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1.

Aim

To compare outcomes between prenatally and postnatally diagnosed CDH in a large multicenter database of prospectively collected data and evaluate factors associated with poorer outcome for prenatally diagnosed CDH.

Material and Methods

We used information from the multicenter, multinational CDH Study Group database on patients born between 2007 and 2015. We compared differences between prenatally and postnatally diagnosed CDH with respect to survival, side, size, ECMO needs, associated major cardiac malformations and liver position.

Results

3746 cases of CDH were entered in the registry between 2007 and 2015, with an overall survival of 71%. Of those, 68% had a prenatal diagnosis. Survival rates were significantly better in the postnatally diagnosed group, 83 vs 65%. There was a higher proportion of bigger defect sizes, C and D, in the prenatally diagnosed group, but the survival rates were similar when patients were stratified by defect size. The rate of ECMO utilization was higher overall in the prenatally diagnosed group, 33 vs 22%, but it was similar within similar defect sizes. Right-sided defects are more commonly missed at prenatal screening than left-sided CDH, 53 vs 35% (p?<?0.0001).

Conclusions

Prenatally diagnosed CDH is associated with larger defect sizes compared to those with a postnatal diagnosis, and consequently have higher morbidity and mortality. Right-sided CDH are more often missed at prenatal ultrasound. The increasing rate of prenatal detection requires a clear understanding of accurate risk stratification, in order to counsel families and to provide appropriate perinatal management.

Level of Evidence

I for a Prognosis Study – This is a high-quality, prospective cohort study with 99% of patients followed to the study end point (death or discharge).  相似文献   

2.

Aim

The most common cause of congenital bladder outlet obstruction (BOO) is posterior urethral valves (PUV). Initial treatment requires decompression, but transurethral incision (TUI) or primary diversion is all described. There is no randomized control trial to guide management. This study aims to describe management, circumcision, and UTI rate in a national cohort of PUV boys.

Methods

Boys diagnosed with BOO were recruited (via BAPS CASS) over 1?year with ethics committee approval (ref: 12/SC/0416). Data were collected via questionnaire, presented as number (%), analyzed by Mann–Whitney/chi-square/Fisher Exact tests, and p?<?0.05 was taken as significant.

Results

BOO presented in 121 boys during 2014–2015, and 113 were PUV. Catheter placement in 87/121(72%) was more likely to happen in antenatal vs. postnatal vs. late(> 1?y) presentations, p?<?0.0001. Polyuria occurred in 23/45(51%), 12/48(25%), 0/28(0%), respectively, p?<?0.0001. Initial surgical treatment was TUI in 108/121(89%) and vesicostomy in 2. Two ureterostomies were secondary procedures. Circumcision was performed in 52/121(43%) in antenatal presentation vs. postnatal vs. late 27/45(60%), 20/48(42%), 2/28(7%), respectively, p?=?0.01. 69 UTIs occurred in 49 patients. Circumcision was associated with an 86% reduced risk of UTI, p?<?0.0001. There was a 66% reduction in UTI risk associated with TUI alone, p?<?0.01. There was 1 death due to pulmonary hypoplasia and renal failure, and 2 experienced end-stage renal failure (ESRF).

Conclusion

Standard treatment for BOO and PUV in the current UK cohort is urethral catheterization followed by TUI. Supravesical diversion is a rescue therapy. UTIs are common and reduced by circumcision, with 43% being circumcised. Initial mortality rate was 1%, and 1.6% present in ESRF.

Level of Evidence

Prognostic study – Level I – Prospective National Cohort Study.  相似文献   

3.

Importance

Telemedicine is an emerging strategy for healthcare delivery that has the potential to expand access, optimize efficiency, minimize cost, and enhance patient satisfaction.

Objective

To review the current spectrum, potential strategies, and implementation process of telemedicine in pediatric surgery.

Design

Review and opinion design.

Setting

n/a.

Participants

n/a.

Main outcomes and measures

n/a.

Results

n/a.

Conclusions and relevance

Telemedicine is an emerging approach with the potential to facilitate efficient, cost-effective delivery of pediatric surgical services.

Brief Abstract

Telemedicine is an emerging strategy for healthcare delivery that has the potential to expand access, optimize efficiency, minimize cost, and enhance patient satisfaction. The objectives of this review are to explore common terms in telemedicine, provide an overview of current legislative and billing guidelines, review the current state of telemedicine in surgery and pediatric surgery, and provide basic themes for successful implementation of a pediatric surgical telemedicine program.

Type of Study

Review.

Level of Evidence

Level V.  相似文献   

4.

Purpose

There has been a paradigm shift from corticosteroid to propranolol treatment for infantile hemangiomas (IHs), with surgical resection reserved for complicated or persistent IHs. The purpose of this study was to determine if propranolol treatment was associated with decreased utilization of surgical resection compared to corticosteroids.

Methods

A single center retrospective chart review of all corticosteroid or propranolol treated IHs between 2005 and 2014 was performed. Demographic and clinical data were collected. Both univariate and multivariate analyses were performed with the primary outcome of requiring surgical intervention.

Results

Of 652 patients with IH, 52 were treated with oral corticosteroids and 195 with propranolol only. Surgical intervention was required in 14 (27%) of steroid patients vs 18 (9%) of propranolol patients (p?<?.001). On multivariable analysis patients treated with steroids had 3.3 the odds of requiring surgery when compared to propranolol patients (p?=?.001). Prematurity (< 37?weeks) was also associated with increased odds of surgery (OR?=?2.8, p?=?.003).

Conclusion

Patients treated with propranolol required significantly fewer surgical interventions than those treated with corticosteroids suggesting a more efficacious treatment paradigm. Prematurity increases the need for surgical intervention regardless of the modality of medical treatment.

Level of evidence

Level III, treatment study.  相似文献   

5.

Purpose

The management of intestinal malrotation in infants with omphalocele varies among surgeons. Herein, we aimed to determine whether infants with omphalocele should be investigated for malrotation.

Methods

Using a defined search strategy, three investigators identified all studies reporting patients with omphalocele and malrotation. Outcome measures included: 1. incidence of malrotation; 2. correlation with the abdominal size defect in patients with omphalocele; 3. risk of volvulus in those not investigated for malrotation; 4. incidence of adhesive bowel obstruction in those who underwent Ladd's procedure. The meta-analysis was conducted according to PRISMA guidelines and using RevMan 5.3.

Results

Of 111 articles analyzed, 12 (3888 children) reported malrotation in 136 patients (3.5%). Malrotation was equally found in patients with major (15.2%) and minor (13.6%; p?=?0.52) omphalocele. A volvulus was more common in children who had Ladd's procedure (8%) than in those who did not (1%; p?=?0.03). Adhesive bowel obstruction rate was similar in both groups (5% vs. 3%; p?=?0.21).

Conclusion

The incidence of malrotation in infants with omphalocele is low but probably underreported, and is not influenced by the size of the defect. At present, there is no evidence in the literature to support investigations to detect malrotation in infants with omphalocele.

Type of study

Therapeutic.

Level of evidence

III  相似文献   

6.

Background and purpose

Clinical trials organization can be daunting especially when orienting to a new system. The steps to a successful clinical trial are not concrete and vary based on the system.

Methods

In this section the discussion centers on how to shape the question for the clinical trial which is rational and feasible to answer within the planned study design.

Findings

Senior mentorship, collaboration and early involvement of stakeholders can help shape a successful clinical trial. Keeping in mind ethics and the processes within a system will make planning easier. Questions about key elements of the trial should be answered early to prevent delays of study initiation.

Conclusion

Clinical trial development and implementation can be very rewarding, but successful outcomes require careful planning and considerations.  相似文献   

7.

Background and Rationale

Several studies have suggested that the incidence of infantile hypertrophic pyloric stenosis (IHPS) has decreased in recent decades. This decrement is controversial and not fully explained. Concurrently, there has been a major increase in folic acid consumption by pregnant women to prevent neural tube defects. We aimed to describe IHPS incidence in Israel in recent years and to assess its potential association with folic acid consumption.

Methods

Using the electronic medical database of a 2.1 million member health organization in Israel, we identified all cases (n?=?1899) of IHPS occurring between 1999 and 2015. Cases were individually matched with up to 5 controls (n?=?7350) by birth date, sex, and region. Odds ratios and 95% confidence intervals by tertiles of cumulative dose of supplemented folic acid between three months prior to pregnancy and up to birth of index child were calculated using conditional logistic regression.

Results

During the study period IHPS incidence declined from 4.3 in 1999 to 2.1 per 1000 live births in 2015(p?<?0.0001). No significant (p?=?0.81) association was observed between folic acid intake during pregnancy and risk of IHPS incidence. Preterm birth and infant's use of macrolides during first 3 postnatal months were significantly (p?<?0.01) associated with increased risk of IHPS.

Conclusions

Similar to other countries, IHPS incidence in Israel has decreased in recent years. The decrement cannot be explained by increased use of folic acid.

Type of Study

Case Control Study.

Level of Evidence

Level III.

Summary

Using linkage to a large electronic patient database, this study investigated the association between the decrease in infantile hypertrophic pyloric stenosis and maternal exposure to folic acid during pregnancy.  相似文献   

8.

Background

Penetrating stab wounds in children are relatively rare and no clear recommendations for the optimal evaluation have been devised. An acceptable traditional approach to the patient with an abdominal stab wound who does not require urgent surgery is selective nonoperative management and serial exams. The use of routine computed tomography remains an actively utilized investigation for these patients at many institutions.

Purpose

We hypothesize that the approach to pediatric stab wound victims should be distinctly different than that of adult counterparts in order to minimize radiation exposure.

Methods

A retrospective cohort study involving abdominal stab wounds among pediatric trauma patients (age < 14) compared with adults between the years 1997 and 2016 was conducted utilizing the Israeli National Trauma Registry.

Results

A total of 92 children and 4444 adults were identified from the registry for inclusion. Among the children 20 (21.7%) patients had intraabdominal injury compared to 1730 (38.9%) among adult counterparts. Four children were hemodynamically unstable, two of them were referred directly to operating room and two others were treated without surgery. Among the remaining 88 children there was no observed mortality.

Conclusions

The majority of pediatric stab wounds trauma victims have minor abdominal injuries. We do not recommend the routine utilization of abdominal CT scan in the evaluation of abdominal stab wounds. Observation with serial exams and minimization of radiation exposure from CT are warranted in this unique population.

Type of study

Retrospective comparative study.

Level of evidence

3.  相似文献   

9.

Objective

The objective of this study was to report our multidisciplinary diagnostic approach for patients with anterior mediastinal masses (AMM).

Methods

A retrospective review of patients with AMM at a tertiary pediatric surgical oncology centre (January 2011–December 2016) was performed. We analyzed data on clinical presentation, mode of tissue diagnosis, anesthetic techniques, and complications.

Results

Of the 44 patients admitted with AMM (median age 11?years, 27 males and 17 females), 22 had respiratory symptoms. Imaging revealed tracheobronchial compression in 26 children. Twenty patients had a lymph node biopsy. Ten patients had image-guided core biopsy of the mediastinal mass, and 2 had mediastinoscopic biopsy of a paratracheal lymph node. One patient with likely recurrence of a relapsed metastatic ethmoid carcinoma did not have a biopsy. The diagnosis was made from alternative tissues, such as pleural fluid in 4 and peripheral blood in 7 patients. Twenty-five anesthetics were assessed, as 14 patients required no or only local anesthesia, and 5 had unavailable anesthetic notes. Eighteen of 25 patients were anesthetized maintaining spontaneous breathing, mostly by means of ketamine sedation. There were no major anesthetic complications.

Conclusion

Safe tissue diagnosis of anterior mediastinal masses can be obtained by a personalized multidisciplinary approach. Use of alternative tissues, local anesthesia, and ketamine sedation help minimize the need for general anesthesia, muscle paralysis, and controlled ventilation.

Level of evidence

IV (Case Series with no Comparison Group).  相似文献   

10.

Purpose

Children failing medical management for severe constipation and/or fecal incontinence may undergo surgical intervention for antegrade enema administration. We present a modification of the laparoscopic-assisted percutaneous endoscopic cecostomy (LAPEC) procedure that allows primary placement of a skin-level device.

Methods

A single-institution retrospective review was performed from 2009 to 2015. In the modified technique the colonoscope is advanced to the cecum, cecal suspension sutures are placed under laparoscopic visualization, and percutaneous needle puncture of the cecum is performed under direct laparoscopic and endoscopic visualization. A skin-level cecostomy tube is then placed over a guide wire. Patient characteristics and 30-day results were analyzed by Fisher's exact test.

Results

Fifty-two patients underwent attempted LAPEC. Successful LAPEC using both laparoscopic and endoscopic guidance was achieved in 46 (88.5%). A MIC-KEY device was placed in 38. Corflo PEG tube placement was necessary in 14 due to high BMI (mean 28.4). Colonoscopy failed to reach the cecum in 6 and laparoscopy alone was utilized to achieve successful tube placement. Cecostomy site infections occurred in 3 (5.8%), only in those undergoing PEG placement using a pull technique (p?<?0.05).

Conclusion

Primary placement of a skin-level device was successful in the majority of patients undergoing cecostomy tube placement for bowel management utilizing antegrade colonic enemas. This technique avoids a second anesthesia for tube conversion. Visualization via colonoscopy with the use of cecal suspension sutures is recommended. High BMI necessitates initial placement of a PEG tube and complications exclusively occurred in this group.

Type of Study

Clinical.

Level of Evidence

IV Case series study.  相似文献   

11.

Background

The Lancet Commission on Global Surgery highlighted global surgical need but offered little insight into the specific surgical challenges of children in low-resource settings. Efforts to strengthen the quality of global pediatric surgical care have resulted in a proliferation of partnerships between low-and middle-income countries (LMICs) and high-income countries (HICs). Standardized tools able to reliably measure gaps in delivery and quality of care are important aids for these partnerships. We undertook a systematic review (SR) of capacity assessment tools (CATs) focused on needs assessment in pediatric surgery.

Methods

A comprehensive search strategy of multiple electronic databases was conducted per PRISMA guidelines without linguistic or temporal restrictions. CATs were selected according to pre-defined inclusion criteria. Articles were assessed by two independent reviewers. Methodological quality of studies was appraised using the COSMIN checklist with 4-point scale.

Results

The search strategy generated 16,641 original publications, of which three CATs were deemed eligible. Eligible tools were either excessively detailed or oversimplified. None used weighted scores to identify finer granularity between institutions. No CATs comprehensively included measures of resources, outcomes, accessibility/impact and training.

Discussion

The results of this study identify the need for a CAT capable of objectively measuring key aspects of surgical capacity and performance in a weighted tool designed for pediatric surgical centers in LMICs.

Type of Study

Systematic Review.

Level of Evidence

II.  相似文献   

12.

Objective

To describe the prevalence and outcome of assisted home feeding (AHF) in medically complex neonatal intensive care unit (NICU) patients, and to identify variables associated with AHF in this population.

Study Design

1223 infants who survived to discharge from 2013 to 2015 were identified in our single-center, retrospective cohort study at a large tertiary referral NICU. Demographic and selected disease-specific variables were compared between infants discharged on full oral feeding (PO) versus AHF.

Result

404 (33%) infants were discharged on AHF (NG?=?201, GT?=?186, NJ?=?17). AHF neonates were born at an earlier gestational age, lower birth weight, had longer hospital admission, greater post-menstrual age at discharge, and had more associated co-morbidities compared to the PO group.

Conclusion

AHF was a frequently used and safe intervention in our large cohort of infants.

Level of Evidence

Treatment Study Level III.  相似文献   

13.
14.

Purpose

Management of postoperative pain is a significant challenge following the Nuss procedure. Epidurals, PCAs, and newer analgesia modalities have been used elsewhere without demonstrating consistent improvement in the reported length of hospital stays (LOS). We reviewed a large single surgeon experience identifying three different methods of analgesia used over time to highlight marked improvement in patient LOS.

Methods

IRB approval was obtained and patient clinical information was retrospectively reviewed from 2001 to 2017. The primary outcome variable was length of hospital stay. An expanded preoperative consultation reviews the issue of pain, the negative impact of anxiety on recovery, and our current success of shortened hospital stays with our patients.

Results

One hundred and seventy-three patients representing three different analgesia approaches had a LOS of 4.4 days (epidural); 2.2 days (PCA/intercostal nerve block); and 1.6 days (scheduled oral pain meds/intercostal nerve blocks). The current LOS for patients is 1.0 day. Patients successfully stop using narcotics by the end of the first week postoperatively.

Conclusions

Intraoperative intercostal nerve blocks, scheduled postoperative pain medications, and enhanced preoperative consultation aimed to educate patients about anxiety and reframe patient pain expectations have collectively decreased LOS, and reduced postoperative narcotic usage.

Type of study

Clinical research

Level of evidence

Level III  相似文献   

15.

Objective

The purpose of this study is to evaluate the effect of Intravesical Botulinum toxin injection on the symptoms and urodynamic parameters in pediatric patients with idiopathic overactive bladder (iOAB) refractory to medical treatment.

Materials and methods

The study was designed as an open-label uncontrolled therapeutic clinical trial. The eligible patients who underwent Intravesical botulinum toxin injection were evaluated before treatment. The evaluation included a 7-day paper bladder diary to assess OAB symptoms (frequency, urgency urinary incontinence (UUI) and nocturnal enuresis (NE)), filling the Arabic International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI short form), and conducting urodynamic study. The Urodynamic parameters obtained were the maximum filling detrusor pressure, cystometric bladder capacity, and compliance. After 12?weeks of the intravesical injection, the patients were revaluated and the results were compared using paired samples t-test.

Results

The study enrolled 75 patients. And of those, statistical analysis was done on 46 patients who did follow the study protocols. The mean age was 8.9?years and male to female ratio was 1:4. There was a statistically significant improvement in overactive bladder symptoms and urodynamic parameters in the patient injected with botulinum toxin with minimal side effects.

Conclusion

The evidence in this study would support the safety and efficacy of Intravesical botulinum toxin injection in children with refractory idiopathic OAB with significant improvement of symptoms, quality of life, as well as urodynamic parameters.

Type of Study

Open-label uncontrolled therapeutic clinical trial.

Level of Evidence

III  相似文献   

16.

Background

Congenital chylous ascites poses a significant challenge in neonatal care, and often results in prolonged, complex hospital stays and increased mortality. Few effective options exist in refractory cases.

Methods

Patients aged 0 to 12?months with refractory chylous ascites underwent retroperitoneal exploration after medical treatment and minimally invasive therapies were unsuccessful. The retroperitoneum was completely exposed via left and right medial visceral rotation and opening the lesser sac. Visible leaks were ligated, and alternating layers of fibrin glue and Vicryl mesh were used to cover the entire retroperitoneum.

Results

All 4 patients had resolution of their chylous ascites. None required reoperation or reintervention for chyle leaks. All achieved goal enteral feeds at a median of 29?days postoperatively and were discharged from hospital at a median of 42?days postoperatively.

Conclusions

Management of chylous ascites is extremely challenging in refractory cases. Complete retroperitoneal exposure with fibrin glue and Vicryl mesh application offers a definitive, reliable therapy for achieving cessation of lymphatic leakage and ultimate recovery for patients who fail all nonoperative approaches.

Study type

Therapeutic.

Level of evidence

IV  相似文献   

17.

Background

The treatment of ovarian masses in pediatric patients should balance appropriate surgical management with the preservation of future reproductive capability. Preoperative estimation of malignant potential is essential to planning an optimal surgical strategy.

Methods

The American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee drafted three consensus-based questions regarding the evaluation and treatment of ovarian masses in pediatric patients. A search of PubMed, the Cochrane Library, and Web of Science was performed and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to identify articles for review.

Results

Preoperative tumor markers, ultrasound malignancy indices, and the presence or absence of the ovarian crescent sign on imaging can help estimate malignant potential prior to surgical resection. Frozen section also plays a role in operative strategy. Surgical staging is useful for directing chemotherapy and for prognostication. Both unilateral oophorectomy and cystectomy have been used successfully for germ cell and borderline ovarian tumors, although cystectomy may be associated with higher rates of local recurrence.

Conclusions

Malignant potential of ovarian masses can be estimated preoperatively, and fertility-sparing techniques may be appropriate depending on the type of tumor. This review provides recommendations based on a critical evaluation of recent literature.

Type of study

Systematic review of level 1–4 studies.

Level of evidence

Level 1–4 (mainly 3–4).  相似文献   

18.

Background

Immaturity of the host immune system and alterations in the intestinal microbiome appear to be key factors in the pathogenesis of necrotizing enterocolitis (NEC). The aim of this paper is to weigh the evidence for the use of probiotics to prevent NEC in premature infants.

Methods

Animal studies, randomized controlled trials, observational cohort studies and meta-analyses involving administration of probiotic products for the prevention of NEC were reviewed. This review of the evidence summarizes the available preclinical and clinical data.

Results

In animal models probiotic microbes alter the intestinal microbiome, decrease inflammation and intestinal permeability and decrease the incidence and severity of experimental NEC. In randomized, placebo-controlled trials and cohort studies of premature infants, probiotic microbes decrease the risk of NEC, death and sepsis.

Conclusion

Evidence is strong for the prevention of NEC with the use of combination probiotics in premature infants who receive breast milk. The potential risks and benefits of probiotic administration to premature infants should be carefully reviewed with parents.

Type of study

Therapeutic.

Level of evidence

I.  相似文献   

19.
20.

Purpose

To investigate the factors affecting primary bladder closure in cloacal exstrophy (CE). A successful primary closure is important for optimizing reconstructive outcomes, and it is a critical first-step in the reconstruction of CE. The authors' hypothesize that a smaller diastasis and use of an osteotomy are independent predictors of a successful closure.

Methods

A prospectively maintained database of 1332 exstrophy-epispadias complex (EEC) patients was reviewed for CE patients closed between 1975 and 2015. Univariate and multivariable analyses were performed to identify significant factors associated with CE primary bladder closure.

Results

Of 143?CE patients identified, 99 patients met inclusion criteria. Median follow-up time was 8.82 [IQR 5.43–14.26] years. In the multivariable model, the odds of having a successful closure are about 4 times greater for the staged cloacal approach compared to the 1-stage approach (OR, 3.7; 95% CI 1.2–11.5; p-value?=?0.023). Also, having an osteotomy increases the chance of a successful closure by almost six-fold (OR, 5.8; 95% CI 1.7–19.6; p-value?=?0.004).

Conclusions

Using the staged approach with a pelvic osteotomy is paramount to a successful primary closure in CE. The authors strongly recommend using the staged approach and osteotomy as these factors independently increase the chance for a successful primary bladder closure.

Study Type

Therapeutic study.

Level of Evidence

Level III, Retrospective comparative study.  相似文献   

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