurrence of the disease. CONCLUSIONS: These preliminary results show that PEPSiT is a highly promising method. It is safe and well-tolerated by patients (short hospital stay, quick return to normal life, low pain and analgesic consumption). Two recurrences of disease were treated by re-PEPSiT.

Thoracoscopic repair of congenital isolated H-type tracheoesophageal fistula.

BACKGROUND/PURPOSE: The available literature on congenital isolated H-type tracheoesophageal fistula (TEF) is limited, and preferred approach varies among centers (cervicotomy, thoracotomy, thoracoscopy). We aimed to present one of the biggest case series of thoracoscopic approach for congenital isolated TEF and to assess the method's feasibility and outcomes. METHODS: Retrospective review of thoracoscopic TEF repair experiences at 2 European university pediatric surgery centers. RESULTS: 9 boys and 3 girls were involved in the study (age 5 days-4 years), 8 of them were newborns (mean birth weight 3013 g, mean gestational age 39 weeks). The most common presenting symptoms were desaturations on feeding in neonates and recurrent respiratory tract infections in older children. The diagnoses were established on contrast study and confirmed with rigid bronchoscopy. The fistulas were located at or below the thoracic inlet; the fistulas were 2 cm above the carina to half the height of the trachea. All patients underwent successful thoracoscopic TEF repair. There were no conversions. The postoperative course was uneventful in all but one who had rethoracoscopy for prolonged postoperative chylothorax. All patients had satisfactory vocal cord function. One patient required reoperation for fistula recurrence 8 months after primary surgery. CONCLUSION: Thoracoscopic approach for isolated H-type TEF seems to be possible as a procedure of choice with satisfactory results and all benefits of minimally invasive procedure. LEVEL OF EVIDENCE: IV (case series).

Conjugated Hyperbilirubinemia in Infants: Is There Still a Role for ERCP?

Over a twenty-year period, we performed 255 ERCP procedures in infants aged up to 1 year. ERCP was indicated in cholestatic infants with suspicion of biliary obstruction. The most common diagnosis was biliary atresia (48%), choledochal cysts (13%), and choledocholithiasis (4%). The procedure complication rate was 13.7%. Hyperamylasemia occurred in 12.9%. More severe complications were rare-0.8% of ERCP procedure. There were no cases of postprocedural pancreatitis or death. Our study has proved that ERCP is a safe and reliable method in this age group. Its high specificity and negative predictive value for extrahepatic biliary atresia can prevent unnecessary surgeries in patients with normal bile ducts or endoscopically treatable pathologies.

Removal of Ingested Magnetic Bodies via Laparoscopic Appendectomy.

Ingestion of a foreign body is a frequent diagnosis in the pediatric population. In a small percentage of cases, foreign bodies themselves are strong magnets, and swallowing of multiple magnetic bodies can lead to serious complications in the gastrointestinal tract. Two consecutive case reports of patients who swallowed two magnetic beads are presented. In both cases, the abdominal radiograph described two magnets in contact, one in the area of the left hypochondrium and one in the right hypogastrium. Attempts of endoscopic localization and removal were unsuccessful. Due to the failure of magnet progression, laparoscopic revision of the abdominal cavity was indicated in both patients on the 25th and 4th day after swallowing. Using the magnetic forces between the magnets and the laparoscopic instruments, the foreign bodies were localized in the appendix of the first patient and in the cecum of the other one. The magnets were extracted together with the removal of the appendix in both patients. This is one of the first articles describing the successful extraction of foreign magnetic bodies from the gastrointestinal tract via laparoscopic appendectomy.

The Impact of Anti-Tumor Necrosis Factor Alpha Therapy on Postoperative Complications in Pediatric Crohn's Disease.

INTRODUCTION: The incidence of Crohn's disease (CD) within the pediatric population is increasing worldwide. Despite a growing number of these patients receiving anti-tumor necrosis factor α therapy (anti-TNF-α), one-third of them still require surgery. There is limited data as to whether anti-TNF-α influences postoperative complications. We evaluated postoperative complications in patients who were or were not exposed to anti-TNF-α therapy in our institutional cohort. MATERIALS AND METHODS: A retrospective review of CD patients who underwent abdominal surgery between September 2013 and September 2018 was performed. The patients were divided into two groups based on whether they were treated with anti-TNF-α within 90 days before surgery. Thirty-day postoperative complications were assessed using Clavien-Dindo classification (D-C); this examination included surgical site infections (SSIs), stoma complications, intra-abdominal septic complications, non-SSIs, bleeding, ileus, readmission rate, and return to the operating room. Mann-Whitney U-test, Fisher's exact test, and multivariate logistic regression analyses were used for statistical analysis. RESULTS: Sixty-five patients (41 males) with a median age of 16 years (range: 7-19) at the time of operation were identified. The most common surgery was ileocecal resection in 49 (75%) patients. Forty-three (66.2%) patients were treated with anti-TNF-α preoperatively. Seven patients (11%) experienced postoperative complications. There was no statistically significant difference in postoperative complication in patients who did or did not receive anti-TNF-α before surgery (D-C minor 2.3% vs. 4.6%, p = 1; D-C major 7% vs. 9.1%, p = 1). CONCLUSION: The use of anti-TNF-α in pediatric CD patients within the 90 days prior to their abdominal surgery was not associated with an increased risk of 30-day postoperative complications.

Urinary I-FABP, L-FABP, TFF-3, and SAA Can Diagnose and Predict the Disease Course in Necrotizing Enterocolitis at the Early Stage of Disease.

Necrotizing enterocolitis (NEC) is a severe gastrointestinal disease affecting mainly preterm newborns. It is characterized by unexpected onset and rapid progression with specific diagnostic signs as pneumatosis intestinalis or gas in the portal vein appearing later in the course of the disease. Therefore, we analyzed diagnostic and prognostic potential of the markers of early NEC pathogenesis, such as excessive inflammatory response (serum amyloid A (SAA)) and gut epithelium damage (intestinal and liver fatty acid-binding protein (I-FABP and L-FABP, respectively) and trefoil factor-3 (TFF-3)). We used ELISA to analyze these biomarkers in the urine of patients with suspected NEC, either spontaneous or surgery-related, or in infants without gut surgery (controls). Next, we compared their levels with the type of the disease (NEC or sepsis) and its severity. Already at the time of NEC suspicion, infants who developed NEC had significantly higher levels of all tested biomarkers than controls and higher levels of I-FABP and L-FABP than those who will later develop sepsis. Infants who will develop surgery-related NEC had higher levels of I-FABP and L-FABP than those who will develop sepsis already during the first 6 hours after the abdominal surgery. I-FABP was able to discriminate between infants who will develop NEC or sepsis and the SAA was able to discriminate between medical and surgical NEC. Moreover, the combination of TFF-3 with I-FABP and SAA could predict pneumatosis intestinalis, and the combination of I-FABP, L-FABP, and SAA could predict gas in the portal vein or long-term hospitalization and low SAA predicts early full enteral feeding. Thus, these biomarkers may be useful not only in the early, noninvasive diagnostics but also in the subsequent NEC management.

Current management of pediatric appendicitis: A Central European survey.

BACKGROUND: Appendicitis is one of the most common diagnoses in pediatric populations. Although new recommendations for the treatment of pediatric appendicitis were published, management varies among different institutions. OBJECTIVES: To determine current practices in 4 (n = 4) representative pediatric surgical departments in Central Europe. MATERIAL AND METHODS: One department from each of the 4 countries was surveyed using an online questionnaire. Questions focused on preoperative, operative and postoperative practices in 2018, particularly those related to antibiotic (ATB) therapy and laparoscopy. RESULTS: A total of 519 appendectomies were performed, among which 413 (79.6%) were laparoscopic appendectomies (LAs), with a conversion rate of 5.1%. Appendectomy, as an elective procedure, was performed in 43 (8.3%) patients. One-quarter (129 patients) had complex appendicitis and 72.3% of these were operated laparoscopically. In 3 departments, ATB prophylaxis was administered, based on the decisions of the operating surgeon. One department used standard ATB prophylaxis (metronidazole). Whenever phlegmonous appendicitis was detected, ATB were administered therapeutically in 2 departments. Two other departments administered ATB based on surgeon decision. The choice of ATB was not standardized. If complex appendicitis was detected, all sites administered ATB therapeutically. The type of ATB treatment was standardized in complex cases in 2 departments. Thirty-four complications (6.6%) at surgical sites were recorded - 4.1% (16/390) after uncomplicated and 14% (18/129) after complex appendicitis. Thirty-two occurred after acute surgeries and 26 of these followed laparoscopic procedures. Postoperatively, intra-abdominal abscesses occurred in 3.5% of laparoscopic and in 2.9% of open appendectomy (OA) cases. CONCLUSIONS: This questionnaire study showed that treatment outcomes for appendicitis in children in Central Europe are comparable with data reported in the literature. Laparoscopic appendectomy is the predominant surgical method, but there is a little consensus for ATB treatment in the management of appendicitis at our 4 pediatric surgical departments.

Influence of Surgical Excision on the Survival of Patients With Stage 4 High-Risk Neuroblastoma: A Report From the HR-NBL1/SIOPEN Study.

PURPOSE: To evaluate the impact of surgeon-assessed extent of primary tumor resection on local progression and survival in patients in the International Society of Pediatric Oncology Europe Neuroblastoma Group High-Risk Neuroblastoma 1 trial. PATIENTS AND METHODS: Patients recruited between 2002 and 2015 with stage 4 disease > 1 year or stage 4/4S with MYCN amplification < 1 year who had completed induction without progression, achieved response criteria for high-dose therapy (HDT), and had no resection before induction were included. Data were collected on the extent of primary tumor excision, severe operative complications, and outcome. RESULTS: A total of 1,531 patients were included (median observation time, 6.1 years). Surgeon-assessed extent of resection included complete macroscopic excision (CME) in 1,172 patients (77%) and incomplete macroscopic resection (IME) in 359 (23%). Surgical mortality was 7 (0.46%) of 1,531. Severe operative complications occurred in 142 patients (9.7%), and nephrectomy was performed in 124 (8.8%). Five-year event-free survival (EFS) ± SE (0.40 ± 0.01) and overall survival (OS; 0.45 ± 0.02) were significantly higher with CME compared with IME (5-year EFS, 0.33 ± 0.03; 5-year OS, 0.37 ± 0.03; P < .001 and P = .004). The cumulative incidence of local progression (CILP) was significantly lower after CME (0.17 ± 0.01) compared with IME (0.30 ± 0.02; P < .001). With immunotherapy, outcomes were still superior with CME versus IME (5-year EFS, 0.47 ± 0.02 v 0.39 ± 0.04; P = .038); CILP was 0.14 ± 0.01 after CME and 0.27 ± 0.03 after IME (P < .002). A hazard ratio of 1.3 for EFS associated with IME compared with CME was observed before and after the introduction of immunotherapy (P = .030 and P = .038). CONCLUSION: In patients with stage 4 high-risk neuroblastoma who have responded to induction therapy, CME of the primary tumor is associated with improved survival and local control after HDT, local radiotherapy (21 Gy), and immunotherapy.

The intestinal fatty acid-binding protein as a marker for intestinal damage in gastroschisis.

BACKGROUND/PURPOSE: We analyzed the capacity of urinary Intestinal fatty acid-binding protein (I-FABP) to quantify the degree of mucosal injury in neonates with gastroschisis (GS) and to predict the speed of their clinical recovery after surgery. METHODS: In this prospective study, we collected urine during the first 48h after surgery from neonates operated between 2012 and 2015 for GS. Neonates with surgery that did not include gut mucosa served as controls for simple GS and neonates with surgery for intestinal atresia served as control for complex GS patients. The I-FABP levels were analyzed by ELISA. RESULTS: Urinary I-FABP after the surgery is significantly higher in GS newborns than in control group; I-FABP in complex GS is higher than in simple GS. I-FABP can predict subsequent operation for ileus in patients with complex GS. Both ways of abdominal wall closure (i.e. primary closure and stepwise reconstruction) led to similar levels of I-FABP. None of the static I-FABP values was useful for the outcome prediction. The steep decrease in I-FABP after the surgery is associated with faster recovery, but it cannot predict early start of minimal enteral feeding, full enteral feeding or length of hospitalization. CONCLUSION: Urinary I-FABP reflects the mucosal damage in gastroschisis but it has only a limited predictive value for patients' outcome.