Abstracts DGKCH

Monosegment liver graft in pediatric liver transplantation: Advantage and limitation

(Abstract ID: 1022)

J. Li¹, B. Buchholz¹, U. Herden¹, L. Fischer¹

¹Universitätsklinikum Hamburg-Eppendorf

Background:

The left lateral segment from an adult donor can be too large for a small infant when the GRWR is >4.0%. In children with "high urgent" status, many donor offers despite of excellent graft quality would be rejected by the recipient institute due to size mismatch. The judgment often occurred after shipping, which resulted a prolonged cold ischemia time for the later recipient in addition to the prolonged waiting time of the child. Using monosegment liver graft might help to facilitate the organ acceptance in small infant.

Materials and methods:

More than 60 pediatric liver transplantations have been performed in authors’ institute during the last three years. The patients were grouped according to age, body weight and body height. The small infant with body weight below 10 kg was identified. The number of rejected offer due to size mismatch after shipping was counted in patients receiving left lateral segment and in patients receiving monosegment as the liver graft. The preoperative patient conditions as well as the postoperative complications were compared.

Results:

During last three years, only two monosegment graft liver transplantation have been performed in authors’ institute. Both of them received segment II liver graft, which was generated after left lateral/ right tri-setion splitting. Additional 20 minutes were needed for preparation of the monosegment graft. No on-table cholangiogram was performed.Patients receiving monosegment graft had more instable clinical condition, reflected by intensive care unit treatment preoperation, compared to patients with left lateral liver graft. No graft after shipping was rejected in both patients. Postoperatively, one patient had cholangitis with an occluded subsegment bile duct which was diagnosed by ultrasound examination and confirmed by MRI. The cholangitis could be controlled by antibiotics. No surgical revision was carried out. The postoperative course in the other patient receiving monosegment graft was uneventful.

Conclusion:

The problems related to large-for-size grafts could be overcome by the introduction of further reduced LLS grafts to segment II graft for smaller children. To avoid subsegment bile duct occlusion, an on-table cholangiogram should be performed.

Picture:

Split für Monosegment Lebertransplantat

Intra-abdominal lymphatic malformations: Our 20 years experience

(Abstract ID: 523)

P. Gasparella¹, E. Haxhija¹, C. Castellani¹, H. Till¹

¹Universitätsklinik für Kinder- und Jugendchirurgie, Graz

Background:

According to the International Society for the Study of Vascular Anomalies (ISSVA) classification, lymphatic malformations (LMs) are characterized by a congenital altered development of the lymphatic vessels. Only 5% of LMs are described in the intra-abdominal region. The purpose of this report is to analyse the clinical features of LMs in our patients’ series and their outcome.

Materials and methods:

We performed a retrospective review of the data of patients treated at our department from 1997 to 2018 with histologically confirmed intra-abdominal LM.

Results:

During the study period 12 patients were treated for intraabdominal LM. M:F ratio was 1:1. The average age at diagnosis was 5.1 years (Range 0.0-13.2 yrs.). Seven patients presented with abdominal pain as onset symptom. In only 2 cases the diagnosis was suspected prenatally. The mesenteric localization was the most frequent (9 pt.), followed by omentum (2 pt.) and retroperitoneum (1 pt.). All patients were treated surgically; in two cases we first performed a laparoscopic approach, but in one patient a conversion was necessary. In the majority of our patients intestinal resection was necessary (8 pt.). However, in large LMs it was impossible to preoperatively predict the intraoperative extension of the LMs. No postoperative complications and no subsequent recurrences were recorded.

Conclusion:

Intra-abdominal LMs are rare and usually present during the first decade of life with abdominal pain as the leading symptom. Laparoscopic exploration may define the localized extension of LMs. Surgical treatment may be curative.

Embolization and surgery of a large neonatal lymphatic-capillary malformation. An exceptionally life-saving procedure

(Abstract ID: 833)

S. von der Heydt¹, J. C. López Gutiérrez², W. Henrich¹, C. Bührer¹, B. Gebauer¹

¹Charité Universitätsmedizin Berlin

²Hospital Universitario La Paz, Madrid

Background:

Lymphatic malformations (LMs) are a type of congenital vascular malformation of the lymphatic system. They consist of variously dilated cysts or channels lined by typical endothelial cells of lymphatic phenotype. LMs occur all over the body, however, the most common anatomic locations include the head and neck (60 - 75 %), followed by the axilla (20 %). Current LM classification differentiates between macrocystic, microcystic and mixed LMs combining both macro and micro components.

Several case series of fetal LMs of the axillary region have been reported. However, cases with intralesional bleeding are rather uncommon. The majority of lymphatic malformations are detected prenatally. High vascularity increases the risk of intralesional bleeding and may cause prenatal and perinatal death.

Therapies for lymphatic malformations vary depending on the location, size and character of the cysts, as well as the experience of the physicians involved. Sclerotherapy, surgery, laser therapy and systemic therapies are being employed, often in combination. To our knowledge there are no reported cases in the literature of combined therapy (embolization and surgery) in a preterm low birth weight infant with a large lymphatic malformation.

Materials and methods:

We report a unique case of a preterm female with a giant axillary-thoracic-abdominal lymphatic malformation with life-threatening intralesional bleeding in utero.The infant underwent successful combination therapy with embolization followed by surgical excision.

Results:

Ours is a unique case of a preterm infant with low-birth-weight where selective embolization functioned as a life-saving procedure for hemostasis and facilitated successful resection of the LM.

Conclusion:

The strategy highlights the need for a multidisciplinary, multimodal approach to complex vascular malformations.

Picture:

Giant lymphatic-capillary malformation

Clinical outcome after percutaneous sclerotherapy of venous malformations in the head and neck region in children

(Abstract ID: 277)

A. Burger¹, D. Vollherbst¹, J. Hoffmann¹, M. Möhlenbruch¹, P. Günther¹

¹Universitätsklinikum Heidelberg

Background:

The aim of the study was to evaluate the clinical outcome after sclerotherapy of venous malformations (VM) in the head and neck region in children.

Materials and methods:

Between June 2011 and September 2019 a total of 29 children (13 male, 16 female) between 0 and 16 years (mean: 7years) with VM in the head and neck region were retrospectively included in this study.

Initial sclerotherapy was performed due to aesthetic reasons (62.1%), functional impairment (13.8%), pain (10.3%), increasing size (10.3%) and bleeding (3.4%).

The mean volume of the VM in the pre-interventional MRI was 32 ml (range: 1 to 326 ml).

Mean follow up after the first sclerotherapy was 15 months.

Clinical outcome after sclerotherapy was evaluated as the main endpoint.

Results:

Patients underwent between 1 and 11 sessions of percutaneous sclerotherapy (mean 2.6, total of 76) with aethoxylsclerol (polidocanol) under general anesthesia.

In two cases (1.5%) post-interventional, self-limiting bleeding ocurred. No other servere complications were observed, especially no necrosis with resulting scar.

17 patients (58.6%) showed clinical improvement, eight of them substantially (27.6%). Ten cases (34.5%) showed no changes, while a size progression occured in two cases (6.9%) after therapy.

Post-interventional MRIs were rarely carried out due to the need of sedation and mostly easy accessibility of VMs for clinical evaluation.

Conclusion:

Percutaneous sclerotherapy of venous malformations in the head and neck region in children is a scarless, safe and effective treatment option.

Superior sternal cleft – a rare case

(Abstract ID: 374)

T. Zönnchen¹, S. Muth¹, P. Schwerk¹, G. Fitze¹

¹Universitätsklinikum Dresden

Background:

The superior sternal cleft is a chest wall malformation caused by a defect in sternal fusion between sixth and tenth week of gestation. The incidence of this defect is 2:100,000 live births, corresponding to less than one percent of all chest wall deformities. The sternal cleft is classified in superior, inferior or complete and may be associated with PHACES syndrome. The aim of the surgical correction is to ensure bony protection over the mediastinal structures. It is a rare malformation that is also rarely published.

We present the case of a 2-year-old girl who was introduced during our consultation hours. A distinct protrusion of the thoracic wall in the upper part of the sternum was observed, especially in infancy, with an increase of pressure in the thoracic cavity. This could be reproduced at any time.

Results:

In addition to the clinical signs of the sternal cleft, an MRI provided further information on the extent of the anterior chest wall abnormality. It showed a congenital sternal cleft in the upper half of the sternum with a large proportion of thymus, protruding into the cleft when the pressure increased. The lower sternum and the other bony thorax were inconspicuous. Due to this constellation, the indication for the correction of the sternal fissure with thymus resection was made and performed at the age of 2.5 years.

Intraoperative the skin incision was made lengthwise directly above the sternum, from the jugulum to the xiphoid process. A sternotomy was performed from caudal to cranial with the Lepp chisel. This was followed by the preparation and removal of a ventral part of the thymus. Two wings of the distal part of the sternum were prepared and detached from distally in the longitudinal direction so that they could be easily turned over cranially in the further course. The raised sternal wings were fixed ventrally and dorsally with perichondral sutures with the respective margin of the sternal fissure. An Insertion of a 8 CH- drainage retrosternal was made. Now all PDS sutures were tied individually so that an ideal closure of the sternum from the xiphoid to the jugulum was possible. The corresponding anatomical layers were then readapted. During surgery, all circulatory and respiratory parameters were completely unaffected, so that no significant increase in pressure in the chest could be assumed.

Afterwards the girl was transferred to our children's intensive care unit for postoperative monitoring and was able to transfer to our paediatric surgical ward the following day. The antibiotic therapy was started perioperatively as a single shot with cefuroxime and continued postoperatively until the 5th day. The drainage was quickly removed. We discharged the girl in good general condition on the 7th postoperative day for further outpatient treatment.

Conclusion:

The girl was presented again 3 months after surgery. The girl is feeling well. The scar is non-irritant. The sternum is completely reconstructed and closed up to the jugulum so that there is no clinical instability of the thorax. According to the parents, the girl is also fully resilient again. According to her age, she has been exercising herself completely regularly, e.g. trampoline jumping.

The risk of repairing sternal malformations is the hemodynamic effect of compression of the heart and large vessels, which can be caused by the repair itself. Given the rare occurrence of sternal malformations, the repair should be performed in experienced centers where the full arsenal of pediatric specialists is available for the pre- and post-operative care of these sensitive patients.

Picture:

preoperative MRI

Microsurgical reconstructions in the childhood and young adulthood in oral maxillofacial surgery

(Abstract ID: 384)

E. Gudewer¹, M. Kos¹, G. Popken¹, C. Dinu¹, L. Li¹

¹Klinikum Oldenburg

Background:

Microsurgical reconstructions in childhood and young adulthood are special cases. The decision and implementation of this surgical technique is a great responsibility and should be performed by surgeons who have a lot of experience in microsurgical tissue transfer.

Materials and methods:

Since 2008,11 patients aged from 2 to 26 years (6 male, 5 female) received 13 microsurgiacal grafts. 2 patients were under 10 years, 1 was 16 years and 10 were between 20 and 26 years old. 9 microsurgical transfers were done to he facial area and 4 to opther parts oft the body: lower leg, thigh, perianal region and axilla. Facelift access was selected at 5 patients. The indication for microsurgial tissue transfer was found in the following diagnoses: tumor (3x): ossifying fibroma, intraoral squamous cell carcinoma, ameloblastoma; trauma (2x): defect wounds by dog bite, open fracture by road accident; osteomyelitis lower jaw (2x), hemiatrophia faciei (2x), acne inversa (1x), Crohn´s disease (1x). Based on photo documentation the initial situation, the surgery technique and the postoperative courses are presentetd and evaluated.

Results:

In all patients a complete defect coverage or reconstruction could be achieved. A young woman had developed an extensive mandibular necrosis from progressive chronic osteomyelitis. After the first mandibular reconstruction with microsurgery fibula-flap she developed an profound wound indefction and the graft was lost. A few month later, she got a second fibula transplant. A two year old girl had two large defect wounds (thigh and face) as a result of dog bite attack. Both were treated with mikrocsurgical flaps (latissimus dorsi (2x)). Through the facelift access in 5 patients, scares were avoided in the visible area oft he face. The vascular connections werde done in the facial area to the large vessles: externa carotid artery and internal jugular vein in end-to-side technique and with continous sutures. In the case of a child vascular spasm occures after the vascular anastomosis, which resolved only alter hours. Furtunately the graft survived without any damage. Serious permanent morbidities in the donorside dit not occur. The psotoperativ hospital stay for all patietns was 14 to 22 days

Conclusion:

Each microsurgical graft in the young ptients was preoperatively discussed with regard to alternative treatment options and aesthetic aspects. A particular challange ist the vascular connection in childhood, since the vascular lumina are still very small and a reactive vascular spasm may occur. Aethetic aspects have a high priority in young life years and should be taken into account when planning the operation (access, suture techniques etc.). Both the soft tissue grafts and the bone grafts bring stable results and are suitable for later rehabilitation oft he mouth (dental implants) as well as for further aesthetic corrections oft he face. The case studies show that microsurgical flaps are feasible in children and young adults. With good functional result (mouth opening) and aesthetic outcome (facelift access) these methods can shorten hospital stay, accelerate paticipation in following treatments and bring a better quality of live.

Functional Reconstruction of Congenital and Acquired Pediatric Facial Paralysis

(Abstract ID: 603)

A. Kehrer¹, P. Lamby¹, V. Brabant¹, D. Lonic¹, P. Heidekrüger¹, M. Jakob¹, L. Prantl¹

¹Universitätsklinikum Regensburg

Background:

Dysfunction of the VII. cranial nerve is specifically stigmatizing for children in a psychosocial fashion. Irreversible facial paralysis may be seen after infection, trauma or have oncological, congenital or idiopathic reasons. Partial or complete dysfunction may cause severe functional and aesthetic impairments. Symptoms are hypolacrimation, synkinesia, mimic contractures, conjunctivitis, muscular weakness, dysarthria, oral incontinence, asymmetry and impaired spontaneity of facial expression. In the following paper, the international gold standard of functional reconstruction will be outlined.

Materials and methods:

Functional reconstruction has to differentiate between early irreversible types and chronic forms of facial paralysis. Clinical examination and modern scoring systems provide orientation. Relevant clinical aspects are illustrated presenting an extensive anatomical and histological facial nerve study at the University of Regensburg. In addition, all major operation techniques are demonstrated with patient cases.

Results:

Nerve transfers and cross-face-nerve-grafts (CFNG) have become important key elements in reconstruction of early irreversible cases in our center. Free functional muscle transplantation has been established as a gold standard in facial reanimation of long standing facial paralysis. Add-op procedures may further improve symmetry and aesthetics. Every mode of treatment is presented with actual cases from our patient series.

Conclusion:

Irreversible facial paralysis may be successfully treated with a differentiated, staged functional surgical reconstruction. Peer bullying may be avoided.

Picture:

freie gracilis- Muskeltransplantation vorher-nachher

Lipografting in Reconstructive Peadiatric Surgery

(Abstract ID: 243)

D. L. Francia¹, M. Spiekman¹, P. Degenhardt¹, M. Ghods¹

¹Ernst von Bergmann Klinikum Potsdam

Background:

Lipografting is emerging as a "rescue" treatment for postoperative sequelae and soft tissue volume defects in paediatric surgery, thus children are considered as a patient group to target on in next future. Posttraumatic scars and burns can cause functional impairment, e.g. restriction in range of motion (ROM) or disfiguring defects might occur after oncologic interventions. Painful fibrotic affections are often going along with skin-affecting diseases like Scelodermia and Morbus Ledderhose and seen in children, too. However no operative reconstructive treatment is currently used for all these sequelae as a reliable standard so far.Therefore the authors investigated the use of a minimally invasive operative procedure called Adipose Cells derived Regenerative Therapy(ACRT), which based on largeEuropean multi-center trial in 2017 already lead to reliable results in adults (1,2).

Materials and methods:

From September 2016 to June 2019 a case series of 9 patients suffering from a large number of fibrotic skin sequelae underwent the ACRT-Protocol as a "rescue" procedure, which adheres to water-jet assisted lipotransfer. The interventions (average OR Time 50min) were performed once to three times in each patient with a follow-up after 7, 30, 120 days (max.1 year) postoperatively. Several body parts were treated using water-assisted hydrodissection/ACRT. Outcome was evaluated based on digital pictures, patient- questionnaires, VAS-Scale and ROM. Skin biopsies for histological analysis were taken in selected patients, as well (Add.1).

Results:

Relevant functional and aesthetic improvements are achieved by the use of ACRT-Protocol associated with very short hospitalization and minor complications like haematomas. Combined to conservative scar treatments e.g. compression garments and physiotherapy an increase of skin morbidity and decrease of pain perception (VAS Scale 78.8%) leaded to a higher ROM (70.2%). Questionnaires reported long-term high patients satisfaction (average 92.6% after 6-12 months).

Conclusion:

Lipotransfer as a reconstructive technique can be applied with a standard protocol like ACRT in paediatric patients affected with different types of fibrotic skin lesions. The presented algorithm can be applied as a useful adjunctive "rescue" treatment and may offer a patient friendly solution. Further studies are necessary currently planned aiming on the safe and large numbered apply of ACRT in this particular patient group.

1) Hoppe, D.L., Verbrennungsnarben, in Autologe Fettgewebstransplantation, K. Ueberreiter, Editor. 2016, Springer-Verlag Berlin Heidelberg: Germany.

2)Spiekman, M., J.A. van Dongen, J.C. Willemsen, et al., The power of fat and its adipose-derived stromal cells: emerging concepts for fibrotic scar treatment.J Tissue Eng Regen Med, 2017.

Picture:

Add.1

Dissecting the complex genetics of Hirschsprung‘s disease unmasked novel players in its pathoetiology

(Abstract ID: 351)

B. Niesler¹, T. Mederer¹, S. Schmitteckert¹, L. Carstensen¹, P. Günther¹, P. Romero¹

¹Universitätsklinikum Heidelberg

Background:

Hirschsprung’s disease (HSCR) is characterized by a lack of enteric neurons (aganglionosis) in distinct segments of the colon causing megacolon formation. Its pathomechanisms originate in early embryonic development due to dysfunctions of neural crest cells (NCCs). During enteric nervous system (ENS) development, proliferation, migration, differentiation and cell survival of NCC-derived progenitor cells are impaired. The surgical resection of the aganglionic part represents the only treatment option to date. Unsatisfactorily, patients often suffer lifelong from gut dysfunctions and no cure is available. HSCR is classified as multifactorial disorder in which various gene variants shape the phenotype. However, to date identified risk loci (>20 genes) only account for a minority of patients and the molecular pathomechanism is poorly understood.

Materials and methods:

We aimed to identify and characterize novel candidate genes for HSCR. In order to evaluate the genetic findings a complementary study pipeline was established taking genetic, bioinformatic, molecular and functional data into account. Whole exome sequencing was performed on the DNA of two sporadic long-segment HSCR cases and their non-affected relatives.

Results:

Identified genetic variants were bioinformatically filtered to identify putative candidate genes and further narrowed down to four candidates based on literature and network analyses. All four genes were found to be expressed in murine gastrointestinal tissue of different developmental stages and in human fetal and adult colon. To further prove their relevance for HSCR-specific pathomechanisms, the novel candidates were investigated in a genome-engineered neuronal cell culture model. Gene-specific knockout cell clones were generated using the CRISPR/Cas9 technology in SHSY5Y cells and investigated on morphological and functional level. Comparative analyses of differentiation behaviour, proliferation and migration capacity as well as cell survival during neuronal differentiation were assessed.

Conclusion:

Thereby, further evidence accumulated that depicted candidates might play a role in the pathoetiology of HSCR and our study pipeline was proven feasible to represent a valuable approach.

Long-term outcome of patients with esophageal atresia and very low birth weight (

(Abstract ID: 623)

L. A. Ritz¹, A. Widenmann-Grolig², S. Jechalke², E. Lurz¹, S. Bergmann¹, D. von Schweinitz¹, J. Hubertus¹

¹Dr. von Haunersches Kinderspital, München

²KEKS e.V., Stuttgart

Background:

Two-stage repair of esophageal atresia (EA) is a valid option in very low birth weight (VLBW) and extremely low birth weight (ELBW) infants. Whether this approach is superior to primary esophageal repair is still under discussion, and no clear guidelines exist. Aim of this study was to show surgical outcome post-2-stage surgery and primary esophageal repair in a cohort of VLBW infants retrieved from a large national patient organization (KEKS e.V) database.

Materials and methods:

VLBW infants (birthweight < 1500g) were retrieved from the national German patient organization (KEKS e.V). Structured questionnaires were sent to all patient families by the organization and responses were pseudonymized and provided back to our institution. The questionnaire addressed 2 demographic items, 8 clinical features, 8 questions on clinical/surgical management and 10 healing-process items.

If available, anonymized medical reports were provided in addition for further analysis.

Results:

We analysed 48 questionnaires of 22 male (46%) and 26 female (54%) patients born between November 1988 and October 2019 of whom 29 (61%) were born after January 2011. Median birth weight was 1230g (720g - 1500g). Most patients suffered from Vogt Type IIIb EA (n=36, 75%). Primary anastomosis was done in 24 (50%) infants. Anastomotic insufficiency (AI) was reported in 9 (19%) with a preponderance of those who underwent primary repair (n=6, 67% of n=9). Recurrent fistula (RF) was seen in 7 (15%) infants, 6 (86% of n=7) of them had primary repair. A total of 23 (48%) infants developed anastomotic strictures (AS) of which 13 (57% of n=23) were after primary repair.

Conclusion:

This analysis shows an almost equal distribution of primary and staged repair for VLBW/ ELBW with EA. AI, RF, and AS were remarkably predominant in the group of primary repair, even if not statistically relevant, due to the small sample size. Larger international cohorts are needed to identify the best surgical approach for these vulnerable infants.

Total colonic aganglionosis. Diagnostic and therapeutic strategies

(Abstract ID: 684)

S. Märzheuser¹, M. Minderjahn¹, J. Weide¹, K. Rothe¹

¹Charité, Berlin

Background:

Total colonic aganglionosis is a rare variant of Hirschsprung`s disease. It involves the entire colon which is aganglionic and may also extend proximal into the small bowel. Clinically it appears to represent a different spectrum of malformation concerning presentation, difficulties in diagnosis and treatment.

Materials and methods:

We conducted a retrospectiv research of patients who were diagnosed and treated with total colonic aganglionosis at our hospital within the last five years. Patients were included if they had a biopsy confirmed diagnosis of total colonic aganglionosis. We analyzed anamnestic data, diagnostic procedures, number of surgical procedures before and after confirmed diagnosis. Duration of hospitalization. Postoperative management and quality of life.

Results:

Between 2013 and 2018, 14 patients with total colonic aganglionosis were seen at our targeted clinic, the age at diagnosis varied between five days and 20 months. The Number of surgical procedures varied between three procedures and 12 operations including final corrective surgery. Two patients had a colectomy without the need of ileostomy. 8 patients received ileoanal anastomosis without parallel ileostomy formation. Four patients haven´t had corrective surgery yet. Postoperative care includes home rectal irrigation, probiotic medication and regular appointments at our specialized consultancy. On the basis of our data, we propose a diagnostic and therapeutic regime for patients with total colonic aganglionosis.

Conclusion:

Diagnostic delay in total colonic aganglionsis can be substantial particularly in patients that are not directly referred to expert centers for diagnostic workup. Facilitating communication between expert centers and other pediatric surgical units may be a strategy to shorten diagnostic odyssey.

Simultaneous transanal pull-trough and stoma-closure

(Abstract ID: 746)

M. Minderjahn¹

¹Charité Universitätsmedizin Berlin

Background:

Hirschprung’s disease (HD) is a rare congenital anomaly characterized by aganglionosis of the distal bowel. In 30–50% of the cases neonates undergo a colostomy, a large portion undergoes colostomy in the further course. Treatment of histopathologically validated Hirschprung’s disease involves Transanal Endorectal Pull-Through (TEPT) resecting the aganglionic part of the bowel.

In our center for pediatric colorectal malformations we see many patients who received colostomy in other hospitals for TEPT. In almost all cases we refrain from staged procedures and perform stoma-closure and pull-through at the same time.

Materials and methods:

We retrospectively reviewed all patients who underwent stoma-closure and TEPT simultaneously. Patients with concomitant diseases as further complex congenital deformities were excluded. Data of previous surgeries were requested and reviewed. The primary diagnosis in all patients was Hirschsprung's disease with a definitive transition zone between aganglionic and ganglionic bowel. We analyzed epidemiological data, patient’s extended medical history, intraoperative findings, length of aganglionic bowel, position of colostomy, duration of hospitalization, rate of complications and postoperative management.

Results:

Out of 72 patients who underwent TEPT for HD at our clinic in the last 4 years, 12 patients received simultaneous stoma-closure. All patients preoperatively received contrast enema to ensure patency of the aboral stoma. Recovery was fast and feeding was resumed within 24 hours. None of the patients needed dilatation with a hegar sounds as no anastomotic stricture occured. There were no complications that needed follow-up operation in all but one case, where patient suffered from free air in the abdomen as a sign of anastomotic insufficiency which lead to relaparotomy.

Conclusion:

The overall results of the simultaneous approach are promising. We suggest the this approach should be considered as treatment option in patients with Hirschsprungs and colostomy, as it is well tolerated, hospital time saving and has no significant complications.

Preliminary Results of Sacral Nerve Stimulation in Children with Hirschsprung’s Disease

(Abstract ID: 878)

M. Besendörfer¹, C. Simon¹, J. Syed¹, A. Füldner¹, V. Schellerer¹, S. Diez¹, K. Matzel¹

¹Chirurgische Klinik des Uni-Klinikums Erlangen

Background:

Chronic constipation and encopresis after surgical therapy of Hirschsprung´s disease is a frequent problem, yet treatment options are limited. Overlayed by different comorbidities it often results in complex situations. Sacral Nerve Stimulation (SNS) is already established for treatment of refractory fecal incontinence and constipation in adults and rarely used in children. The aim of this study was to establish an innovative therapy for patients with intractable Hirschsprung´s disease.

Materials and methods:

4 patients of age 9-15 years, three male and one female with aganglionic megacolon were enrolled. All patients included were surgically treated beforehand and had history of refractory constipation, encopresis and enuresis. The Erlangen algorithm includes surgical and non-surgical therapy with transanal pull-through, anal sphincter botulinum toxin injection, biofeedback and enteral surface stimulation (ESS). A two-step approach was used: first a temporary lead was placed into the left S3 sacral nerve root monitoring successful stimulation followed by implantation of permanent tined lead electrodes. Threshold of stimulation ranged from 1,5V to 3V with a pulse width of 210 µs and frequency of 15 Hz.

Results:

Implantation of temporary electrodes was performed on all 4 patients. Complications included two dislocations of the test lead in one patient. 3 patients showed immediate improvement of constipation with decrease of defecation frequency, normalization of stool consistency and straining at stool. Two of these patients underwent implantation of permanent electrodes. After two weeks both patients were connected to an impulse generator system (InterStim II® System, Medtronic Inc., Minneapolis, MN, USA) implanted into subcutaneous tissue. The third patient showed no relapse of symptoms after removing the temporary lead since one year, bypassing the implantation of permanent electrodes. Our two-step approach was not executed in this case. The fourth patient suffering from postoperative complications of the transanal pull-through (anastomotic insufficiency and retrorectal abscess) showed no signs of improvement. All patients suffering from enuresis (2) showed improvement in frequency and urgency on urination.

Conclusion:

SNS is a promising and safe treatment for patients with intractable Hirschsprung´s disease. One patient persisted with release of symptoms even after explantation of the stimulating electrodes, possibly indicating a codependence of psychological and neurological pathways. Neverthelesss, the algorithm tools seem to be preliminary enriched, but long-term results need to be awaited.

Potential risc factors and time of diagnosis of anorectal malformations in children

(Abstract ID: 909)

N. Becker¹

¹Universitätsklinikum Ulm

Background:

The incidence of anorectal malformation (ARM) is 1 to 5000 livebirth new-borns. Associated anomalies occur in up to 64%. Aim of our study was to evaluate potential risc factors and the time of diagnosis of ARM in children who were treated in our hospital between 2004 and 2014.

Materials and methods:

44 patients met the inclusion criteria. 26 healthy children and its mothers served as a control group. A retrospective analysis of patients’ data was conducted. Additionally a modified pregnancy questionnaire of the Malformation Monitoring, Otto-von-Guericke-University (Magdeburg, Germany) was handed to the mothers to assess potential risc factors. It included questions concerning chronic diseases, infections during pregnancy, hormonal treatment, changes in life style (nutrition, diet, medication), body weight prior to and during pregnancy, and drug consumption (alcohol, smoking, illicit drugs), as well as environmental factors and diagnostic of ARM.

Results:

Age difference between mothers and fathers of the patients (5,7 years) was significantly (p=0.028) higher compared to the control group (3,3 years). Abnormalities during pregnancy occurred significantly more often in ARM mothers (p=0.002). They had significantly more frequent positive vaginal smears of group B streptococci (p=0.024) and suffered significantly more often from emesis (p=0.025). ARM mothers had significantly more chronic diseases (p=0.018), took less medications (p=0.013) and less folic acid prophylaxis (p=0.041) compared to mothers of healthy children. Iodine intake was significantly more frequent for ARM mothers (p=0.035). They were exposed to nicotine more often and continued nicotine consumption during pregnancy significantly longer (14,2 pregnancy weeks) than mothers of the control group (4,0 pregnancy weeks; p=0.036). 68,1% (n=30) of the ARM patients showed an associated anomaly, especially of urogenital origin (45,5%, n=20). Diagnosis was made in 72,7% (n=32) of ARM children within neonatal examination on first day of life. A delayed diagnosis occurred in 27.3% of ARM children (n=12) either with recto-perineal or vestibular fistula. In 13.7% diagnosis of ARM was made after the seventh month of life which applied to 11.4% of girls (n=5) and to 2.3% of boys (n=1).

Conclusion:

A combination of various risc factors seems to play a role in the developement of ARM, which takes place at an early stage of pregnancy. In general, further studies are necessary to identify potential risk factors. An interdisciplinary evaluation in case of clinically ambiguous findings is essential for a quick diagnosis of ARM to provide an adequate therapy and to improve the childrens’ outcome.

Markers of NETosis do not predict neonatal sepsis: A pilot study

(Abstract ID: 54)

C. Stiel¹, C. Ebenebe¹, M. Trochimiuk¹, L. Pagarol-Raluy¹, D. Singer¹, K. Reinshagen¹, M. Boettcher¹

¹Universitätsklinikum Hamburg Eppendorf

Background:

Early onset sepsis (EOS) in neonates potentially results in substantial morbidity and mortality. Due to unspecific clinical signs and limited laboratory tests, diagnosis is often delayed which deteriorates prognosis and emphasises the importance of identifying biomarkers for neonatal sepsis. Neutrophils release neutrophil extracellular traps (NETs) to form a protective mesh that filters and destroys pathogenic organisms. Markers of NETs formation have recently been shown to correlate with inflammatory diseases like sepsis. In neonatal sepsis, however, NETs are not well understood yet. Therefore, the aim of this study was to evaluate markers of NETs formation in umbilical cord blood as a predictor of neonatal sepsis.

Materials and methods:

We conducted a prospective study, including term and preterm neonates who have been recruited at birth from 03-11/2017. Umbilical cord blood samples were obtained immediately after birth and following markers of inflammation und NETs formation were assessed: blood count, CRP, IL-6, levels of cell-free DNA (cfDNA), neutrophil elastase (NE) and myeloperoxidase (MPO). The study population included neonates with confirmed early-onset sepsis. A control group was generated by the selection of neonates via propensity score matching. All data were analyzed with SPSS Statistics 24 and GraphPad Prism 8.

Results:

Umbilical cord blood samples of 491 neonates have been obtained, of whom 17 neonates (n=17) presented boths clinical and laboratory signs of an infection within the first 72 hours. 17 neonates (n=17) without signs of infection were matched as control group. IL-6 differed significantly (p=0.0029) between both groups, whereas further infection parameters like CRP and neutrophils and in particular the surrogate markers of neutrophilic activation and NETs formation did not show any significant differences.

Conclusion:

NETs markers in umbilical cord blood appear not to predict neonatal sepsis. These findings probably result from the neonates` inability or delayed ability to form NETs, which is suspected to be a main reason for the increased risk of severe infections in neonates, but is also assumed to prevent negative NET-mediated consequences during perinatal adaptation. However, the sample size in this pilot study was small, thus future studies should include a larger study group.

Does cholangitis after Kasai procedure really matter in terms of mid-term outcome in biliary atresia?

(Abstract ID: 64)

O. Madadi-Sanjani¹, S. Eckmann¹, D. Fortmann¹, J. Kuebler¹, C. Petersen¹

¹Medizinische Hochschule Hannover

Background:

Cholangitis following Kasai-procedure is known to be an important prognostic factor for the postoperative outcome and the survival with native liver. While no guidelines for cholangitis in infants exist, surgeons and pediatric hepatologists show a tendency to start broad-spectrum antibiotic regimes, whenever there is a suspicion of postoperative cholangitis in patients with biliary atresia. While the pathogenesis of cholangitis in adolescent and adults is different, the consensus based Tokyo guidelines have improved the management significantly. We therefore present our experience of different post-Kasai antibiotic regimes and modified Tokyo guidelines for cholangitis in infants.

Materials and methods:

We performed a retrospective chart review of 91 patients who underwent Kasai-portoenterostomy between 2007 to 2014 at the Hannover Medical School. We identified the age at Kasai, the postoperative antibiotic regime and the symptoms interpreted as cholangitis.

Results:

Antibiotic regimes during the investigational period included third generation cephalosporines (ceftriaxone, cefotaxime) and aminopecillines plus b-lactamase inhibitor (UnacidÒ, TazocinÒ). Diagnosis was usually made 11.6 days (± 3.8) following Kasai-procedure in 29 infants (31.5%) based on increasing cholestatic and inflammatory parameters (92.6%) as well as clinical signs, e.g. fever, feeding problems and abdominal distension. Analysis did not consider any superiority of the regimes, while the indication for antibiotic regime changes in some cases seemed weak. Based on the survival with native liver, the early postoperative Cholangitis seems to be no significant prognostic factor for the long-term outcome (p=.79).

Conclusion:

While the etiology of post-Kasai cholangitis, especially in infants already on prophylactic antibiotic treatment, is still unknown, a definition of this condition is necessary. We therefore present a modification of the Tokyo guidelines for cholangitis during infancy.

NETosis of long-term surviving Neutrophils

(Abstract ID: 121)

J. P. Kolman¹, M. Trochimiuk¹, B. Appl¹, L. Pagerols Raluy¹, M. Boettcher¹, K. Reinshagen¹, V. Nikolaev¹, J. Trah¹

¹Universitätsklinikum Hamburg Eppendorf

Background:

With neutrophil extracellular traps discovered as double-edged swords of innate immunity, neutrophils became of great interest. As one of the first line responders to infections neutrophils play a crucial role for the defence against pathogens. Neutrophil extracellular traps, composed of chromatin fibers and granule enzymes, help to ensnare pathogens but were shown to be a predisposing factor for several autoimmune diseases, because extracellular DNA, histones and several granule enzymes trigger the production of autoantibodies. Neutrophil extracellular traps were also shown to play a major role in appendicitis, necrotizing enterocolitis and wound healing. As terminally differentiated cells with a short lifespan of 6-8h in peripheral blood neutrophils are not suitable for cell culture, which narrows the possible procedures for the examination of their function.

Materials and methods:

We tested lipopolysaccharide, different cytokines and the effects of C-X-C chemokine receptor type 4 on neutrophil survival and activation over 72 hours. After 6h, 24h, 48h and 72h we evaluated the ability of cultured neutrophils to release neutrophil extracellular traps by assays for neutrophil elastase, myeloperoxidase and cell free DNA.

Results:

Lipopolysaccharide and cytokines can alter the survival rates of neutrophil granulocytes in culture conditions, whilst the C-X-C chemokine receptor type 4 seems to have no significant effects. Neutrophil activation may play a central role in survival with changes on the release of neutrophil extracellular traps.

Conclusion:

These data provide helpful information on how to culture neutrophils over several days considering their ability to release neutrophil extracellular traps. Surviving neutrophils without impaired functionality would enable to further examine their role in the immune system regarding neutrophil extracellular traps.

Neutrophil Extracellular Traps (NETs) as predictors for appendicitis

(Abstract ID: 214)

M. Eßer¹, S. Klohs¹, I. Königs¹, A.-L. Schacker¹, N. Mokhaberi¹, M. Trochimiuk¹, B. Appl¹, K. Reinshagen¹, L. Pagerols Raluy¹, M. Boettcher¹

¹Universitätsklinikum Hamburg-Eppendorf

Background:

As one of the most common emergencies, appendicitis plays an important role in pediatric surgery. The current means of diagnosis are unspecific and of low predictive value. Since it has been established that neutrophils and NETosis contribute significantly to diseases such as sepsis and other inflammatory diseases, this study investigates the correlation of NETs markers to acute appendicitis and aims to establish said markers as a diagnostic method in the context of a liquid biopsy.

Materials and methods:

For the study about 200 children were included that presented with suspected appendicitis at the University Medical Center Hamburg-Eppendorf and the Children’s Hospital in Hamburg-Altona. Exclusion criteria were significant immune deficiencies and chronic inflammatory bowel diseases. As a control group, children without appendicitis or with pathologically classified catarrhal appendicitis were selected. Blood samples were collected before, during and on days 3, 5 and 7 after surgery. In cases of appendectomy, tissue samples were obtained. All blood samples were analyzed regarding cell-free DNA (cfDNA), neutrophile elastase (NE), myeloperoxidase (MPO) and citrullinated histone H3 (H3cit) by means of ELISAs or fluorometric or absorbance assays. The corresponding tissue samples were histologically assessed for DAPI, NE, MPO and H3cit.

Results:

In total the samples of 200 children were analyzed, of which 60 were allocated to the control group. The children with appendicitis were stratified into two groups according to pathologically determined severity of appendicitis. The group with gangrenous and perforated appendicitis, i.e. the most severe group, showed significantly higher levels of the investigated markers than the intermediate group with phlegmonous appendicitis or the control group.

Conclusion:

NETs markers seem to be a well-fitting representation of the level of severity of the disease and correlate significantly with the level of NETosis in the tissue which makes them a great choice for a liquid biopsy and thus offer a new possibility to diagnose and tailor therapy of appendicitis in children. Further studies will have to establish specific thresholds for each marker to enable the clinician to identify the severity of appendicitis and thus the level of risk of perforation or other complications.

Antitumor effects of curcumin in pediatric rhabdomyosarcoma cells in vitro and the role of XPO1

(Abstract ID: 240)

V. Ellerkamp¹, C. Sorg¹, F. Weber¹, J. Fuchs¹, E. Schmid¹

¹Universitätsklinikum Tübingen

Background:

Rhabdomyosarcoma (RMS), the most common pediatric soft tissue sarcoma, has an unfavorable outcome in advanced tumor stages with less than 30% failure-free survival. Curcumin is a promising drug in complementary oncology with few side effects but proven efficacy in various adult oncological entities. XPO1 is a nuclear export protein, involved in cancer cell growth. The present study analyzed the effects of curcumin on pediatric rhabdomyosarcoma cell lines in vitro, and its impact on XPO1.

Materials and methods:

RMS cell lines (RD, RH30, ZF, SRH), and SKMC cells were treated with different doses curcumin, with phototherapy (488 nm) or in combination with vincristine or dactinomycin. Furthermore, the cells were treated with of the XPO1 inhibitor selinoxor. MTT test was used for analysis of RMS tumor cell viability. Clonal cell growth was assessed via colony forming assays and migration of the cells was analyzed with scratch tests. Annexin V staining was used to determine apoptosis in flow cytometry. Possible RMS resistance towards curcumin after long-term treatment was analyzed with MTT tests. Expression of XPO1 and the dependent tumor protein cyclin D was analyzed with western blots; the effects of curcumin and the selective inhibitor selinexor were compared.

Results:

Curcumin decreased cell viability in all tested RMS cell lines in a concentration-dependent manner with IC50 =14-20 µM. Curcumin enhanced the effects of the cytotoxic drugs vincristine or dactinomycin, and led to reduced migration and increased cell apoptosis. In combination with phototherapy (488 nm), curcumin decreased the cell viability in minute

Conclusion:

Curcumin effectively inhibits the malignant properties of pediatric RMS cells and should be focused on as a useful additional agent in standard chemotherapy of RMS in children.

Personalized treatment response assessment using microcalorimetry – exemplified on clear cell renal sarcoma

(Abstract ID: 293)

S. Gros¹, C. Supuran², S. Holland-Cunz¹, O. Braissant³

¹Universitäts-Kinderspital beider Basel

²University of Florence

³University of Basel, Allschwil

Background:

We present a novel approach to a personalized therapeutic concept for solid tumors. The use of microcalorimetry as a refined in vitro method for evaluation of drug susceptibility in organotypic slice culture has not previously been established.

Materials and methods:

We illustrate this on a case of clear cell renal sarcoma, for which only a generalized treatment concept exists, using microcalorimetric drug response assessment of experimental inhibitors in the tumor slice culture.

Results:

With our experiments we demonstrate that within 48 hours we are able to detect a response to antitumor substances by using microcalorimetric measurements of tumor slice cultures alone. Expression of target proteins is confirmed.

Conclusion:

Rapid microcalorimetric drug response assessment can refine a general treatment concept when it is applied in cases in which tumors do not respond to conventional chemo-radiation treatment. For solid tumors, which do not respond to classical treatment, and especially for rare tumors without an established protocol rapid microcalorimetric drug response testing presents an elegant novel approach to test alternative therapeutic approaches.While improved treatment concepts have led to improved outcome over the past decades, the prognosis of high risk disease is still poor and rethinking of clinical trial design is necessary. A small patient population combined with the necessity to assess experimental therapies for rare solid tumors rather at the time of diagnosis than in relapsed or refractory patients provides great challenges. The possibility to rapidly compare established protocols with innovative therapeutics presents an elegant novel approach to refine and personalize treatment.

The research study has already been published in a similar form as follows: Gros SJ, Holland-Cunz SG, Supuran CT, Braissant O.Personalized Treatment Response Assessment for Rare Childhood Tumors Using Microcalorimetry-Exemplified by Use of Carbonic Anhydrase IX and Aquaporin 1 Inhibitors. Int J Mol Sci. 2019 Oct 9;20(20). pii: E4984. doi: 10.3390/ijms20204984.

Interleukin-1ß receptor blocker inhibit NETosis – potential treatment in pediatric sepsis?

(Abstract ID: 319)

H. Wadehn¹, M. Trochimiuk¹, B. Appl¹, L. Pagerols Raluy¹, I. Königs¹, K. Reinshagen¹, M. Boettcher¹, J. Trah¹

¹Universitätsklinikum Hamburg Eppendorf

Background:

Apart from phagocytosis and degranulation, neutrophils have the ability to eliminate microorganisms by building neutrophil extracellular traps (NETs). These fibrous networks primarily consist of decondensed DNA and associated proteins like neutrophil elastase (NE) or myeloperoxidase (MPO). In addition to infection control, NETs also occur in severe pediatric diseases such as necrotizing enterocolitis, appendicitis or excessive immune reactions like sepsis. Although infections are treated with antibiotics, sepsis mortality remains high, especially in children. It could be proven that NETosis and dysregulation of its process could aggravate the outcome of septic patients. Increased levels of IL1ß could be detected during the acute phase of septic infections. Furthermore, there is evidence that disruption of the IL18/ IL1R1/IL 17 pathway might be a new therapeutic target for human neonates suffering from sepsis.

Materials and methods:

Neutrophils were isolated from blood samples of healthy donors. They were pretreated with the IL1ßR-Antagonist Anakinra for 10, 30 and 60 minutes with concentrations of 100ng/ml, 100µg/ml and 1 mg/ml before stimulation with phorbol myristate acetate (PMA) to induce NETosis. Quantification of the NETs-formation was performed by measuring the associated proteins NE and MPO by using absorbance measurement-based assays. The qualitative analysis of the proteins mentioned above was conducted by immunofluorescence staining.

Results:

Pretreatment of neutrophils with Anakinra results in a significantly lower release of NETs compared to the untreated control group; depending on concentration and time. Both the amount of released neutrophil elastase and myeloperoxidase decreased as a result of pretreatment. We were able to confirm this observation by immune staining. Additionally, we could demonstrate that the reduction of protein release is caused by a reduction of NETosis and not due to other processes.

Conclusion:

With our data, we are able to show that a pretreatment with Anakinra can reduce NETs-building. We assume this effect could be used to avoid dysregulation in the progress and formation of NETs at some critical point, when NETosis becomes overwhelming and starts to cause damage. This may prevent sepsis from aggravating into multi organ failure. Therefore, we believe that treatment with Anakinra could improve the outcome in pediatric and neonatal sepsis patients.

Optimization of a murine model of necrotizing enterocolitis

(Abstract ID: 330)

M. Klinke¹, D. Vincent¹, M. Trochimiuk¹, A. Appl¹, B. Tiemann¹, K. Reinshagen¹, L. Pagarols Raluy¹, M. Boettcher¹

¹Universitätsklinik Hamburg-Eppendorf

Background:

Necrotizing enterocolitis (NEC) is one of the most devastating diseases affecting neonates. As a result, a lot of research has focused on developing better therapeutic strategies for NEC. However, an issue affecting NEC research and application of research findings, is the difficulty of translating the results obtained from animal NEC models commonly implored to study NEC to human neonates with NEC. However, the differences observed in NEC severity in mice compared to humans, may partly be due to differences in neutrophil concentrations among newborn humans (50-70%) and neonatal mice (10-25%). The aim of our study was to evaluate the effect of an altered neutrophil concentration, in order to improve current murine NEC models.

Materials and methods:

In total, 44 C57BL6 neonatal mice were included, of which 40 were subjected to an established NEC induction paradigm. Out of the 40 animals, ten were used as controls, whereas the remaining 30 received granulocyte colony stimulating factor (G-CSF) once daily. The G-CSF group was further divided into two subgroups: (1) wildtype, and (2) ELANE-knockout (ELANE-KO). Survival, NEC severity, tissue damage, neutrophil activation, and NETosis were evaluated.

Results:

G-CSF administration resulted in significantly higher neutrophil levels and vastly elevated NEC manifestation rates with consecutive tissue damage and intestinal inflammation, without affecting overall mortality. Animals without functioning neutrophil elastase (ELANE-KO) appeared to have been protected from NEC development.

Conclusion:

Through administration of G-CSF we were able to improve a murine NEC model, resulting in high NEC manifestation rates. Additionally, no maternal separation or hypothermia was necessary, making the model more ethical and animal friendly. Moreover, the addition of G-CSF administration to previously validated animal NEC models may yield a better understanding of NEC pathogenesis and may more accurately reflect human physiology.

Cytokine Profiles in Fetal Tracheal Fluids are significantly altered and can distinguish between CDH survivors and non-survivors

(Abstract ID: 369)

R. Wagner¹, J. Deprest², C. Pascoe³, D. Patel³, M. Lacher¹, R. Keijzer³

¹Uniklinikum Leipzig

²KU Leuven

³University of Manitoba, Winnipeg

Background:

There is emerging evidence that immunological processes contribute to the pathogenesis of Congenital Diaphragmatic Hernia (CDH). We previously found that cytokine signalling pathways are enriched in nitrofen-induced hypoplastic lungs. Here, we aimed to analyse cytokine profiles in tracheal fluids from CDH fetuses who underwent fetoscopic endoluminal tracheal occlusion (FETO).

Materials and methods:

Following ethical approval (HS15293 (H2012:134)) we obtained tracheal fluids from severe CDH cases undergoing FETO at balloon removal. Groups were divided into patients eventually surviving FETO (n=4) and non-survivors (n=4). Cytokines were profiled using a Luminex 42-plex array. Bioinformatic analysis was performed with R Studio. Mann-Whitney U test was used for statistical analysis with significance set at p<0.05.

Results:

Cytokine signatures in prenatal tracheal aspirates were altered between CDH fetuses that later survived FETO and non-survivors. Gestational age was 28.1 weeks (survivors) and 27.9 weeks (non-survivors) and observed-over-expected lung-to-head ratios were 22.5 % and 21.6%, respectively. G-CSF (Fold Change 2.5), IL-2 (FC 2.5), IL-8 (FC 8), IL-9 (FC 1.7), and IL-15 (FC 2.5) were significantly increased in tracheal fluids of survivors. Correlation heat maps showed a stronger correlation of single cytokines among survivors compared to non-survivors. In survivors, EGF, Rantes and IL-1a were negatively correlated with the other cytokines, whereas in non-survivors FGF2 and IL-R1 were negatively correlated with the rest of the profile.

Conclusion:

Cytokine profiles between CDH fetuses who will eventually survive FETO are altered compared to non-survivors. Our results confirmed that immunological processes contribute to the pathobiology of CDH and that a specific cytokine signature is associated with better outcomes.

Abnormal Lung Development in Congenital Diaphragmatic Hernia due to external Stimulation of the innate Immune System

(Abstract ID: 370)

R. Wagner¹, H. Piyadasa², C. Pascoe², D. Patel², M. Lacher¹, N. Mookherjee², R. Keijzer²

¹Uniklinikum Leipzig

²University of Manitoba, Winnipeg

Background:

Although evidence suggests that environmental aspects are involved in causing Congenital Diaphragmatic Hernia (CDH), an "external factor" is unknown. Using omics technologies and bioinformatics we aimed to uncover novel biological processes in the pathogenesis of CDH.

Materials and methods:

After ethical approval (19-010 (AC11436)), total proteins were isolated from nitrofen exposed CDH (n=5) and control (n=5) lungs (Embryonic day 21). Label-free 1-D liquid chromatography coupled with mass spectrometry was performed for proteomic profiling. Bioinformatic analysis was performed using R Studio Software. Pathway analysis and protein interaction networks were created with ingenuity pathway analysis and networkanalyst.ca. Immunohistochemistry (IHC) and in-situ Hybridization (ISH) against viral proteins or RNA were performed in human fetal CDH lungs.

Results:

The proteomic profile of hypoplastic nitrofen lungs showed a strong immunological signature with significant upregulation of immune response proteins. Network analysis identified interleukin signalling, cytokine signalling and innate immune response as the most enriched biological processes. CREB-binding protein, Thyrosine-proteine kinase Lyn, Signal transducer and activator of transcription 3 and nuclear factor kappa-light-chain-enhancer of activated B cells were central hubs for protein interactions within our network analysis. Pathways correlated to viral stimuli, especially Epstein Barr Virus (EBV) were significantly enriched in hypoplastic lungs. Using IHC and ISH we could not detect EBV or Human Cytomegalovirus (HCMV) in human fetal CDH lungs yet.

Conclusion:

Nitrofen exposed hypoplastic lungs showed a marked immune response due to an external viral stimulus. Overwhelming immune responses due to viral stimulation in human fetuses or nitrofen in the rat model could potentially explain abnormal lung development in CDH.

Influence of DNases and NETs on appendicitis

(Abstract ID: 482)

J. Wenskus¹, M. Mokhaberi¹, L. Wahjudi¹, L. Pagerolus Raluy², M. Trochimiuk², B. Appl², H. Rhode³, T. Fuchs³, K. Reinshagen¹, M. Boettcher²

¹University Medical Centre of Eppendorf and Altona`s Children Hospital, Hamburg

²University Medical Center Hamburg-Eppendorf

³Universitätsklinikum Hamburg-Eppendorf

Background:

Nonoperative appendicitis management has generated considerable interest as an alternative approach to surgical appendicitis treatment. However, many limitations still exist and the question of how nonsurgical management can be optimized in the future arises. One potential new approach in the nonsurgical treatment of appendicitis may be explained by neutrophils and neutrophil extracellular traps (NETs), as they play a dominant role in bacterial infections such as appendicitis. Therefore, the aim of this study was to investigate the influence of NETs, and their counterparts DNases, in an appendicitis murine model in order to find new therapy targets.

Materials and methods:

The study’s subjects were six-week-old female mice (WT, DNase-1-KO, DNase1/3-KO, PAD4-KO) that underwent an appendicitis induction paradigm through a modified CLP procedure. Mice were divided into four groups: The control group (1) received a vehicle (carrier solution for DNases), while the antibiotic group (2) received cefuroxime and metronidazole. The DNase group (3) was treated with DNase, and the combination group (4) received antibiotics and DNase. The medication was given 48 hours after the CLP procedure twice daily for 48 hours intraperitoneally. Euthanasia was performed after 96 hours. We assessed survival rate, bacterial translocation, and histology. Moreover, immunofluorescence microscopy and western blot were performed.

Results:

In our study, the combination of DNase and antibiotics led to improved survival rates and reduced inflammation. These effects were confirmed using knockout mice: animals without NETs (PAD4-KO) showed better survival and less inflammation under antibiotic therapy than animals without DNase (DNase-1-KO, DNase1/3-KO). Moreover, animals incapable of NETs formation demonstrated a bacterial translocation of gram-positive pathogens (in the liver, spleen and heart), while animals without DNase, gram-negative pathogens predominated.

Conclusion:

Our study suggests that lysis of NETs or their absence improves efficacy of antibiotic therapy. The translocation of gram-positive pathogens in these animals may be an indicator for a better clearance of gram-negative bacteria. However, further studies should be conducted.

Inhibition of neutrophil extracellular traps formation significantly improves wound healing after thermal injuries in mice

(Abstract ID: 536)

A. Heuer¹, I. Königs¹, C. Götz¹, L. Pagerols Raluy¹, M. Trochimiuk¹, B. Appl¹, K. Reinshagen¹, T. Fuchs¹, M. Boettcher¹

¹Universitätsklinikum Hamburg-Eppendorf

Background:

Despite complex treatment algorithms for burn wounds, 70% of all thermal injuries (TI) lead to hypertrophic scaring. Subsequently, quality of life is greatly decreased due to the massive functional, aesthetic and psychosocial sequelae. Burn interventions target the systemic inflammation response to accelerate re-epithelization, which is one of the most important positive prognostic markers for an optimal outcome after TI. Neutrophil granulocytes (NG) infiltrate the wound after burn trauma and mediate microvascular damage in the zone of stasis through the formation of neutrophil extracellular traps (NETs). Secondary expansion of necrosis into initially vital neighboring dermis likely results from a NG triggered local inflammatory response and NET induced hypercoagulation at the burn wound site as well as adjacent tissue up to 60 days after the initial TI. We hypothesized that NET targeted therapies, including DNase and peptidyl arginine deminase type IV (PAD4) inhibitors, reduce inflammation, promote reepithelization and reduce scarring in an experimental model of TI. The purpose of this study was to investigate postburn NG influx and NET formation relative to healing and scarring in a murine model of thermal burns.

Materials and methods:

A cutaneous full-thickness scald was induced on the dorsal region of C57BL6/J mice, which were either wild type, DNase1-knockout-, DNase1L3-knockout- and PAD4-knockout- animals. The wild type group was divided into treatment groups, receiving DNase1 or Dnase1l3 injections and control groups, receiving vehicle injections. Mice were euthanized at selected time points over four weeks (72h, 7d, 14d, 28d), and the lesions evaluated using macroscopic scores and histological examination. Endpoints were time until full re-epithelisation was achieved, scar structure (collagen I/III ratio, fiber organization and density), wound contractility (alpha-smooth muscle actin (SMA)) and activation of NG and NET release (NE, MPO, H3cit), being markers for inflammation.

Results:

As with human burns the scald healed through both contraction and re-epithelization. Control groups showed an immediate increase in NG and NET numbers, abnormal collagen I/III ratios and fiber organization. SMA did not resolve within 28 days. In groups where NETs were reduced through treatment or their formation was inhibited (PAD4-KO mice), the reduction of NG and NETs correlated with a significant accelerated re-epithelisation, higher collagen typ I count, stable fiber organization and restricted tissue contraction reflected in physiologic alpha-SMA distribution. In mice incapable of degrading NETs (DNase1- / DNase1L3-KO) re-epithelisation is significantly prolonged until 28 days through massive local inflammation.

Conclusion:

NETs appear to play a central part in wound healing of TIs. In mice, NETs seem to induce local inflammation, delay wound closure and impair various aspects of wound healing like reduced collagen organization and increased tissue contraction in the burn area. Decreasing the deleterious NETs through NET targeted therapies significantly improved healing. Thus, the therapy could revolutionize burn care by accelerating re-epithelisation and reducing scarring; ultimately, it may lead to better aesthetic and functional outcome in burn patients.

Mucosal monosaccharide transporter expression in newborns with jejunoileal atresia and along the adult intestine

(Abstract ID: 546)

R. N. Vuille-dit-Bille¹, S. Holland-Cunz¹, C. F. Meier², F. Verrey²

¹Universitäts-Kinderspital beider Basel

²Institute of Physiology and Zurich Center for integrative human physiology

Background:

In newborn rodents, intestinal maturation involves delayed fructose transporter GLUT5 expression until weaning. In jejunoileal atresia (JIA), distal intestinal segments lack exposure to amniotic fluid containing carbohydrates. We assessed in human newborns the impact of intestinal maturation and obstruction on mucosal monosaccharide transporter expression.

Materials and methods:

Samples were obtained from 10 newborns operated for small intestinal atresia and from 17 adults undergoing gastroduodenoscopy and/or ileocolonoscopy. mRNA expression of the monosaccharide transporters SGLT1, GLUT1, GLUT2, GLUT5, and GLUT7 was measured in neonate samples proximal and distal of the atresia as well as in adult duodenum, ileum, and colon. Protein expression and localization was assessed using immunofluorescence.

Results:

Although mRNA expression of monosaccharide transporters did not significantly differ between newborn and adult samples, immunofluorescence staining of the basolateral hexose transporter GLUT2 appeared noticeably stronger in newborns when compared to adult duodenum and ileum. Moreover, luminal fructose transporter GLUT5 protein was absent in 0–4 days old neonates. The mRNA expression of the five tested monosaccharide transporters was unchanged distal from the JIA relative to proximal and also protein expression of luminal sodium-dependent glucose transporter SGLT1 and of basolateral GLUT2 visualized by immunofluorescence staining was unchanged. With the exception of glucose transporter GLUT1 that showed highest expression levels in colon, all investigated hexose transporters showed strongest expression in duodenum, lower levels in ileum and lowest in colon.

Conclusion:

Human newborns lack small intestinal fructose transporter GLUT5 protein expression and small intestinal atresia does not affect the expression of hexose transporters.

Liquid biopsy in pediatric solid tumors: Analysis of biomarkers in activated macrophages in the peripheral blood of pediatric solid tumors

(Abstract ID: 577)

E. Schmid¹, M. J. Stagno¹, R. Handgretinger¹, J. Fuchs¹, S. Warmann¹

¹Klinik für Kinder- und Jugendmedizin Tübingen

Background:

Various immune reactions to tumors have been observed, such as a very early step phagocytosis of tumor cells by macrophages. The Epitope Detection in Monocytes (EDIM) blood test allows detection of intracellular tumor-protein epitopes in peripheral blood macrophages after phagocytosis of tumor cells. This blood test detects tumor proteins such as transketolase-like 1 (TKTL1, activation of aerobic glycolysis) and Apo10 (DNaseX, proliferation defect) in a non-invasive way by isolating peripheral blood macrophages’ intracellular epitopes after phagocytosis of tumor cells. Other attractive biomarkers such as the ganglioside GD2, which is highly expressed in neuroblastoma, could be used for the EDIM blood test. In the present study the role of TKTL1, Apo10, and GD2 as potential targets for liquid biopsy in pediatric solid tumors has been evaluated.

Materials and methods:

We analyzed blood samples from pediatric patients with neuroblastoma (n=38), nephroblastoma (n=17), soft tissue sarcomas (n=32), and hepatoblastoma (n=9), and healthy individuals (n=37). Macrophages (CD14 /CD16 ) were isolated from peripheral blood (before tumor resection), analyzed using flow cytometry, and assessed for the presence of intracellular epitopes of tumor proteins Apo10, TKTL1, and GD2 (neuroblastoma) using the EDIM blood test. Furthermore, expression levels of TKTL1, Apo10, and GD2 (neuroblastoma) in tumor samples and in tumor cell lines from neuroblastoma, soft tissue sarcomas, and hepatoblastoma origin were analyzed using RT-PCR, flow cytometry, and immunohistochemistry. To prove that macrophages phagocytose tumor cells and internalize them, we did several further co-culture experiments with peripheral blood and LAN-1 cell line.

Results:

Phagocytized tumor-related protein epitopes Apo10 and/or TKTL1 in all pediatric solid tumor patients and additionally GD2 in neuroblastoma were detected in the CD14 /CD16 macrophages of all analyzed patients. A significant upregulation of Apo10 (>130) and/or TKTL1 (>119) and GD2 expression (p<0.0001) in tumor samples from pediatric solid tumor patients was observed in comparison to healthy individuals. Expression levels of TKTL1 and Apo10 were elevated in all investigated pediatric tumor samples. We observed a differential elevation of TKTL1 and Apo10 expression in tumor cell lines. A significant upregulation of TKTL1, Apo10, and GD2 in LAN-1 cells co-incubated with peripheral blood was observed, compared to peripheral blood cells alone or peripheral blood cells incubated with DMEM Medium.

Conclusion:

The EDIM blood test might serve as an additional non-invasive tool for liquid biopsy in pediatric solid tumor patients. Future studies should investigate risk stratification at initial diagnosis, treatment monitoring, early detection of tumor relapses, and determination of tumor biology. Further studies including longitudinal analyses are necessary to correlate EDIM results with tumor-specific characteristics and imaging data, and thus determine the applicability of this method for the treatment of tumor patients.

First genome-wide association study of esophageal atresia with or without tracheoesophageal fistula (EA/TEF) identifies common risk variants near the FOX gene cluster and HNF1B

(Abstract ID: 620)

J. Gehlen¹, H. Reutter², R. Zhang², A. Sungur³, A. Hilger², J. Schumacher¹, @. great-Konsortium¹

¹University Hospital of Marburg

²University Hospital Bonn

³University of Marburg

Background:

Esophageal atresia with or without tracheoesophageal fistula (EA/TEF) is the most common congenital malformation of the upper digestive tract. This report describes the first genome-wide association study (GWAS) to identify risk loci for EA/TEF. On the polygenic level, analyses were performed to test whether GWAS associations are enriched in rat esophageal/tracheal transcriptome data from embryonic days (E) of relevance to EA/TEF.

Materials and methods:

The European GWAS discovery sample comprised 387 EA/TEF patients and 1,308 controls. Genome-wide significant EA/TEF associations were investigated in an independent European EA/TEF replication sample (total of 432 patients and 652 controls). Transcriptome-wide expression analyses were performed in rat tissues from E11, E12, E13, and E14.

Results:

Genome-wide significant associations were found on chromosome 16q24 next to the Forkhead-Box (FOX) gene cluster (P = 1.83 x 10-08) and on chromosome 17q12 next to the HNF1 homeobox B (HNF1B) gene (P = 2.62 x 10-09). Both findings were replicated in the independent EA/TEF sample (P = 1.67 x 10-06 on chromosome 16, P = 4.77 x 10-04 on chromosome 17). A Bonferroni-corrected significant enrichment of GWAS associations among differentially expressed genes was found for E13 vs. E11-12. Nominally significant enrichment of GWAS associations were found for E11 vs. E12-14 and E12 vs. E13-14.

Conclusion:

The present study shows that common genetic variants at the FOX gene cluster and HNF1B are genetic risk factors for EA/TEF. On the polygenic level, the data implement different embryonic processes in disease development, including the separation of the esophagus and trachea at E13.

Picture:

Regional association plot at chromosome 16q24 and chromosome 17q12

Lithocholic bile acid induces apoptosis in human nephroblastoma cells: A non-selective treatment option

(Abstract ID: 230)

J. Arand¹, A. Mühling¹, J. Oh¹, M. Trochimiuk¹, L. Pagerols-Raluy¹, M. Saleem², K. Reinshagen¹, J. Trah¹, M. Boettcher¹

¹Universitätsklinikum Hamburg-Eppendorf

²University of Bristol

Background:

Lithocholic bile acid (LCA) has been reported to have selective anti-tumor effects on many tumor cell lines including neuroblastoma or glioblastoma. Wilm’s tumor shares similarities with neuro- and glioblastoma. Hence, the aim of the study was to evaluate the effects of LCA on nephroblastoma.

Materials and methods:

To test the effects of LCA, nephroblastoma cell line WT-CLS1 was used. SK-NEP1 that was originally classified as nephroblastoma cell line were meanwhile reclassified as a Ewing sarcoma cell line was tested as well. As controls healthy cell lines from embryonic kidney HEK-293 and from adult kidney tissue RC-124 as well as podocytes were used. The effects were evaluated using proliferation assay, caspase activity assay, FACS and Western blot.

Results:

LCA showed a dose and time-dependent anti-tumor effect inducing apoptosis in nephroblastoma cells. However, these effects were not limited to the nephroblastoma cell line but also affected healthy kidney cell lines and the sarcoma cells; only podocytes are significantly less affected by LCA (at dosages <200µm). There were no significant differences regarding the TGR5 receptor expression; the only know extracellular receptor for LCA so far.

Conclusion:

The study shows that LCA has a strong, yet unselective anti-tumor effect on all in vitro cell-lines, sparing highly differentiated cell-lines like podocytes in lower concentrations. Further studies are needed to verify our results before dismissing LCA as an anti-cancer drug.

A new valid animal model for the evaluation of Hyperthermic Intraperitoneal Chemotherapy (HIPEC) in pediatric rhabdomyosarcoma

(Abstract ID: 321)

B. R. Wagner¹, A. Adamus¹, P. Jank¹, C. Denkert¹, G. Seitz¹

¹Universitätsklinik Marburg

Background:

Rhabdomyosarcomas (RMS) are the most common pediatric soft tissue sarcomas. Peritoneal sarcomatosis (PS) represents a rare and critically advanced tumour stage with very unfavourable prognosis. In order to improve survival of these patients cytoreductive surgery (CRS) in combination with hyperthermic intraperitoneal chemotherapy (HIPEC) has been established as novel curative treatment approach. CRS and HIPEC in children have been used sparsely in very few centers worldwide. In spite of promising clinical reports, there is still a lack of information regarding optimal drug combinations, treatment duration and local effects. Therefore, there is an urgent need for a reproducible animal model of both PS and HIPEC treatment.

The aim of the study was to establish a murine animal model for further evaluation of HIPEC treatment approach.

Materials and methods:

Human alveolar RMS cells (Rh30, DMSZ no.: ACC 489) were xenotransplanted intraperitoneally to 98 NOD/LtSz-scid IL2Rcnull-mice at day 0. After tumour growth, the animal underwent continuously intraperitoneal chemotherapy for 60 minutes by using cisplatin of 30 or 60mg/m2 heated to 37° or 42°C under general anesthesia at day 21. The animal of the control group underwent continuously intraperitoneal lavage for 60 minutes by using 0.9% sodium chloride solution heated to 37° or 42°C. Tumour dissemination was documented by an own peritoneal cancer index (PCI) adapted for the animal model. Tumours were resected at the end of the perfusion and animals were sacrificed. Cellular effects were evaluated by confocal microscopy after histopathological and immunohistochemical staining using KI-67. Additionally, abdominal tumor spread was documented by small animal MRI.

Results:

Xenotransplantation of RMS cells led to an extensive peritoneal dissemination in more than 90% of the cases (mean PCI-Score: 6,9 +/- 0,4). Main tumour masses were typically found on the greater curvature of the stomach followed by perisplenic, perihepatic and smaller sporadic mesenteric dissemination. HIPEC was feasible in all animals without major side effects. Immunohistochemical investigation using KI-67 revealed no early concentration- or temperature-dependent effect of cisplatin-based HIPEC on the RMS cells. The proliferation rate was comparable to untreated tumours. MRI scans showed a disseminated tumour distribution and effects of chemotherapy.

Conclusion:

To our knowledge, this is the first animal model for evaluation of HIPEC in pediatric RMS showing that HIPEC is feasible in small animals. In our study, cisplatin-based HIPEC had no early effect on the proliferation of RMS cells, what might be caused by the applied concentration of cisplatin. This model allows further insights into the possible efficiency of HIPEC in RMS and allows an evaluation of a combination of CRS/HIPEC and other local treatment approaches such as photodynamic therapy in the future. Further studies using other drug combinations and treatment will follow to further assess this treatment approach.

The acute correction of post-traumatic cubital Axis Deformity

(Abstract ID: 302)

A. Herzog¹, T. Wirth¹, F. Fernandez¹

¹Olgahospital, Stuttgart

Background:

Fractures around the elbow represent the most common skeletal trauma in childhood and adolescence. However, its sufficient management remains often challenging. An inadequate initial treatment leads to malunion that causes abnormal growth, which further develops into cubital axis deformity.

The purpose of this study is to evaluate the acute correction of cubital axis deformity through three different surgical approaches: the supracondylar dome-osteotomy, the lateral/medial closing/open-wedge-osteotomy and the unilateral external fixation.

Materials and methods:

A cubitus varus was defined with a Baumann's angle more than 81° while a cubitus valgus with a Baumann's angle less than 64° that was measured in an anteroposterior radiograph of the elbow.

During a period of 10 years between 2009 and 2019, a total of 40 cases of post-traumatic cubital axis deformity, of which 23 cases of cubitus varus and 17 cases of cubitus valgus, underwent acute surgical correction at the age of 13 ± 4.3 years with the initial trauma dated 4.8 ± 3.2 years back.

A dome-osteotomy was performed in 16 cases, while 13 cases were corrected through a wedge-osteotomy and the other 11 cases through an external fixation.

Results:

The aimed reference range of the Baumann's angle was achieved in all cases.

The age upon correction was significantly younger in the external fixation sub-cohort with 8.3 ± 2.3 years compare to those in the dome-osteotomy and the wedge-osteotomy sub-cohorts with 14.7 ± 2.8 years and 15.0 ± 4.2 years, respectively.

The consolidation period was considerably longer in the external fixation sub-cohort with 8.5 ± 2.2 weeks compare to those in the dome-osteotomy and the wedge-osteotomy sub-cohorts with 7.2 ± 1.8 weeks and 7.6 ± 3.4 weeks, respectively.

Conclusion:

The age upon correction, and more specifically, the age-correlated geometry of the distal humerus plays a critical role in choosing the optimal surgical approach. A sufficient implant implementation of an internal fixation is challenging in the younger patients.

The correction results in the dome-osteotomy sub-cohort and those in the wedge-osteotomy sub-cohort are generally comparable.

However, the risk of intraoperative injury of the ulnar nerve during a wedge-osteotomy through a medial incision and the wedge-induced translation, which further results in the postoperative prominence of either the lateral condyle or the medial epicondyle are contraindications that must be taken into consideration.

Concurrently, the supracondylar dome osteotomy is proceeded through a posterior incision by utilizing a triceps-splitting technique that doesn't put the ulnar nerve at risk and its non-wedge approach results in a more balanced anatomical proportion of the distal humerus.

Presurgical planning and simulation of supracondylar closed wedge osteotomy of a pediatric cubitus varus deformity on 3D-printed humeri

(Abstract ID: 682)

L. Tüshaus¹, T. Friedrich², M. Wattenberg², T. Buzug², L. Wünsch¹

¹UKSH, Lübeck

²Universität zu Lübeck

Background:

An individual and careful planning is an integral part of the treatment of posttraumatic deformities in children and adolescents. Especially computed tomography (CT) images of those patients can be utilized for 3D-printed patient specific anatomical models. These prints are enhancing surgeon's understanding of their patient’s particular anatomy, and therefore are very helpful in preoperative planning and simulation.

Materials and methods:

In the present case a left supracondylar humerus fracture of a pediatric patient (Type IV according to v. Laer) has healed in misalignement after the initial operative treatment and has led to a cubitus varus deformity. A preoperative CT dataset of the humerus of six-year-old boy was semi-automatically segmented by a threshold-based region-growing algorithm and some manual correction. The segmented structure was converted into a printable polygon-surface mesh, which was smoothed using a Laplacian smoothing filter. The segmented structure was printed with a common 3D-printer (Ultimaker 3, Ultimaker B.V., Geldermalsen, Netherlands) in the fused deposition modelling method. Four models were printed from polylactic acid (PLA) and used for practicing the surgery by positioning Kirschner wires to mark the cutting planes. The angles between these were measured and adjusted until they matched the previously calculated angles. The models were then sawed along the cutting planes defined by the wires. The procedure of the training surgery was slightly altered for each model to find the best case-matching approach.

Results:

During the simulation of the surgery, the Kirschner wires were easy to place in the printed part, while sawing the models turned out to be difficult, due to the low melting temperature of the thermoplastic PLA. As it has been expected, the 3D-printing thermoplastic material behaves differently than real bone when it comes to sawing and drilling. However, practicing different variants of the supracondylar domosteotomy by means of 3D-printed bone models has turned out very useful for the planning and final execution of the surgery. The following clinical course was uneventful. The postoperative radiographs showed a good bony healing. The percutaneous Kirschner wires could be removed after 4 weeks in the outpatient clinic. Clinically, the varus angle was 20° preoperatively and 0° postoperatively. The elbow showed an improved range of motion and better cosmetic appearance. The lateral condyle was slightly prominent.

Conclusion:

Even though experienced orthopedic surgeons are familiar to work with X-ray images and datasets from CT, the possibility to plan a surgery with a real physical model of the deformity can increase the insight into the anatomical features of the affected bones. The proposed method shows, that 3D-printing enables to train a complex surgery on anatomical models, which precisely resemble the patient's anatomy. However, the choice of the material, which is used to produce the models, can be improved in order to allow for a more precise simulation and to mimic physiological properties of bones.

Laparoscopic resection of dysontogenetic liver cysts in children and infants

(Abstract ID: 31)

A. Schmidt¹, I. Tsiflikas¹, J. Fuchs¹, S. Warmann¹

¹Universitätsklinikum Tübingen

Background:

Dyosontogenetic liver cysts in children and infants are rare. The cysts are heterogeneous in histology and the diagnosis may define a simple cyst, intrahepatic choledochal cyst, complex biliary cyst, cystic mesenchymal hamartoma, or ciliated hepatic foregut cyst (CHFC). Asymptomatic cysts need no therapy, but especially large cysts may compress related vascular or biliary structures and cause symptoms such as pain, nausea or obstructive jaundice. Furthermore, CHFC contain a risk of malignant transformation to squamous cell carcinoma. Different nonsurgical and surgical procedures for the treatment have been described, including open and laparoscopic resection of the cyst. The use of minimally invasive surgery has been reported only in few cases. We present a series of laparoscopic resections of dysontogenetic liver cysts in children and infants.

Materials and methods:

Between 2005 and 2018, 7 children with dysontogenetic liver cysts underwent minimally invasive resection. We retrospectively analyzed patient data and surgical data, clinical course and outcome.

Results:

Median age of the 7 patients (4 girls and 3 boys) was 8 months (3 days - 6 years); 5 of them were younger than 1 year. Median body weight at surgery was 9.4 kg (2.9 - 15.5). The cysts showed a median diameter of 5.4 cm (3.8 - 7.9). A total excision was performed in 6 patients, a deroofing in 1 patient. Median time for surgery was 120 min (60 - 171). All procedures could be completed laparoscopically. In 3 cases, a puncture of the cyst was performed before resection, because of the size of the cyst. Histology was consistent with dysontogenetic cyst in all cases, without signs for malignancy. Median follow-up was 6.5 months (16 days - 38 months). The only complication we observed was bile leakage in one child which ceased after conservative therapy. No recurrence of the cyst was observed in any of the cases.

Conclusion:

Laparoscopic excision of dysontogenetic liver cysts is an attractive approach for surgical treatment of this pathology in children and infants. However, it is a demanding surgical procedure, which requires a decent patient selection as well as profound surgical skills.

Classical but not rap music significantly improves training of complex motor skills: A pilot RCT

(Abstract ID: 51)

S. Mietzsch¹, R. Bergholz¹, J. Boettcher¹, L. Klippgen¹, J. Wenskus¹, K. Reinshagen¹, M. Boettcher¹

¹Universitätsklinikum Hamburg-Eppendorf

Background:

Acoustic distractions have been shown to increase the level of stress and workload in the operating room. Noise significantly reduces surgical performance, but experienced surgeons are able to reduce the acoustic perception of their surroundings to maintain a high level of performance in complex surgical tasks. However, music is shown to improve learning and performance of complex motor skills like laparoscopic suturing. Aim of this study was to evaluate the influence of music on laparoscopic training.

Materials and methods:

To evaluate the effects of music on training, subjects were asked to perform four surgeon's square knots on a bowel model within 30 minutes - prior and post 3 hours of hands-on training. To examine long-term skills, the same students were asked to perform a comparable, but more complex, task (four slip knots in a model of esophageal atresia) 6 months post initial training as a follow-up measurement. Total time, knot stability (evaluated via tensiometer), suture accuracy, knot quality (Muresan scale), and laparoscopic performance (Munz checklist) were assessed.

Results:

Twenty-four students were included in the study; after simple randomization, sixteen were trained while exposed to music (eight to Bach and eight to Bushido) and eight with traditional methods. Seven were lost due to follow up. Both groups had comparable baseline characteristics and significantly improved after training, in all parameters assessed in this study. Subjects that trained with classical music were superior in terms of speed, knot quality, and procedural performance.

Conclusion:

Music during acquisition of complex motor skills, like laparoscopic suturing and knot tying, is superior to traditional training. Especially, music considered non-disturbing significantly improved speed, knot quality, and performance. Thus, one incorporation of pleasant music into surgical skills training and the OR should be considered.

Alternative thoracoscopic management of congenital pulmonary airway malformation with incomplete interlobar fissures

(Abstract ID: 280)

R. Vahdad¹, B. R. Wagner¹, P. D. Hoyer¹, V. Vasileiadis¹, B. vom Hofe¹, F. Obermayr¹, G. Seitz¹

¹Universitätsklinikum Marburg

Background:

The postnatal surgical management "thoracotomy versus thoracoscopy" of congenitial pulmonary airway malformation (CPAM) in children is still a topic of debates. A reduction in length of hospital stay, reduction in days spent with a chest tube, shorter hospital stay, better cosmesis and decreased postoperative pain was observed after the minimal invasive approach, but operative times are longer. The incomplete interlobar fissures (IIFs) are rare anatomical conditions. The thoracoscopic resection in case of IIFs is surgically challenging. The pulmonary vessels are not directly visible at depth. The fusion of the interlobar fissures makes identification of the pulmonary artery (PA) and pulmonary veins (PV) extremely difficult during thoracoscopic lobectomy (TL). Intraoperative bleeding and bronchial and pulmonary parenchymal injuries are not unusual. We describe in this study an alternative surgical procedure at TL for IIFs with the goal to facilitate of the operation complexity and reduction of complications.

Materials and methods:

Four children aged 6 months-60 months Mean: 9 +/- with CPAM and IIFs underwent TL from July 2016 to September 2019 were included in the study. Only 3mm instruments and a 5mm camera were used. The direct dissection and ligation of the PV at the hilum as first step can facilitate the identification of the PA on the hilum. The PA of the pulmonary lobe can be exposed und resected as a guiding structure in the IIFs. This procedure leads to the bronchus, which can be resected according stitch-ligation. Now, the fused fissures line can be safely sealed and resected by electro-hook. At the end of the operation a chest tube was placed. No stapler was used during the operation.

Results:

There were no intraoperative and postoperative complications according to the Dindo-Clavien classification. The mean operating time was 202 minutes. The mean ventilation time after surgery was 10.5 h. The chest tube was removed after 5,6 days. All patients recovered quickly and no respiratory symptoms occurred postoperatively. The mean follow-up time is 1.6 years.

Conclusion:

TL for IIS in children with CPAM can be performed thoracoscopically safely and successfully. The risk of bleeding and the risk of air leakage can be minimized by ligatures according to the described method.

Picture:

thoracoscopic lobectomy CPAM

The minimally invasive COHEN-procedure as treatment of vesicoureteral reflux in children

(Abstract ID: 545)

C. Kruppa¹, K. Schuchardt¹, G. Fitze¹

¹Uniklinikum Dresden

Background:

In the surgical treatment of vesicoureteral reflux the COHEN-procedure is well established as an elegant and standardized operation. The aim of this study was to evaluate if the implementation of a minimally invasive vesicoscopic approach is practicable and if it results in higher comfort for the patients than open surgery.

Materials and methods:

Since 2010 we have performed COHEN-procedure for vesicoureteral reflux in 115 children. 79 of them were treated vesicoscopically. All patients had a history of recurrent severe urinary tract infections.

Results:

The urological outcome was excellent in both groups with only one recurrent reflux in the vesicosopic group.

For the patients the endoscopy was combined with less postoperative pain, less painrelief medication, easy micturition, shorter stay in hospital and excellent cosmesis.

Conclusion:

To perform the endoscopic approach for the COHEN-procedure in reflux surgery is more challenging to the surgeon and has a longer learning curve than the open method. Once established the duration of the minimally invasive operation decreases rapidly and becomes acceptable compared to open surgery. Bilateral reflux can safely be treated in one step even in combination with double systems.

Most of the children needing an operative treatment of vesicoureteral reflux will profit by minimally invasive surgery. This endoscopic procedure will not be feasible in very small children or in patients with additional pathology when other operative principles are more suitable.

How to improve long-term outcome after minimal-invasive repair of congenital diaphragmatic hernia – a critical review of all cases in 10 years

(Abstract ID: 694)

K. B. Zahn¹, T. Schaible¹, L. Wessel¹

¹Universitätsmedizin Mannheim

Background:

In literature higher recurrence-rates have been reported for minimally invasive surgery (MIS) compared to open surgery (OS) already during the first hospital-stay. Also, higher recurrence-rates have been reported after MIS-patch-implantation and therefore the longterm-efficacy has been questioned. The purpose of this study was to critically review all patients operated within 10 years to draw conclusions how to improve long-term-efficacy.

Materials and methods:

Follow-up-data was collected prospectively within a longitudinal, structured follow-up program also comprising regular radiologic imaging and analzed retrospecively with a minimal follow-up of two years.

Results:

Between 2008 and 2017 100 patients were operated by MIS and survival was 100%. 92% were neonates and in 97% thoracoscopy applied. In 75% a primary repair was achieved, in 25% a non-absorbable patch was implanted. There was one in-hospital-recurence. 11 recurrences were observed after primary repair, 2 after implantation of a plane patch, and 1 after implantation of a cone-shaped patch. So far no patient with a 'sublay’-patch recurred. 3 recurrences were detected after 1 year, with one lethal incarceration.

Conclusion:

There are several surgical steps that help to prevent recurrence in the longterm: Hernial sacs should be resected. It is crucial to reduce tension on the diaphragm and implant patches more liberally. In cases of patch-implantation it is essential to promote adhesions between prosthetic material and diaphragm to prevent recurrence, because patients do not develop intestinal adhesions.

During follow-up radiologic imaging and parent-counseling are mandatory, because recurrence develops with growth and may not cause specific symptoms - but still bears the risk of intestinal incarceration, bowel gangrene and lethal septicaemia. With rising experience and meticulous technique recurrence-rates similar to those in open surgery seem to be achievable. Yet longterm follow-up until adulthood has to be awaited for final judgement on efficacy.

Fetus in Fetu: Lessons learned from a large multicenter cohort study

(Abstract ID: 42)

H. Taher¹, O. Muensterer², M. Abdellatif¹, A. Wishahy¹, S. Kaddah¹, A. Hussein¹, G. El Tagy¹, M. Elbarbary¹, S. Anis¹, S. Tawfik¹

¹Cairo University

²Universitätsmedizin Mainz

Background:

Fetus in Fetu (FIF) is an extremely rare condition ofabnormal twinning during embryogenesis. Most publications are singlecase reports. We describe the combined experience of four large tertiaryreferral centers with FIF which were not previously reported orpublished, and thereby draw conclusions to establish criteria for theworkup, diagnosis, and management including intra-operative risk.

Materials and methods:

A survey was forwarded to a national Pediatric Surgey groupwhich includes members from all Pediatric surgery Centers in the countryenquiring about unpublished cases of FIF encountered over a 20 yearinterval. The cohort was analyzed for age of presentation, type ofpresentation, diagnostic workup, surgical management, and outcome.

Results:

From 1998 until 2018, a total of 10 FIF cases were included inthe study. Mean age of presentation was 4 months. Computedtomography (figure a) and ultrasound were the main preoperative diagnostic modality in our cohort. Most masses had a distinct capsule resembling the ambiotic membrane (figure b and figure c, yellow arrow). FIF includes a more or less organized conglomerate of different organoid structures (figure c). Sometimes, an umbilical chord was also present (figure c, red arrow, figure d, black arrow). Resection of the mass was curative in 9 cases.Two cases in which the FIF was in direct topographic proximity to thebiliary tree suffered severe intra-operative or lethal postoperative complications.

Conclusion:

Pediatric surgeons should have a high index of suspicion for dealing with FIF if they encounter a mass with well-differentiated organs, a distinct membranous capsule, and an umbilical cord-like structure. Care must be taken to define the potentially variable vascular supply of the mass, and to make sure it does not adhere to vital structures of the host, particularly the biliary tract. In our series, the longest follow up was 5 years and the shortest follow up was 6 months. Complete excision of FIF is the treatment of choice andgenerally results in excellent long-term quality of life in survivors. Mortality is low.

Picture:

Fetus in Fetu is well defined on computed tomography (a). It is often enclosed by a glistening capsule (b) and consists of organoid structures (c). Sometimes an umbilical chord is present (arrow, d).

Proteus-Syndrome: Integra treatment and split-skin draft as an alternative to incomplete excisions

(Abstract ID: 340)

T. Kosk¹

¹Uniklinikum Dresden

Background:

Proteus-Syndrome is a rare genetically disorder characterized by overgrowth of organs and tissue. Typically this overgrowth is asymmetric with a great variety of patterns. The skin can be affected by a lesion known as cerebriform connective tissue nevus and occurs mainly on the soles of the feet. These skin malformations may lead to significant physical anomalies. Surgical treatment has been discussed in just a few reports indicating incomplete excisions for volume reduction.

Materials and methods:

In this case report we present a 14-year old girl with a cerebriform tissue nevus of the left sole of her foot as well as a megadactylia of her 4th toe. We performed a total exzision of the nevus and treated it with Integra dermal regeneration template. Four weeks later a split-skin graft was applied to the neodermal skin layer.

Results:

One month later 90% of the wound was healed well without signs of infection. The patient could start mobilizing the foot with an excellent aesthetic and functional outcome.

Conclusion:

In Proteus-Syndrome the treatment of cerebriform connective tissue nevi with complete exzision, Integra placement and application of a skin-split must be discussed as a surgical alternative to incomplete exzisions.