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1.

Background/Purpose

Morgagni diaphragmatic hernia (MH) is rare. We report our experience based on routine patch use in MH repair to curb recurrence. A systematic review and meta-analysis were performed to study the recurrence and complications associated with minimally invasive surgery and the use of patch.

Methods

We retrospectively reviewed all cases of MH who underwent first-time repair in 2012-2017 in our institution to determine recurrence and complication rate. A MEDLINE search related to minimally invasive surgery (MIS) and patch repair of MH was conducted for systematic review. Eligible articles published from 1997-2017 with follow-up data available were included. Primary outcomes measured were recurrence and complication. Meta-analysis to compare open versus MIS and primary versus patch repair in the MIS group were performed in comparative cohorts. Continuous data were presented as median (range), and statistical significance was P < 0.05.

Results

In our institution, 12 consecutive patients aged 17-month-old (22 days-7 years), underwent laparoscopic patch repair of MH, with one conversion to laparotomy. No recurrence or significant complication occurred over a follow-up period of 8 months (1-48 months).Thirty-six articles were included from literature review and were combined with the current series. All were retrospective case reports or series, of which 6 were comparative cohorts with both MIS and open repairs. A total of 296 patients from 37 series were ultimately used for analysis: 80 had open repair (4 patch) and 216 had MIS repair (32 patch), with a patch rate of 12%. There were 13 recurrences (4%): no difference between open and MIS repairs (4/80 vs 9/216, p = 0.75); recurrence rate following primary repair was 13/260 (5%), but no recurrence occurred with 36 patch repairs. Meta-analysis showed no difference in recurrence between open and MIS repair (p = 0.83), whereas patch repair was associated with 14% less recurrence compared with primary repair, although it did not reach statistical significance (p = 0.12). There were 13 complications (5%): no difference between open and MIS repairs (5/80 vs 8/216, p = 0.35). One small bowel obstruction occurred in a patient who had laparoscopic patch repair.

Conclusion

In MH, recurrence and complication rates are comparable between MIS and open repairs. Use of patch appeared to confer additional benefit in reducing recurrence.

Type of Study

Systematic review

Level of Evidence

3A  相似文献   

2.

Purpose

This study aimed to evaluate the usefulness of laparoscopic repair of inguinal hernia (LR) in infants in comparison with open hernia repair (OR).

Methods

We retrospectively analyzed the clinical data of 465 infants treated for inguinal hernia from January 2006 to December 2015. Among them, 124 underwent LR and 341 underwent OR.

Results

In the OR group, 16.1% (55/341) primarily underwent bilateral inguinal hernia repair and 13.6% (42/308) subsequently developed metachronous contralateral inguinal hernia during follow-up. In the LR group, 75.8% (94/124) underwent primary bilateral inguinal hernia repair and only 1.6% (2/123) developed metachronous contralateral inguinal hernia. The mean operation times of unilateral inguinal hernia repair showed no statistical differences between LR and OR. However, the mean operation times of bilateral inguinal hernia repair were shorter in LR (39.8 ± 10.4 vs. 51.1 ± 14.4 min, p < 0.001). Postoperative recurrence and wound infection showed no statistical differences between the groups, but postoperative scrotal swelling was more common in OR (0.0% vs. 4.0%, p = 0.006).

Conclusion

LR in infants showed a lower incidence of metachronous hernia, shorter operation times, and better postoperative course than OR. LR could be considered the primary operation method in infants with inguinal hernia.

Levels of Evidence

Prognosis Study, Retrospective Study, Level III.  相似文献   

3.

Background

Subcutaneous endoscopically-assisted ligation (SEAL) for pediatric inguinal hernia repair has gained in popularity although variations in techniques exist. Peritoneal scarring by thermal injury has been described as an adjunct. We explored the hypothesized inverse-correlation between peritoneal scarring and recurrence after SEAL.

Methods

We conducted a single-center retrospective review of all patients < 18 years old undergoing SEAL between 2010 and 2016 (REB-20172727). Demographics and outcomes were investigated. Univariate and multivariable logistic regressions were performed to evaluate the association between peritoneal scarring and recurrence.

Results

We identified 272 patients. Median age was 3 years, 35% were female, and 19% were born premature. Median follow-up was 30 months, ≥ 1 visit/patient. Bilaterality was noted in 35%. There were no reported cases of metachronous hernia, vas injury, testicular atrophy or chronic pain, and recurrence rate was 4.6%. Prematurity, unilateral repair, incarceration, and suture-type (Ti-Cron® vs. Ethibond®) had significant correlation with recurrence on univariate analysis (p < 0.25). Surgeon experience did not. Peritoneal scarring, performed in 195 cases (72%), was not predictive of recurrence (adjusted OR = 0.87, p = 0.830) on multivariable analysis.

Conclusion

The rate of complications with SEAL compares favorably to published data. Thermal injury was not associated with improved recurrence rates. The benefits of peritoneal scarring may not outweigh the risks.

Level of Evidence

III – Retrospective Case–Control Study.  相似文献   

4.

Background

Prosthetic patches can be used to repair large congenital diaphragmatic hernia defects but may be associated with infection, recurrence, and thoracic deformity. Biosheets (collagenous connective tissue membranes) have been used in regenerative medicine. We evaluated the efficacy of Biosheets in a rabbit model.

Methods

Biosheets were prepared by embedding silicone plates in dorsal subcutaneous pouches of rabbits for 4 weeks. In group 1 (n = 11), Gore-Tex® sheets (1.8 × 1.8 cm) were implanted into a diaphragmatic defect. In group 2 (n = 11), Seamdura®, a bioabsorbable artificial dural substitute, was implanted in the same manner. In group 3 (n = 14), biosheets were autologously transplanted into the diaphragmatic defects. All rabbits were euthanized 3 months after transplantation to evaluate their graft status.

Results

Herniation of liver was observed in 5 rabbits (45%) in group 1, 8 (73%) in group 2, and 3 (21%) in group 3. A significant difference was noted between groups 2 and 3 (P = 0.017). Biosheets had equivalent burst strength and modulus of elasticity as native diaphragm. Muscular tissue regeneration in transplanted biosheets in group 3 was confirmed histologically.

Conclusion

Biosheets may be applied to diaphragmatic repair and replacement of diaphragmatic muscular tissue.

Level of evidence

Level III.  相似文献   

5.

Purpose

For the last seven years, our institution has repaired infants with CDH that require ECMO early after cannulation. Prior to that, we attempted to decannulate before repair, but repaired on ECMO if we were unable to wean after two weeks. This study compares those strategies.

Methods

From 2002 to 2016, 65 infants with CDH required ECMO. 67.7% were repaired on ECMO, and 27.7% were repaired after decannulation. Data were compared between patients repaired ≤ 5 days after cannulation (“early protocol”, n = 30) and > 5 days after cannulation or after de-cannulation (“late protocol”, n = 35). We used Cox regression to assess differences in outcomes between groups.

Results

Survival for the early and late protocol groups was 43.3% and 68.8%, respectively (p = 0.0485). For patients that were successfully decannulated before repair, survival was 94.4%. Moreover, the early repair protocol was associated with prolongation of ECMO (16.8 ± 7.4 vs. 12.6 ± 6.8 days, p = 0.0216).After multivariate regression, the early repair protocol was an independent predictor of both mortality (HR = 3.48, 95% CI = 1.28–9.45, p = 0.015) and days on ECMO (IRR = 1.39, 95% CI = 1.07–1.79, p = 0.012). All bleeding occurred in patients repaired on ECMO (29.5%, 13/44).

Conclusions

Our data suggest that protocolized CDH repair early after ECMO cannulation may be associated with increased mortality and prolongation of ECMO. However, early repair is not necessarily harmful for those patients who would otherwise be unable to wean from ECMO before repair. Further work is needed to better move towards individualized patient care.

Type of study

Treatment Study.

Level of evidence

Level III.  相似文献   

6.

Background

Extracorporeal membrane oxygenation (ECMO) is commonly required in neonates with congenital diaphragmatic hernia (CDH) complicated by pulmonary hypertension (PH). ECMO carries significant risk, and is contraindicated in the setting of extreme prematurity or intracranial hemorrhage. Pumpless arteriovenous ECMO (P-ECMO) may represent an alternative for respiratory support. The present study summarizes our initial experience with P-ECMO in a lamb model of CDH.

Study design

Surgical creation of CDH was performed at 65–75 days' gestation. At term (135–145 days), lambs were delivered into the P-ECMO circuit. Three animals were maintained on a low-heparin infusion protocol (target ACT 160–180) and three animals were maintained with no systemic heparinization.

Results

Animals were supported by the circuit for 380.7 +/? 145.6 h (range, 102–504 h). Circuit flow rates ranged from 97 to 208 ml/kg/min, with adequacy of organ perfusion demonstrated by stable serum lactate levels (3.0 +/? 1.7) and pH (7.4 +/? 0.3). Necropsy demonstrated no evidence of thrombogenic complications.

Conclusion

Pumpless extracorporeal membrane oxygenation achieved support of CDH model lambs for up to three weeks. This therapy has the potential to bridge neonates with decompensated respiratory failure to CDH repair with no requirement for systemic anticoagulation, and may be applicable to patients currently precluded from conventional ECMO support.  相似文献   

7.

Background

This study compared perioperative outcomes between laparoscopic surgery (LS) and open surgery (OS) for pediatric inguinal hernia repair, using a national inpatient database.

Methods

Using the Diagnosis Procedure Combination database in Japan, we compared duration of anesthesia, postoperative complications, recurrence, and metachronous hernia (MH) between LS and OS for children undergoing inguinal hernia repair from July 2010 to March 2016. We used multivariable logistic regression analysis for postoperative complications and Cox regression analysis for recurrence.

Results

For 75,486 eligible patients (LS 20,186 vs. OS 55,300), the median follow-up was 815 (381–1350) days in LS and 1106 (576–1603) days in OS. The duration of anesthesia was significantly longer in LS than in OS for unilateral surgery (80 vs. 70 min, p < 0.001) but shorter for bilateral surgery (86 vs. 96 min, p < 0.001). LS had a lower proportion of MH than OS (0.3% vs. 3.4%, p < 0.001). There was no significant difference between LS and OS in complications (odds ratio: 0.55; 95% confidence interval: 0.22–1.38; p = 0.20) or recurrence (hazard ratio: 1.24; 95% confidence interval: 0.86–1.79; p = 0.89).

Conclusions

LS patients had lower proportions of MH than OS patients. Complications and recurrence did not differ significantly between LS and OS.

Type of study

Retrospective study.

Levels of evidence

Level III.  相似文献   

8.

Purpose

Inguinal hernias are common in premature infants, but there is substantial variation with regards to timing of repair. We sought to quantify and explain this variation.

Methods

Cohort study of infants < 34 weeks gestation diagnosed with an inguinal hernia and discharged from one of 329 neonatal intensive units between 1998 and 2012. Multivariable logistic regression clustered by site was used to evaluate demographic, clinical, maternal, and socioeconomic variables associated with pre-discharge repair.

Results

A total of 8037 infants met study criteria, and 3230 (40%) received a pre-discharge repair. The frequency of pre-discharge repair varied by site from 9% to 84%, and increased over the study period from 20% in 1998 to 45% in 2012. Concurrent gastrostomy or fundoplication and lower socioeconomic status were associated with an increased odds of receiving a pre-discharge repair.

Conclusion

There is substantial variation with regards to the timing of repair of inguinal hernias in premature infants, with an increasing number of infants receiving repair prior to hospital discharge over time. Concurrent gastrostomy or fundoplication and socioeconomic status are associated with timing of repair.

Level of evidence

IV.  相似文献   

9.

Background

Inguinal hernia repair using a percutaneous internal ring suturing technique is an effective alternative technique to conventional laparoscopic hernia repair. It is one of the most commonly used approaches for laparoscopic hernia repair in children. However, most percutaneous techniques have utilized extracorporeal knotting of the suture and burying the knot subcutaneously. This approach has several drawbacks. The aim of this study is to present a modified technique for single cannula needlescopic assisted hernia repair in children.

Patients and methods

Three-hundred and fifty-seven patients with 397 indirect inguinal hernias underwent a one port needlescopic assisted inguinal hernia repair. The open internal inguinal ring [IIR] was closed using an 18-gauge epidural needle [EN], a 14-gauge venous access cannula [VAC], and a homemade suture device. Saline was injected extraperitoneally around the IIR for hydrodissection. The main outcome measurements were: feasibility, safety of the technique, operative time, recurrence rate, and cosmetic results.

Results

This prospective study was conducted on 357 patients at Al-Azhar, Alexandria, and Mansoura University Hospitals during the period from June 2012 to October 2015. There were 286 males and 71 females. The mean age was 2.6 ± 1.3 years (range = 4 months to 6 years). One-hundred and ninety-eight patients presented with a right-sided inguinal hernia, 119 patients with a left-sided hernia, and 40 patients with bilateral inguinal hernia. The mean operative time was 12.6 ± 1.7 min (range = 8–15 min) for unilateral cases and 18.6 ± 1.7 min (range = 14–20 min) for the bilateral repairs. No wound complications or umbilical hernias developed. The mean follow-up period was 18.6 ± 1.2 months (range = 11–36 months). During the follow-up period, no recurrence was detected, and the scars were nearly invisible.

Conclusion

This preliminary study shows that a single port needlescopic assisted hernia repair in infants and children is a very promising technique to achieve nearly scarless surgery. The procedure is very safe, rapid, easy to learn, and reproducible.  相似文献   

10.

Background

Minimal access surgery (MAS) has gained popularity in infants less than 5 kg, however, significant challenges still arise in very low weight infants.

Study design

A retrospective chart review was performed to identify all infants weighing less than 3 kg who underwent an advanced MAS or equivalent open procedure from 2009 to 2016. Advanced case types included Nissen fundoplication, duodenal atresia repair, Ladd procedure, congenital diaphragmatic hernia repair, esophageal atresia/tracheoesophageal fistula repair, diaphragmatic plication, and pyloric atresia repair. A comparative analysis was performed between the MAS and open cohorts.

Results

A total of 45 advanced MAS cases and 17 open cases met the inclusion criteria. Gestational age and age at operation were similar between the cohorts, while infants who underwent open procedures had significantly lower weight at operation (p = 0.003). There were no deaths within 30 days related to surgery in either group. Only 3 MAS cases required unintended conversion to open. There were 2 (4.4%) postoperative complications related to surgery in the MAS cohort and 2 (11.8%) in the open cohort.

Conclusion

Advanced MAS may be performed in infants weighing less than 3 kg with low mortality, acceptable rates of conversion, and similar rates of complications as open procedures.

Type of study

Prognosis study.

Level of evidence

Level III.  相似文献   

11.

Purpose

Undescended testis (UDT) is the most common congenital anomaly of the male genitalia. The American Urological Association guidelines recommend orchiopexy by age 18 months to ameliorate the risk of subfertility. The study aim was to assess adherence to these guidelines on a national level.

Methods

We retrospectively reviewed both the State Ambulatory Surgery Database (SASD) in 2012 and the Pediatric Health Information System (PHIS) for 2015. All patients aged 18 years or less with a diagnosis of UDT who underwent orchiopexy were included. Demographic data including age at repair as well as surgical subspecialty and payer status were extracted.

Results

Analysis of the 2012 SASD for New Jersey, Florida, and Maryland yielded 1654 patients. The majority were white, 791 (48.3%), with a median age at repair of 4 years (IQR 1–8). Most patients, 1048 (64%), had orchiopexy later than age 2. A total of 844 males were identified from the PHIS database. Of these, 63% were white. The median age at repair was 5 years (IQR 1–9). There were 577 (68%) patients older than 2 years at orchiopexy.

Conclusion

Almost 70% of boys with undescended testes in the United States are undergoing orchiopexy at least 6 months later than the recommended age.

Type of study

Retrospective.

Level of evidence

III.  相似文献   

12.

Background/Purpose

Our previously published data suggested several risk factors for infection after the Nuss procedure. We aimed to further elucidate these findings.

Methods

An IRB-approved (14–03-WC-0034), single institution, retrospective review was performed to evaluate the incidence of postoperative Nuss bar infections associated with seven variables. These were subjected to bivariate and multivariable analyses. A broad definition of infection was used including cellulitis, superficial infection with drainage, or deep infection occurring at any time postoperatively.

Results

Over 7 years (4/1/2009–7/31/2016), 25 (3.2%) of 781 patients developed a postoperative infection after primary Nuss repair. Multivariable analyses demonstrated an increased risk of infection with perioperative clindamycin versus cefazolin for all infections (AOR 3.72, p = .017), and specifically deep infections (AOR 5.72, p = .004). The risk of a superficial infection was increased when antibiotic infusion completed > 60 min prior to incision (AOR 10.4, p = .044) and with the use of peri-incisional subcutaneous catheters (OR 8.98, p = .008).

Conclusion

Following primary Nuss repair, the rate of deep bar infection increased with the use of perioperative clindamycin rather than cefazolin. The rate of superficial infection increased when perioperative antibiotic infusion was completed more than 60 min prior to incision and with the use of peri-incisional subcutaneous catheters. Further studies are needed to better understand these findings.

Type of study

Retrospective chart review.

Level of evidence

Level III treatment study.  相似文献   

13.

Introduction

Anthropometric measurements can be used to define pediatric malnutrition. Our study aims to: (1) characterize the preoperative nutritional status of children undergoing abdominal or thoracic surgery, and (2) describe the associations between WHO-defined acute (stunting) and chronic (wasting) undernutrition (Z-scores <?2) and obesity (BMI Z-scores > + 2) with 30-day postoperative outcomes.

Methods

We queried the Pediatric NSQIP Participant Use File and extracted data on patients’ age 29 days to 18 years who underwent abdominal or thoracic procedures. Normalized anthropometric measures were calculated, including weight-for-height for < 2 years, BMI for ages ≥ 2 years, and height for age. Logistic regression models were developed to assess nutritional outlier status as an independent predictor of postoperative outcome.

Results

23,714 children (88% ≥ 2y) were evaluated. 4272 (18%) were obese, while 2640 (11.1%) and 904 (3.8%) were stunted and wasted, respectively, after controlling for gender, ASA/procedure/wound classification, preoperative steroid use, need for preoperative nutritional support, and obese children had higher odds of SSIs (OR 1.29, 95% CI 1.1–1.5, p = 0.001), while stunted children were at increased risk of any 30-day postoperative complication (OR 1.16, 95% CI 1.0–1.3, p = 0.036).

Conclusion

Children who are stunted or obese are at increased risk of adverse outcome after abdominal or thoracic surgery.

Level of Evidence

III  相似文献   

14.
Prenatal observed/expected lung–to-head ratio (O/E LHR) by ultrasound correlates with postnatal mortality for congenital diaphragmatic hernia (CDH) patients. The aim of this study is to determine if O/E LHR correlates with pulmonary hypertension (PH) outcomes for CDH patients.

Methods

A single center retrospective chart review was performed for CDH neonates from January 1, 2006, to December 31, 2015, (REB #1000053124) to include prenatal O/E LHR, liver position, first arterial blood gas, repair type, echocardiogram (ECHO), and lung perfusion scan (LPS) results up to 5 years of age.

Results

Of 153 newborns, 123 survived (80.4%), 58 (37.9%) had prenatal O/E LHR, and 42 (27.5%) had postnatal ECHO results. High mortality risk neonates (O/E LHR ≤ 45%) correlated with higher right ventricular systolic pressure (RVsp) at birth. Generally PH resolved by age 5 years. LPS results did not change over time (p > 0.05) regardless of initial PH severity, suggesting that PH resolution did not correlate with increased ipsilateral lung perfusion to offload the right ventricle.

Conclusion

Prenatal prognostic markers correlated with initial PH severity for CDH newborns, but PH resolved over time despite fixed perfusion bias to the lungs. These results suggest favorable PH outcomes for CDH patients who survive beyond infancy.

Type of Study

Retrospective Cohort Study.

Level of Evidence

3b  相似文献   

15.

Aim

Localized intravascular coagulopathy is present in children with venous malformations (VMs) as evidenced by elevated D-dimer levels. Few studies have looked into the changes in D-dimer after sclerotherapy and its correlation with treatment outcome and complications. Our study aims to investigate changes in D-dimer in children with VMs undergoing alcohol sclerotherapy.

Methods

A prospective cohort study from 2014 to 2016, which included children (< 18 years) with VM undergoing alcohol sclerotherapy, was completed. Demographics and lesion characteristics were recorded. Perioperative D-dimer levels were collected 2 weeks prior to treatment (baseline) and on postoperative days 1, 2, 5, and 14, respectively. A raised postoperative D-dimer was defined as a peak level of at least 50% increase of baseline D-dimer. Children were followed up with documentation of lesional size at 6 months and long-term recurrence beyond 6 months of treatment.

Results

Eighteen children were identified (10 females, 8 males) with a median follow up of 21 months. Overall, 15 patients (83%) had a satisfactory outcome. Baseline D-dimer levels were high in 8 patients (44%). Postoperative D-dimer level was raised in 12 patients irrespective of their baseline levels, with 92% peaking on postoperative day one (n = 11). In the elevated D-dimer group, 11 patients had a satisfactory outcome, and 10 patients did not have long-term recurrence. We did not encounter any complications in our cohort.

Conclusion

Changes in perioperative D-dimer levels may predict early treatment response and long-term recurrence after alcohol sclerotherapy. With a standardized protocol, alcohol sclerotherapy for venous malformation is safe with minimal complications.

Type of study

Prognosis study.

Level of evidence

IV  相似文献   

16.

Purpose

This study evaluates the results of thoracoscopic management of complex, non-type C, EA and TEF in infants.

Methods

From March 2000 to February 2017, 23 patients were treated for Type A N = 13, Type B N = 4, and Type E N = 6. Patients diagnosed with EA had G-tube feeds for a period of 4–9 weeks. All procedures were performed thoracoscopically. EA gaps were between 4 and 7 1/2 vertebral bodies.

Results

All surgeries were completed thoracoscopically. Average operative time was 95 min for Type A, 115 min for Type B, and 50 min for Type E. Two patients with long gaps had small leaks which resolved with conservative management. One patient with an H-type was re-intubated causing a partial disruption of the tracheal repair. This required thoracoscopic re-exploration with repair and placement of an intercostal muscle flap. No patient has any clinical evidence of fused ribs, chest wall asymmetry, shoulder girdle weakness, or winged scapula.

Conclusion

Thoracoscopic repair of complex EA and TEF is safe and effective. The excellent visualization of the thoracic inlet allows for extensive mobilization creating sufficient length for long gaps and safely managing high fistulas. This may limit injury to adjacent structures and avoid a neck incision and chest wall deformity.

Level of evidence

IV.  相似文献   

17.

Background

Children with congenital heart disease (CHD) often require noncardiac surgery. We compared outcomes following open and laparoscopic intraabdominal surgery among children with and without CHD.

Methods

We performed a retrospective cohort study using the 2013–2015 National Surgical Quality Improvement Project-Pediatrics. We matched 45,012 children < 18 years old who underwent laparoscopic surgery to 45,012 children who underwent open surgery. We determined the associations between laparoscopic (versus open) surgery and 30-day mortality, in-hospital mortality, 30-day morbidity, and postoperative length-of-stay.

Results

Among children with minor CHD, laparoscopic surgery was associated with lower 30-day mortality (Odds Ratio [OR] 0.34 [95% Confidence Interval 0.15–0.79]), inhospital mortality (OR 0.42 [0.22–0.81]) and 30-day morbidity (OR 0.61 [0.50–0.73]). As CHD severity increased, this benefit of laparoscopic surgery decreased for 30-day morbidity (ptrend = 0.01) and in-hospital mortality (ptrend = 0.05), but not for 30-day mortality (ptrend = 0.27). Length-of-stay was shorter for laparoscopic approaches for children at cost of higher readmissions. On subgroup analysis, laparoscopy was associated with lower odds of postoperative blood transfusion in all children.

Conclusions

Intraabdominal laparoscopic surgery compared to open surgery is associated with decreased morbidity in patients with no CHD and lower morbidity and mortality in patients with minor CHD, but not in those with more severe CHD.

Level-of-evidence

Level III: Treatment Study.  相似文献   

18.

Introduction

Indications for thoracoscopic versus open approaches to repair congenital diaphragmatic hernia (CDH) are unclear as the variability in defect size, disease severity and patient characteristics pose a challenge. Few studies use a patient and disease-matched comparison of techniques. We aimed to compare the clinical outcomes of open versus thoracoscopic repairs of small to moderate sized hernia defects in a low risk population.

Methods

All neonates receiving CDH repair of small (type A) and moderate (type B) size defects at an academic children's hospital between 2006 and 2016 were retrospectively reviewed and analyzed. Patients < 36 weeks gestation, birth weight < 1500 g, or requiring extracorporeal life support were excluded. Demographics, including CDH severity index, and hernia characteristics were recorded. The primary outcome parameter was recurrence. Secondary outcomes included length of hospital stay, length of mechanical ventilation, time to goal feeds, and mortality.

Results

The 51 patients receiving thoracoscopic (35) and open (16) repairs were similar in patient and hernia characteristics, with median 2-year follow-up for both groups. Patients with thoracoscopic repair had shorter hospital stay (16 vs. 23 days, p = 0.03), days on ventilator (5 vs. 12, p = 0.02), days to start of enteral feeds (5 vs. 10, p < 0.001), and days to goal feeds (11 vs. 20, p = 0.006). Higher recurrence rates in the thoracoscopic groups (17.1% vs. 6.3%) were not statistically significant (p = 0.28). Median time to recurrence was 88 days for the open repair and 183 days (IQR 165–218) for the thoracoscopic group. There were no mortalities in either group.

Conclusions

In low risk patients born with small to moderate size defects, a thoracoscopic approach was associated with decreased hospital length of stay, mechanical ventilation days, and time to feeding; however, there was a trend towards higher recurrence rates.

Level of evidence

Level III.  相似文献   

19.

Introduction

Patients with familial adenomatous polyposis (FAP) and ulcerative colitis (UC) commonly undergo restorative proctocolectomy with ileal-pouch anal anastomosis (RP-IPAA). We sought to describe patient characteristics and postoperative outcomes in this patient population.

Methods

Using the National Surgical Quality Improvement Program-Pediatric Participant Use Files from 2012 to 2015, children who were 6–18 years old who underwent RP-IPAA for FAP or UC were identified. Postoperative morbidity, including reoperation and readmission were quantified. Associations between preoperative characteristics and postoperative outcomes were analyzed.

Results

A total of 260 children met the inclusion criteria, of which 56.2% had UC. Most cases were performed laparoscopically (58.1%), and the operative time was longer with a laparoscopic versus open approach (326 [257–408] versus 281 [216–391] minutes, p = 0.02). The overall morbidity was 11.5%, and there were high reoperation and readmission rates (12.7% and 21.5%, respectively). On bivariate analysis, preoperative steroid use was associated with reoperation (22.5% versus 10.9%, p = 0.04). On multivariable regression analysis, obesity was independently associated with reoperation (odds ratio: 3.34 [95% confidence intervals: 1.08–10.38], p = 0.04).

Conclusions

Children who undergo RP-IPAA have high rates of overall morbidity, reoperation, and readmission. Obesity was independently associated with reoperation. This data can be used by practitioners in the preoperative setting to better counsel families and establish expectations for the postoperative setting.

Type of Study

Retrospective Comparative Study.

Level of Evidence

Level III.  相似文献   

20.

Introduction

Contrast-enhanced CT remains the first-line imaging for evaluating postoperative abscess (POA) after appendicitis. Given concerns of ionizing radiation use in children, we began utilizing quick MRI to evaluate POA and summarize our findings in this study.

Materials and Methods

Children imaged with quick MRI from 2015 to 2017 were compared to children evaluated with CT from 2012 to 2014 using an age and weight matched case–control model. Radiation exposure, size and number of abscesses, length of exam, drain placement, and patient outcomes were compared.

Results

There was no difference in age or weight (p > 0.60) between children evaluated with quick MRI (n = 16) and CT (n = 16). Mean imaging time was longer (18.2 ± 8.5 min) for MRI (p < 0.001), but there was no difference in time from imaging order to drain placement (p = 0.969). No children required sedation or had non-diagnostic imaging. There were no differences in abscess volume (p = 0.346) or drain placement (p = 0.332). Thirty-day follow-up showed no difference in readmissions (p = 0.551) and no missed abscesses. Quick MRI reduced imaging charges to $1871 from $5650 with CT.

Conclusion

Quick MRI demonstrated equivalent outcomes to CT in terms of POA detection, drain placement, and 30-day complications suggesting that MRI provides an equally effective, less expensive, and non-radiation modality for the identification of POA.

Type of Study

Retrospective Case–Control Study.

Level of Evidence

Level III.  相似文献   

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