DGKCH/DGNC: Treatment of the hydrocephalus
(Neuro)-Surgical management and consecutive outcome for posthemorrhagic hydrocephalus in premature neonates
C. Bock1, J. Feldmann1, H. Ludwig1
1Universitätsmedizin Göttingen, Göttingen
Background:
Intraventricular haemorrhage (IVH) in premature neonates may lead to severe neurological disability and life-long treatment requirement of posthemorrhagic hydrocephalus (PHHC). Preterm infants are at not only at high risk for different perinatal- but also for hydrocephalus-related complications in the long view. Early Cerebrospinal fluid (CSF) diversion as a temporising measure, or a permanent ventriculoperitoneal shunt in case of manifest posthemorrhagic hydrocephalus is the treatment of choice. Until today no comprehensive evidence-based guidelines exist for the surgical strategy for preterm neonates in regard to recommended time point or type of surgical procedure.
Materials and methods:
By using our institutional Hydrocephalus and Shunt Registry with more than 500 registered paediatric patients, we retrospectively analysed our institutional surgical management standard for preterm newborns of different gestational age presenting with IVH and posthemorrhagic ventricular enlargement. Depending on body weight, extent of head circumference increase and current general clinical condition, patients received implantation of ventricular access devices (VAD) and/or VPS insertion as first line treatment. Clinical course was analysed in regard to rate and aetiology of complications and revision-free shunt survival.
Results:
A total collective of 98 preterm newborns (gestational age 22 to 36 weeks, birth weight 535 to 3600g) and a median follow-up interval 9.9 years post partum could be selected for further investigation. Extent of perinatal IVH was found grade I in 1%, grade II in 24%, grade III in 38% and periventricular hemorrhagic infarction in (PVHI) in 37% of the patient collective. 52% of all patients required first neurosurgical intervention within the first 30 days and 90% within the first 6 months post partum. 75 patients (77%) underwent VAD insertion and repeated CSF puncture as initial surgical treatment, in 71 of these permanent VPS insertion was necessary. 23 patients (23%) met the conditions for direct VPS insertion. Median revision-free shunt survival was found 22.3 months for preterms with previous VAD insertion and 42.2 months for those with direct VPS insertion.
Conclusion:
Premature neonates with IVH show high incidence for consecutive posthemorrhagic hydrocephalus and are at higher risk for early and repeated VP-shunt compliction than mature infants with different hydrocephalus aetiology. Temporising measures via VAD represent a rational strategy to gain time in immature newborns before permanent VPS insertion. A systematic prospective institutional registry provides reliable data to analyse pattern of care and surgical outcome for this delicate group of paediatric patients.
Laparoscopic abdominal v.-p.-Shunt revision in children using a SILS technique (Ei-Optik)
O. Deffaa1, U. Bühligen1, M. Weißer1, M. Lacher1
1Universitätsklinikum Leipzig, Leipzig
Background:
Abdominal v.-p.-shunt revisions due to shunt disconnection, too short peripheral catheters, malresorption or intraperitoneal pseudocysts account for about 1/3 of all v.-p.-shunt-revisions. Since open abdominal shunt revision causes many problems (difficult location of the abdominal catheter, hindered placement of the new catheter especially in adipose patients or patients with a severe deformity of the spine e.g. myelomeningocele, infections) laparoscopic abdominal shunt revision has been used in our institution since 1996. We present our experience with single-incision-laparoscopic-surgery (SILS) abdominal shunt revision from November 1996 to July 2016.
Materials and methods:
Laparoscopic shunt revision has been performed since November 1996 and since the year 2000 we use a SILS-technique with a 5.5 mm optical system and integrated 3.5 mm working channel (“Ei-Optik”, 5.5 mm Surgical Laparoscope, Fa. Richard Wolf). Two techniques were used for laparoscopic catheter revision: a) An unused peripheral catheter is connected via a cervical incision to the dysfunctional catheter which is then grabbed intracorporeally and removed via the working channel. The new catheter can then be placed und laparoscopic guidance into the lesser pelvis b) If the pull-through is not possible (e.g. in case of disconnection of the peripheral catheter) a new peritoneal puncture with a split-catheter can be placed safely under laparoscopic guidance.
Results:
Between 11/1996 and 08/2016 a total of 95 abdominal shunt revisions were performed in children aged from 2 - 17 years. The causes of shunt dysfunction were growth-related shortening of the peripheral catheter in 63 patients (66%), disconnection/ rupture of the peripheral catheter in 17 children (18%), peritoneal pseudocysts in 11 cases (12%) and suspicion of abdominal CSF-malabsorption in 4 children (4%). Operation time varied from 17 to 150 minutes. No shunt infection was detected within the immediate postoperative course of 30 days. There was no intraoperative bowel injury. In 6 cases laparoscopic implantation of the peripheral shunt system was not possible due to peritoneal pseudocysts (4 cases) and significant small bowel adhesions (2 cases). In 5 of these patients a ventriculo-atrial shunt was placed. In one child the abdominal catheter had to be removed via open laparotomy due to extensive adhesions. In 4 patients the procedure had to be converted to multitrocar laparoscopy for destruction or fenestration of pseudocysts.
Conclusion:
Laparoscopic abdominal shunt revision is safe and feasible. The single-port approach used in this study is a suitable truly minimally invasive technique with low morbidity and fast postoperative recovery.
DGKCH/DGPRÄC: Current treatment in burns: cooperation/transition
Breast development and the need of surgical correction after chest scalding in toddlers
K. Schriek1, M. Sinnig1, B. Ludwikowski1
1Kinder- und Jugendkrankenhaus AUF DER BULT, Hannover
Background:
Burns to the chest in young children are common. In the toddler group, scalds are the most frequent cause for presentation at burn units. Chest burns in pre-pubescent children, especially girls, are at risk of significant long-term problems with scarring and breast development requiring reconstructive surgery many years after the initial burn.
Materials and methods:
We reviewed the admissions to our burn unit over a 16-year period: From the total number of 6545 children, who were admitted between 2000-2015, 1234 pediatric patients (550 f: 684 m) suffered chest scaldings or burns.
Results:
In our presentation we determine the frequency of split skin grafting as well as the period of compression garments. We especially focus on the need of further reconstructive surgery during the breast development in girls (289) and boys (407) during puberty.
DGKCH/DGU: Lower extremity injuries
Microsurgical Therapy of Congenital Pseudarthrosis of the Tibia with free vascularized Fibula Flap– Results, Experiences and Technical Refinements
L. H. Evers1, P. Schmid1, H. Mellerowicz1, M. Greulich2, U. von Fritschen1
1Helios Klinikum Emil von Behring Berlin, Akademisches Lehrkrankenhaus der Charité Universität, Berlin
Background:
The reconstruction of elongate tibia bone defects especially in our pediatric patients with congenital pseudarthrosis of the tibia (CPT) is a major surgical challenge. A differentiated and complex therapy concept is mandatory to achieve a long lasting and stable result. The free vascularized fibula flap for tibia replacement of the contralateral side represents a demanding microsurgical option, however its single stage concept has several advantages in comparison to multi stage procedures.
Materials and methods:
Here we present our institutional experience with a total number of 6 patients with extensive tibia defects. We performed 6 microsurgical contralateral Fibula-pro-Tibia operations in these patients for the salvage of the lower extremity. These cases consist of 6 congenital pediatric tibia deformities (median age 7.2 years), which required a microsurgical fibula transfer. Alternative reconstructive options were exhausted prior to this surgery. The follow-up was at least 9 months and the cases were collected over a time period of 5 years.
Results:
All 6 performed microsurgical Fibula-pro-Tibia operations had a successful outcome. We were able to monitor these free flaps with an ultrasound Doppler signal in all cases. The transferred fibular flaps healed without major complications. The radiologic long term results showed a sufficient bony healing and an axis conform position of the fibula. The patients showed a good bearing quality in terms of mechanical load stability of the neo-tibia and symmetric walking properties.
Conclusion:
The microsurgical Fibula-pro-Tibia operation represents especially in pediatric patients a sophisticated and elegant reconstructive alternative in comparison to long lasting multi stage techniques. Our results show, that a single stage operation is able to achieve a permanent reliable and stable result with adequate mechanical properties and sustainability.
DGKCH: The special case
Bilateral tibial Caffey's disease: benign, but tricky
L. Graumann1, D. Zovko1
1UKGM GmbH, Standort Marburg, Marburg
Background:
We report of a very rare case of Caffey’s disease in both lower legs in a 4 month old child.
Materials and methods:
After establishing the diagnosis of bilateral tibial cortical hyperostosis this child was treated conservatively and is still followed-up closely. The present outcome is good.
Results:
Caffey’s disease is a temporary benign infantile osteopathy of unknown origin with rare complications depending on the skeletal site of affection.
Conclusion:
Diagnosis of Caffey's disease sometimes can be challenging. Our case and contemporary world literature’s knowledge are presented.
DGKCH: Forum young pediatric surgery: surgical education - changes - problems - new models
Challenges of training pediatric surgeons for the future– a transatlantic perspective
O. Muensterer1
1Universitätsmedizin Mainz, Mainz
Background:
Pediatric surgery is a relatively young surgical specialty. In the developed world, the combination of low index case volume, work hour restrictions, and an increased number of training slots is progressively eroding pediatric surgical education.The purpose of this study is to characterize the current challenges of pediatric surgical training in western countries and propose potential solutions.
Materials and methods:
Demographic data on birth rate, case volume, number of available postgraduate positions, training structure, along with weekly maximal work hours was extracted from published national statistics in Germany, the United States, and other European nations. Available literature on pediatric surgical training was compiled and analyzed.
Results:
Pediatric surgery training in developed countries faces very similar challenges, including index case volume dilution, a growing number of training positions, and decreasing clinical exposure intervals, particularly in the operating room.
Conclusion:
In order to produce competent and experienced pediatric surgeons in the future, the training structure will have to evolve. Potential solutions include longer training intervals, a two-tier certification program (general pediatric surgery and neonatal/specialty certification), substantial limitation of available training positions, or planned mandatory rotations in countries with high case volume. In any case, the current status quo does not seem sustainable in the long-run.
Halsted’ ‘see one, do one, and teach one’ versus Peyton's’ Four-Step-Approach– A randomized trial for training of laparoscopic suturing and knot tying
P. Romero1, F. Nickel1, P. Günther1
1Universitätsklinikum Heidelberg, Heidelberg
Background:
Minimally invasive surgery (MIS) skill labs offer a safe training environment outside the operating room for new surgeons to practice techniques without compromising patient safety. Although many MIS training modalities exist, the best methodology for teaching intracorporeal suturing and knot tying (ICKT) remains unclear. The aim of this study was to compare the effectiveness of Halsted’s method of “see one, do one, and teach one” with Peyton’s Four-Step Approach for teaching ICKT to medical students.
Materials and methods:
Medical students (n=60) between their third and sixth year of studies with no prior experience in laparoscopy were divided into two groups, one (n=30) which was taught with Halsted’s method and the other (n=30) with Peyton’s method. Participants received 60 minutes to practice ICKT in a laparoscopic box trainer with designated assistance. A single observer evaluated each student’s first three sutures and final suture. Objective Structured Assessment of Technical Skills (OSATS), divided into a procedure-specific checklist (PSC) and a global rating scale (GRS), was used in addition to procedural implementation, knot quality, total time and suture placement accuracy as parameters for assessment.
Results:
After intergroup comparison, performance score and OSATS-PSC significantly differed between the Peyton and Halsted groups in favor of Peyton’s group for each measured suture (p=0.001). OSATS-GRS differed only in the summary of the first three sutures in favor of Peyton’s group (p=0.01). Task time significantly differed between both groups for the first three sutures in favor of Peyton’s group (p=0.03). However, task time for the last suture was similar for both groups. There were no significant intergroup differences in knot quality and accuracy for each measured suture.
Conclusion:
The procedural scoring of Peyton’s group was superior to Halsted’s group. Peyton’s Four-Step Approach appears to be the preferable method for learning complex laparoscopic skills like ICKT.
DGKCH: Research in pediatric surgery
The professional spectrum of pediatric surgery departments in German-speaking countries – an analytical survey on the present status quo
R. Loucas1, O. Muensterer1, M. Loucas1
1Universitätsklinik Mainz, Mainz
Background:
During the 2nd half of the 19th century, pediatric surgery developed as a separate subspecialty in Germany. Pediatric surgeons are considered the last generalists, who operated on a large spectrum of indications in children. Nevertheless, in recent decades, some areas (urology, neurosurgery, others) are seemingly drifting into the respective disciplines. Traditionally, pediatric surgery was a key player in the development of innovative endoscopic and minimally invasive techniques.
The aim of this study is to determine the current spectra of subspecialties and techniques performed among pediatric surgery departments in German-speaking countries.
Materials and methods:
A detailed survey on the current range of subspecialties offered was sent to the chief surgeons of all pediatric surgical units in Germany, Austria, and Switzerland by email and postage. The survey also covered endoscopic and minimalinvasive techniques employed. The results were statistically evaluated.
Results:
Of 94 departments contacted, 69 replied with complete datasets (recall 73%). Practically all units perform pediatric general abdominal and neonatal surgery, while urology, plastic surgery, burn surgery, traumatology and tumor surgery is no longer performed in about one fifth of queried centers (Figure 1). Only about one-third of pediatric surgeons in Germany still offer neurosurgery, thoracic surgery, hepatobiliary surgery or pediatric gynecology. The most commonly performed operations performed using minimalinvasive methods in German speaking countries are cholecystectomy (91%), appendectomy (81%) and splenectomy (44%), while the correction of a diaphragmatic hernia (20%), inguinal hernia (13%) and esophageal atresia (11%) are performed less frequently minimalinvasively. Almost all pediatric surgeons do cystoscopy (97%) and esophagoscopy (85%), but only about half of them perform bronchoscopy (51%) and colonoscopy (61%). There are distinct geographical variations in the spectrum.
Conclusion:
Most pediatric surgery departments in German-speaking countries still offer a very wide spectrum of pediatric surgical subspecialty care, ranging from newborn surgery through urology to plastic reconstructive surgery. In contrast, neurosurgery, thoracic surgery, hepatobiliary surgery and pediatric gynecology have been widely taken over by adult subspecialists. Standard operations, such as appendectomy and cholecystectomy, are usually performed by minimalinvasively in German-speaking countries.
Importance of determining the position of the blind upper pouch in infants with esophageal atresia
R.-B. Tröbs1, J. Wald1
1Marienhospital Herne, Klinikum der Ruhr-Universität Bochum, Herne
Background:
X-ray examination of the upper pouch is part of the routine preoperative examination of infants with esophageal atresia (EA) and tracheoesophageal fistula (TEF). The purpose of the presented study was to examine the variability of the upper pouch position regarding the operation.
Materials and methods:
We examined the position of the upper pouch in preoperative chest x-rays. Morphometry was performed on roentgenograms of 23 infants wit EA (21 distal TEF, 3 proximal and distal TEF, 2 pure EA). We estimated the projection of the caudal end of the upper pouch in relation to the thoracic vertebra. For estimation of the diameter of the pouch we applied the pouch - vertebra ratio (transverse diameter pouch/diameter underlying vertebra).
Results:
The tip of the upper pouch was mainly located at the level of the 3rd thoracic vertebra (level 2.7 ± 1.1 vertebrae). The position varied between the upper border of the first thoracic vertebra and the middle of the 6th vertebra. Near identical levels were found for infants with body weight below (n=5) or above (n=18) 1500g (level 2.5th vs. 3rd vertebra) and for cases with normal anastomotic tension (n=15) vs. high tension (n=8) (identical level at the 3rd vertebra).
Conclusion:
The level of the upper pouch is nearly constantly found at the level of the second and third vertebra. Flexion or extension of the neck influences the upper pouch position (animal experiments).
There might be a trend to a more caudal position in infants below 1500g.
In conclusion, the radiological projection of the upper pouch cannot predict the tension of the anastomotic site. The distance of the segments is mainly affected by the variability of the TEF and the caudal segment of the esophagus.
Regulatory T-cells as novel immune markers in acute appendicitis
S. Holland-Cunz1, L. Sucic1, V. Galatier1, U. Kym1, V. Pfeifle1, S. Keck1
1Universitätskinderklinik beider Basel, Basel
Background:
Inflammatory bowel diseases are characterised by excessive inflammation and defective regulatory immune responses. It has been reported that appendicitis is involved in the prevention of colitis. The appendix is acting as a “safe house” for commensal bacteria, facilitating re-inoculation of the colon after intestinal infections. Further, commensals are essential for the induction of commensal-specific regulatory T cells (Tregs) preventing an immune reaction against the normal flora and regulating excessive immune responses towards dangerous pathogens. In a murine study researchers demonstrated that Tregs were induced in the course of appendicitis and protected the mice against subsequent chemical induced colitis. However, Tregs in children undergoing an appendectomy have never been evaluated.
The aim of this study is to investigate the presence of regulatory T cells in acute appendicitis from children operated at the UKBB Basel.
Materials and methods:
The frequency of regulatory T cells was evaluated in inflamed and non-inflamed regions within the same patient by fluorescent immunostaining. For the first time, we determined Treg frequencies using a defined high-troughput cell image analysing programm (cell profiler) and compared it to traditional time consuming double-blinded visual counting.
Results:
We found in all probed patients an increased Treg frequency in the inflamed dome region. Further, evaluating Tregs by the imaging software generated reliable and fast results compared to traditional manual counting.
Conclusion:
With establishing the method of quantifying Tregs in inflamed appendical tissue it will be possible to perform further studies in basic research. However, regarding the expression of functional immunological reaction in intestinal tissue the presented datas offering a reliable method that could be developed as a diagnostic tool.
Catheter obstruction after implantation of peritoneal dialysis catheter may depend on entry site
J. Radtke1, R.-R. Ridwelski1, M. Reismann1, B. Nashan2, K. Rothe1, M. Koch2
1Charité - Universitätsmedizin Berlin, Berlin
2Universitätsklinikum Hamburg-Eppendorf, Hamburg
Background:
Peritoneal dialysis (PD) is a preferred dialyzing method in children with renal insufficiency. Surgical complications after implantation of peritoneal dialysis catheters are estimated to be 30-40% during the first 8 weeks. Peritonitis and obstruction are the most common complications in the literature.
Materials and methods:
We retrospectively analyzed 154 PD catheters, which were implanted by transplant surgeons (University Medical Center Hamburg-Eppendorf, UKE, Hamburg) and pediatric surgeons (Charité-University Medicine Berlin, Berlin) in 124 children during 2009-2015 (median age 3.0 years; range 0.01-17.1 years; acute renal failure, ARF n=65; chronic renal failure, CRF n=89). Incidence of complications during the first 6 months after implantation was studied.
Results:
Peritonitis and obstruction occurred in 33 (21.4%) and 30 (19.5%) cases, respectively. Leakage (n=18 catheter) occurred more often in children with less than 10 kg of weight (p<0.001). Incidence of obstruction was significantly higher in pediatric surgery (n=21, 30.4%) in comparison to transplant surgery (n=10, 11.8%; p=0.004). Catheters with obstruction were more often implanted in the middle abdomen whereas catheters implanted in the lower abdomen were less likely affected by obstruction.
Conclusion:
Smaller children are more likely affected by leakage whereas operation technique may result in an elevated incidence in obstruction. Nevertheless, implantation of PD catheter is feasible in most children.
Surgical treatment of patients with congenital adrenal hyperplasia
M. Ardelean1, C. Schimke1, G. Brandtner1, R. Metzger1
1SALK, Paracelsus MedizinischePrivatuniversität, Salzburg
Background:
The aim of this study was to evaluate the feminizing genitoplasty in patients with congenital adrenal hyperplasia (CAH) due to 21-hydroxylase deficiency.
Materials and methods:
Twelve 46, XX patients with virilization by CAH (DSD-CAH-patients) have been corrected surgically (2008-2016). All patients receive hormone replacement therapy. Three patients had Prader stage III, six Prader stage IV and three Prader stage V virilization of external genitalia. “One-stage” correction (urethro-vaginoplasty, clitoroplasty, and labiaplasty) was performed in ten patients and “two-stage” correction in two patients.
Results:
The urethro-vaginoplasty was performed in all patients by total urogenital mobilization: between 1.5 and 3 years of age in nine patients, at 7 years- , at 15 years- and at 18 years in one. In ten patients the clitoris and the labia were simultaneously corrected. In the 15-year-old- and in the 18-years-old patients the clitoroplasty was been carried out before 2 years of age. The follow-up included clinical and endoscopic evaluation. Outcome criteria were: appearance of the clitoris, of the labia, of the vagina and urinary continence.The cosmetic results of the clitoris and labia are satisfactory in all patients. Eleven patients have a physiologically-sized vagina. In the 7-year-old Prader-V-patient the introitus is relatively narrow (Hegarstift 6). All patients are continent.
Conclusion:
The total urogenital mobilization allows the urethro-vaginoplasty and preserves the urinary continence in DSD-CAH-patients. “One-stage” correction in an infant leads to good functional and cosmetic results.
Prognostic value of PELD score in children with Biliary Atresia
O. Loose1, L. Hofstetter1, U. Utpatel2, M. Melter2, C. Knorr1
1St. Hedwig, Regensburg
2Universitätsklinik Regensburg, Regensburg
Background:
To decide wether children with biliary atresia profit from Kasai procedure as bridge to transplant or would be better treated with primary liver transplantation depends from different factors. Prognostic parameters of the disease process in children with BIliary Atresia do not yet exist. The objective of this study is to evaluate the correlation of PELD Score and histopathological findings with the outcome after Kasai procedure.
Materials and methods:
A retrospective study was carried out for all patients who underwent Kasai procedure between 2009-2015. A total of 26 patients were analyzed for clinical and biochemical data, immunohistochemistry (Cytokeratin 7) for bile duct proliferation and the ISHAK score for liver fibrosis.
Results:
The study included 39 patients with suspicion on Biliary Atresia. 26 cases were confirmed, beneath this 13 male and 13 female patients and were treated with Kasai procedure. 8 children underwent immediate liver transplantation, five patients went back to their home hospital for further therapy after diagnosis through ERCP in our institution. The average age at kasai procedure was 52 days (16-91), the median time for undergoing liver transplantation (21 patients) was 152 days (28-336), five patients had no need for transplantation until now. ALT/AST levels were significant correlatet with time of kasai procedure.
Conclusion:
Finding a prognostic tool to support decision making in the therapeutic way and inform the parents better about the disease pattern is important. Final evaluation will be made after having finished the histopatological investigations and will be presented at the congress.
White Blood Cell Count Patterns Reflect Hereditary Immunological Conditions in Childhood Appendicitis
M. Reismann1, M. Minderjahn1, J. Radtke1, K. Rothe1
1Charité - Universitätsmedizin Berlin, Berlin
Background:
Phlegmonous appendicitis has been shown to be dependent on the activity of Th2 cells, while advanced (gangrenous and perforated) inflammation is associated with Th1 and 17-dependent mechanisms. The severity marker neutrophil-to-lymphocyte ratio (NLR) is probably strongly affected by these processes. The aim of the present study was to investigate how far these hereditary conditions are reflected in peripheral blood counts of affected children.
Materials and methods:
All patients aged between 7 and 17 years who underwent appendectomy from January 2008 till June 2016 were retrospectively reviewed. Peripheral blood counts of patients with phlegmonous (ph), gangrenous (gg) and perforated (pf) appendicitis were analysed. According to current evidence, relative eosinophilia was interpreted as Th2-associated pattern and relative neutrophilia, monocytosis and basopenia as Th1-/Th17-dependent patterns. To find evidence for hereditary conditions, first degree familial associations were investigated. NLR was given special consideration. Level of significance was p <= 0.05.
Results:
646 children with clear histological evidence for appendicitis were included in the study. Mean neutrophil and monocyte counts in children with gangrenous and perforated appendicitis were increased compared with patients with phlegmonous appendicitis (13.4 ± 4.1 x 109/L (gg) and 13.5 x 3.8 x 109/L (pf) vs. 11.6 ± 4.5 x 109/L (ph), p<0.001; 1.23 ± 0.43 x 109/L (gg) and 1.14 ± 0.5 109/L (pf) vs. 0.93 ± 0.33 x 109/L (ph), p=0.0001). Relative eosinophilia and basophilia was found in phlegmonous inflammation (0.11 ± 0.19 x 109/L (ph) vs. 0.04 ± 0.07 x 109/L (gg) and 0.05 ± 0.1 x 109/L (pf), p<0.05; 0.033 ± 0.031 x 109/L (ph ) vs. 0.027 ± 0.024 x 109/L (pf), p < 0.05). Mean lymphocyte counts were significantly reduced in patients with advanced appendicitis (1.45 ± 0.78 x 109/L (gg) and 1.27± 0.59 x 109/L (pf) vs. 1.8 ± 0.83 x 109/L, p<0.01). Mean NLR correlated significantly with advanced disease. There were significant family-associated differences especially in Th17 dependent subpopulations.
Conclusion:
Peripheral blood count patterns in children with acute appendicitis comply with the view of Th2 and Th1/17 dependent immunological mechanisms for phlegmonous and advanced appendicitis, respectively. Lymphocytopenia and increased NLR are associated with enhanced inflammation. The significance of familial associations suggests hereditary conditions.
Simultaneous serial transverse enteroplasty and small bowel transplantation to overcome the challenges of size-mismatch between adult small-bowel donors and pediatric recipients: Investigating the feasibility of this approach in a chronic porcine model
G. Frongia1
1Chirurgische Universitätsklinik Heidelberg, Heidelberg
Background:
The availability of pediatric donor organs is limited. Adult donor organs can be used for pediatric small bowel transplantation (SBTX) when size-matched donor organs are not available. In such cases, a simultaneous serial transverse enteroplasty (STEP) can address the challenging size-mismatch between donor organs and the recipient. The aim of the present study was to assess for the first time the technical and clinical feasibility of simultaneous STEP and SBTX for the first time in a chronic porcine model.
Materials and methods:
Following recipient enterectomy, a SBTX was performed using 60 cm intestinal segments. Three different size-ratios were studied between donors and recipients: size-matched, size mis-matched, and size mis-matched + STEP (each n=8). The morbidity and mortality, and the clinical, biochemical and functional outcomes were compared after an observation period of two weeks.
Results:
It was technically feasible to simultaneously perform a STEP and SBTX of a primary mis-matched intestinal segment. The postoperative clinical course with stepwise transition to a normal diet was uneventful. No signs of bleeding, leakage, stenosis, or ileus were observed and the operated intestinal segment was well perfused at relaparotomy. Decreased body weight was observed in all groups, but the percentage decrease was lowest in the mis-matched + STEP group. With equal vital enterocyte masses were between the groups, as shown by similar citrulline levels between the groups (p=0.548), the level of the nutritional marker transferrin was highest in the mis-matched + STEP group (p=0.049).
Conclusion:
We have demonstrated for the first time that a simultaneous STEP and SBTX procedure is technically feasible and clinically usable in overcoming the challenges associated with a size-mis-matched SBTX from adult to child. Our short-term findings justify further investigation in a larger series to elucidate the long-term outcome of this procedure.
DGKCH: Pediatric oncology
Complications of central venous access devices in children: The influence of catheter tip position
S. Hofmann1, J. Gödeke1, O. Beck1, J. Faber1, O. Muensterer1
1Universitätsmedizin Mainz, Mainz
Background:
Reliable longterm central venous (CV) access is extremely important in the management of pediatric oncologic patients. However, there is no universal consensus for optimal catheter tip location in children. This study analyzes the risk of complications associated with longterm central venous access in relation to location of the catheter tip.
Materials and methods:
From 2005 until 2015, oncologic pediatric patients with longterm central venous access devices and radiographic documentation of the tip location were retrospectively included in the study. Data on demographics, catheter tip location on chest X-ray, as well as intraoperative and postoperative complications were extracted. Catheter tip location was categorized as high (above the right mainstem bronchus), medium (at the level of the bronchus), and low (below the right mainstem bronchus).
Results:
A total of 191 patients were included in our study (mean age 7.5 years). Thirty-seven complications were recorded. Blood stream infections (n=15, 8%) were most prevalent with catheters in the medium location and equally distributed among catheters placed in high and low position. Dislocations (n=14, 7%) were least likely to occur with low-positioned catheters. Less frequent complications were thrombosis (n=2, 1%) and pulmonary embolism (n=2, 1%). No cases of cardiac perforation, arrhythmia, or myocarditis were recorded in our series.
Conclusion:
Catheter tip position seems to impact on complication profile. While infection does not seem to be influenced by catheter position, dislocation may be less likely in low-positioned catheters. Other complications are rare in children.
Multiphoton Microscopy: Diagnostic Potential for Solid Tumors In Children
S. Waldron1, J. Gödeke1, C.-D. Ries1, L.-M. Sehls1, F. Simon1, O. Muensterer1
1Universitätsmedizin Mainz, Mainz
Background:
Recurrence and prognosis of solid tumors in children depend heavily on precise resection margins. So far, the extent of resection is based on macroscopic features, intraoperative biopsies, or palpatory feedback. Intraoperative frozen section biopsies are less accurate than permanent stains and prolong the operation due to their processing time. Multiphoton Microscopy (MPM) is a novel, real time imaging technique that allows imaging of live tissue up to 1mm in depth. It may be useful for intraoperative intraoperative diagnostics and the determination of clear margins. Three-dimensional real time imaging of tissue could provide immediate feedback to the surgeon on resection margins. So far, however, it is unknown if pediatric solid tumors can be imaged accurately by MPM.
Materials and methods:
In a variety of pediatric solid tumors, we prepared tissue slides of the same resected tissue for conventional microscopy and MPM. We also performed imaging using MPM directly through the capsule. Both imaging modalities were compared via an independent Pathologist. The visibility of typical histologic criteria for the specific tumors were graded and compared.
Results:
Side-by-side qualitative comparisons were performed on ganglioneuroma (GN), pleuropulmonary blastoma (PPB), hepatocellular carcinoma (HCC), adrenal adenoma (AA) and nephroblastoma (NB). Comparison for the tumor-specific findings are seen in table 1. Overall, there was excellent congruency of conventional light microscopy and MPM.
Tumor | Features | Lightmicroscopy | MPM |
---|---|---|---|
GN | - Ganglion cells in stages - Nests of neuroblasts | +++ + | +++ ++ |
PPB | - Cells small, lack of cytoplasm - Nucleus round/ovoid - Nucleus hyperchromatic - Prominent fibrovascular septum | +++ +++ ++ + | +++ +++ ++ + |
HCC | - Trabecular formations - Pleomorph, unordered cells - Pseudocapsule - Clear intercellularmargins | +++ ++ + | +++ +++ ++ |
AA | - Spongiocytes (lipoid granula) - Pseudocapsule - Clear intercellular margins | +++ ++ ++ | ++ +++ +++ |
NB | - Unordered tubules - Epithelial component - Solid tumor cell accumulations - Mesenchymaldifferentiation | +++ +++ +++ ++ | +++ ++ +++ ++ |
Conclusion:
Diagnostic capabilities of MPM in the diagnostics of solid pediatric tumors is comparable or superior to conventional methods. It is capable of visualizing the tumor-typical features both on sectional specimens and through the tumor’s capsule. Before MPM can be applied in the clinical setting, however, further investigation and optimization of the imaging parameters is necessary.
AQP1 influences water permeability and cell motility
S. Gros1, M. Lomorra2, U. Kym1, V. Pfeifle1, C. Palivan2, S. Holland-Cunz1, S. Gros1
1Universitäres KinderspitalBeider Basel, Basel
2University of Basel, Basel
Background:
Cell water permeability has been implicated in mechanisms of tumor cell migration and agility. Aquaporin 1 (AQP1) is a water channel that is up regulated in several solid tumors. The aim of this study was to elucidate how AQP1 expression influences functional behaviour of neuroblastoma cells.
Materials and methods:
Cell permeability of neuroblastoma cells was visualized using confocal microscopy and quantified using stopped flow analysis. For assessment of AQP1 dependent cell motility AQP1 knockdown cells were compared to AQP1 positive cells.
Results:
AQP1 expression significantly changes cell permeability as measured by stopped flow analysis. This effect can be visualized by confocal microscopy. There are significant differences in cell motility depending on different levels of AQP1 expression and AQP1 localization.
Conclusion:
Neuroblastoma cell permeability and motility is influenced by the different levels of AQP1 expression thus modifying their ability to move. The potential of tumor cells to adapt their behavior with changing AQP1 expression might significantly contribute to tumor cell migration and metastases.
Rhabdomyosarcoma Mimicking Bladder Prolapse in a Girl with Persistent Cloaca and Vesicostomy
L. Gindner1, T. M. Boemers1
1Kinderkrankenhaus Köln, Köln
Background:
In children with persistent cloaca, urinary diversion by formation of a vesicostomy can be necessary in selected cases. Especially in girls with an obstructive common channel this is an option for temporary urinary diversionprior to operative reconstruction of the cloaca. Mucosal prolapse is a common complication of vesicostomy. In some cases revisional surgery is necessary. We present a case of an 18 month old infant with persistent cloaca and highly hypoplastic common channel in whom we performed vesicostomy. Initially the child was doing well, but after one year recurrent mucosal prolapse of the vesicotomy led to several operative interventions. However, the mucosal protrusion got worse and posed a significant problem we had not encountered so far. Several biopsies were taken and sent for pathologic workup, but showed no atypical tissue alterations. Finally the child was planned for closure of the vesicostomy and early bladder augmentation. During this operation the mucosal changes resembled a rhabdomyosarcoma, so that again biopsies (frozen section) were sent to the pathologist. These samples confirmed our clinical diagnosis of rhabdomyosarcoma. Continent diversion was therefore cancelled and instead a chemotherapy was initiated. As to our knowledge this is the first case of rhabdomyosarcoma developing in a vesicostomy as well as in a girl with persistent cloaca. This case report aims at demonstrating the pitfalls associated with this rare and unusual case.
DGKCH: Pediatric urology: heydronephroses
Endoscopic treatment of vesicoureteral reflux in complete duplex systems
A. Schmidt1, E. Ellerkamp1, T. Luithle1, J. Fuchs1
1Universitätskinderklinik, Tübingen
Background:
Before 2001, therapy of vesicoureteral reflux (VUR) in complete duplex systems consisted of long-term antibiotics or open surgery by ureteral reimplantation. Meanwhile, endoscopic treatment of VUR has been established in renal single systems. In duplex systems this therapeutic approach is still controversially discussed, especially in the case of high grade VUR (grade III - V).
Materials and methods:
In a retrospective study, we analyzed all children with VUR and complete duplex system, who were treated by endoscopic injection in our department between 2005 and 2016. Whenever possible the subureteral transurethral injection (STING) method and the hydrodistention implantation technique (HIT) were used. 6 weeks after intervention every child had a 99mTc-MAG3 scan. If urinary tract infections occurred again, a voiding cystourethrography was performed. Cure was defined as the absence of urinary tract infections and the absence of VUR respectively.
Results:
In 28 children with complete duplex system and VUR 35 endoscopic injections were performed. Median age was 25.5 months (6 - 119). In 23 cases the lower pole, in 2 cases the upper pole and in 5 cases both poles were treated for VUR. There were no associated complications. We treated 1 grade I VUR, 7 grade II VUR, 17 grade III VUR, 9 grade IV VUR and 1 grade V VUR. Median follow-up time was 20 months (1 - 92). 3 children required treatment due to relapse of VUR. 2 children with initially grade IV VUR had open ureteral reimplantation and 1 child with initially grade III VUR had laparoscopic heminephrectomy of the lower pole.
Conclusion:
Endoscopic treatment of VUR in complete duplex systems was successful in 86% of all cases. Children with low-grade VUR could all (5/5) be cured by this technique. In the high-grade group the success rate was 83% (19/23). In conclusion, our results suggest that endoscopic treatment of VUR, even in case of high-grade VUR, is a reasonable therapy.
DGKCH: Responsibilites and challenges in the surgical treatment of migrants
The health status of minor Refugees: a cross-sectional study
M. Loucas1, O. Muensterer1, R. Loucas1
1Universitätmedizin Mainz, Mainz
Background:
Recently, there has been a sharp rise of refugees entering Germany. Approximately one third of them are under the age of 18. So far, little is known about the general health, acute or chronic diseases, or the immunization rates of this population. Our study describes the general state of health of underage refugees based on a large sample in Rhineland-Palatinate.
Materials and methods:
Using a structured questionnaire, demographic information and health-related elements on birth history, prenatal problems, vaccination history as well as chronic, acute and traumatic disease was collected prospectively in major accommodation centers for refugees.
Results:
A total of 461 minor refugees were included in the study. The majority were boys (54.5%), the average age was 8 years. Out of the 8 recorded countries of origin, most children came from Syria (33.6%), Afghanistan (23.2%) and Egypt (16.5%). Of all participants, 63% were vaccinated according to schedule. Chronic diseases were found in only 13% of the study cohort. A total of 20% experienced physical violence, either during their flight, or in the accommodation facility in Germany. The most common mechanisms for traumatic injuries were falls from a bicycle (38%), followed by burns and scald injuries (7.4%).
Conclusion:
Minor refugees have specific health-related problems and needs that must be considered and addressed in order to ensure appropriate medical care.
DGKCH: Varia
The spaced learning concept significantly improves laparoscopic suturing: A pilot randomized controlled study
M. Mietzsch1, J. Boettcher1, T. Krebs1, K. Reinshagen1, M. Boettcher1
1UKE Hamburg, Hamburg
Background:
Spaced, hypercondensed learning has been shown to be effective in various areas like traditional knowledge or motor skill acquisition. To evaluate the impact of implementation of the spaced learning concept in laparoscopic suturing was the aim of this study.
Materials and methods:
To evaluate the effectiveness of spaced learning, subjects were asked to perform 4 surgeon's square knots on a bowel model prior and post 3 hours of hands-on training. All subjects were medical students and novice in open and laparoscopic suturing. Total time, knot stability (evaluated via tensiometer), suture accuracy, knot quality (Muresan score) and laparoscopic performance (Munz checklist) were assessed. Moreover, motivation was accessed using Questionnaire on Current Motivation.
Results:
Twenty students were included in the study; after simple randomization, ten were trained using “spaced learning” concept and ten conservatively. Both groups had comparable baseline characteristics and improved after training significantly regarding all aspects assessed in this study. Subjects that trained via spaced learning were superior in terms of suture performance, knot quality and suture strength. Ultimately, spaced learning significantly decreased anxiety and impression of challenge compared to controls.
Conclusion:
The spaced learning concept is very suitable for complex motor skill acquisition like laparoscopic suturing and knot tying. It significantly improves laparoscopic performance and knot quality as shown by the knot score and suture strength. Thus, we recommend to incorporate spaced learning into training courses and surgical programs.
DGKCH: Responsibilites and challenges in the surgical treatment of migrants
Multidisciplinary care for Afghan children with extensive thermal injuries (two case reports)
P. Degenhardt1, B. Schwarz1, F. Grauel1
1Klinikum Ernst von Bergmann, Potsdam
Background:
The care of migrants poses a major challenge for the entire society. It can however be carried out successfully by a joint handling and with appropriate human empathy.
Those who work in pediatric surgical departments are dealing with complex untreated malformations, but also with sequelae after extensive trauma to a scale that was no longer known to us.
The main point is not only what is feasible but also the question of to what extent the treated children can receive further medical treatment in their home countries and to what extent can the high medical standards we practice be further implemented in the country of origin.
Besides the actual medical treatment, the focus is also on post-traumatic stress disorder, separation from the family and language barrier issues.
We would like to present two patient cases from our collaboration with the Friedensdorf Essen in which the treatment of extensive thermal injuries is concerned. Together with colleagues from the plastic surgery and pediatric orthopedics department we have tried to develop a realistic treatment plan that can be followed up in the home country of Afghanistan.
Materials and methods:
Die Versorgung von Migranten stellt die gesamte Gesellschaft vor eine hohe Herausforderung, die aber durch ein gemeinsames Handeln realisierbar und mit entsprechender menschlicher Empathie erfolgreich durchgeführt werden kann.
In den kinderchirurgischen Einrichtungen haben wir es dabei mit komplexen unbehandelten Fehlbildungen, aber auch mit Folgezuständen nach ausgedehnten Traumata in einem uns nicht mehr bekannten Ausmaß zu tun.
Im Vordergrund steht neben der Prüfung des machbaren auch die Frage inwieweit die versorgten Kinder ggf. später in ihren Heimatländern weiter medizinisch zu versorgen werden können und welche der hohen medizinischen Ansprüche in unserem Land zu Hause weiter umsetzbar sind.
Neben der eigentlichen medizinischen Behandlung sind posttraumatische Belastungsstörungen, die Trennung von der Familie und Sprachprobleme im Fokus.
Wir möchten zwei Kinder aus dem Friedensdorf Essen vorstellen, die nach ausgedehnten thermischen Verletzungen in unsere Behandlung gekommen sind. Gemeinsam mit den Kollegen der plastischen Chirurgie und der Kinderorthopädie haben wir versucht ein realistisches Behandlungskonzept zu entwickeln, welches auch im Heimatland Afghanistan weit betreut werden kann.
DGKCH: Varia
Mishaps in ancient children: accidents of children in Graeco-Roman antiquity
L. Graumann1
1UKGM GmbH, Standort Marburg, Marburg
Background:
This presentation deals with the physically injured child in Graeco-Roman antiquity. The injured child is of course not a recent and not an exclusive medical phenomenon. Despite the fact that there is nothing like paediatrics or paediatric traumatology in Greek and Roman antiquity, one can find a lot of different ancient sources which tell us the stories of these injured children, boys and girls, and very rarely of the treatment, sometimes of the prevention of accidents.
Materials and methods:
Performing a trial on collecting many different ancient sources about children’s accidents I will present some exemplary cases with preliminary results of this research, here focusing on sources from Late Antiquity. Children of different ages get injured in different, but similar situations.
Results:
Based on recent knowledge about injury biomechanism and its pathological-anatomical consequences in children of different age-groups within today's environment the medical interpreter of the ancient source is able to frame the individual consequences for the described injured child in the past.
Conclusion:
The topic of children’s accidents in antiquity is becoming a vast field for further historical inquiries. Exemplary cases of trauma events in both skeletal remains and written reports should be analyzed on an interdisciplinary basis with a careful close reading and additional medical interpretation to offer a broad scope for each individual case. It is above all this kind of micro-history that counteracts the fact that each unluckily injured ancient child has been forgotten: it gives the child its life back in this virtual manner.
Serial transverse enteroplasty (STEP) for short bowel syndrome in infants using a 5.8mm stapler– a case series
A. Deiß1, A. Alsweed1, S. Rohleder1, J. Gödeke1, V. Engel1, O. Muensterer1
1Universitätsmedizin Mainz, Mainz
Background:
Acquired short bowel syndrome (SBS) is a rare condition in infants associated with significant mortality and morbidity. In some cases, serial transverse enteroplasty (STEP) can elongate the remaining small bowel and facilitate weaning from parenteral nutrition. Until now, 12 mm diameter stapling devices have been used for STEP, which incorporates a substantial portion of resorptive intestinal mucosa into the staple line and thereby defunctionalizes it. Recently, miniature staple devices with a diameter under 6mm have been introduced, which potentially decreases the amount of tissue sacrificed during the procedure. To our knowledge, this is the first report of STEP procedures performed with the novel miniature stapler.
Materials and methods:
Three STEP procedures using a 5.8mm diameter endostapling device were performed in 2 infants. The first patient was a girl born at 34 weeks with type IIIb jejunal atresia who underwent laparotomy on the first day of life. The atresia was located 8cm from the ligament of Treitz, and the bowel was massively dilated. Only 5mm of distal ileum were salvageable. We performed a jejunoileostomy and performed a STEP procedure of the jejunum, increasing the measured length of small intestine to 16 cm. The second patient is a full-term boy who presented with malrotation volvulus to an outside hospital at 2 months of life. He underwent laparotomy and was transferred to our center. Second look exploration revealed 35 cm of viable small bowel. A STEP procedure was performed with the miniature stapler 3 months after presentation, and again at 5 months after initial presentation, increasing the length of small bowel to 65 cm.
Results:
There were no intra- or postoperative complications regarding the STEP. The first patient is now 1 year of age and has recently become enterally autonomous. The second patient is receiving about 50% of his calories enterally at 10 months of age. Both patients have regular, spontaneous bowel movements. They have no obstructive signs or symptoms, and both are anicteric.
Conclusion:
: Performing STEP using the novel miniature staplers is safe and feasible in infants. Less intestinal tissue is sacrificed for the procedure than when using conventional, 12mm diameter endostaplers. Theoretically, more resorptive surface is thereby preserved, and this may facilitate earlier successful intestinal rehabilitation in infants suffering from short bowel syndrome. In order to corroborate these claims, however, further studies are needed.
DGKCH: Diaphragm hernias
Intrathoracic kidney associated with late-presenting diaphragmatic hernia: intermittent tachypnea as unique clinical sign
F. Häcker1, S. Sesia1
1Universitäts-Kinderspital beider Basel, Basel
Background:
Intrathoracic renal ectopia associated with a congenital diaphragmatic hernia represents a very rare congenital malformation. The incidence of intrathoracic renal ectopia with congenital diaphragmatic hernia is reported to be less than 0.25 %.
Materials and methods:
We report on a 5-month-old female infant with late-presenting congenital diaphragmatic hernia having a left-sided thoracic ectopic kidney and adrenal gland. Besides our case report, we performed a review of the recent literature analyzing the incidence of this rare association and the recommendation for surgical repair.
Results:
The prenatal ultrasound showed no pathology, the postnatal ultrasound suggested a left-sided renal agenesia. After recurrent episodes of tachypnea, a chest x-ray confirmed the diagnosis of congenital diaphragmatic hernia at the age of 5 months. CDH was repaired without complications. A true posterolateral Bochdalek CDH without hernial sac was confirmed. The left kidney, the majority of small intestine and colon up to the colon descendens were found to be protruding into the left chest cavity. Intestinal malrotation was excluded. The displaced organs were carefully brought into the abdominal cavity and the diaphragmatic defect was closed by primary repair with interrupted non-absorbable sutures. The left kidney was mobilized without difficulty in a near to normal site, the renal fascia (Gerota) opened and the renal hilus visualised. The left kidney showed no deformed shape, no abnormal rotation and a normal size for the age of the child and a normal abdominal origin of renal vessels. Due to lack of dilatation of the renal pelvis, dissection of the left ureter was not performed. The abdominal wall could be closed tension-free. Postoperatively, the infant progressed well and was discharged on day 10 with full enteral feeding. Postoperative ultrasound scans showed correct position of the left kidney, a normal renal perfusion without any signs of urinary obstruction.
In the recent literature, intrathoracic ectopic kidney was reported in the left hemithorax in 62% of cases, and in the right hemithorax or in both hemithoraces in 36% and 2% of cases, respectively. In compliance with the literature, also in our patient intrathoracic ectopic kidney was located on the same side as the Bochdalek hernia.
Conclusion:
Intrathoracic renal ectopia may be asymptomatic and that late-presenting congenital diaphragmatic hernia should be considered in young children with recurrent respiratory symptoms.
Analyzing the recent literature, we find a controversial discussion leaving the ectopic kidney in the thoracic cavity vs. locating the kidney into the abdominal cavity.
Outcome after fetoscopic tracheal occlusion in neonates with congenital diaphragmatic hernia – a single-center-analysis and review of literature
K. Zahn1, T. Schaible1, L. Wessel1
1UMM Mannheim, Mannheim
Background:
In severe cases of congenital diaphragmatic hernia (CDH) fetoscopic tracheal occlusion (FETO) may be offered to stimulate lung growth and possibly improve postnatal survival. Several studies showed an improved survival in infants with isolated severe CDH after treatment with FETO with published survival rates in up to 49% in left-sided CDH and 35% in right-sided CDH (Jani et al., 2009). In a randomized controlled trial survival was 50% in the FETO-group compared to 4.8% in the nonFETO-group (Ruano et al., 2012). Prematurity is one of the risk-factors for reduced survival in FETO-patients (Ali et al., 2013) and there is an ongoing debate about the benefit of FETO with small patient numbers being published.
Materials and methods:
Neonates with CDH born at our hospital 01/2008 to 12/2015 who had undergone FETO were analyzed in regards to epidemiologic data, postnatal therapy, type of surgery and survival.
Results:
Between January 2008 and December 2015 45 neonates with CDH who had undergone FETO were treated at our hospital. 6 patients only received palliative treatment due to multiple severe anomalies, trisomy 18, severe lung hypoplasia and prematurity. In the intention-to-treat-cohort survival was 61.5% (24/39 patients). Comparing surviving and non-surviving FETO-patients there was no significant difference regarding gestational age (median 35+6 WOG versus 35+4 WOG), application of ECMO-therapy (15/24 pts. versus 13/15 pts., p=0.15), intrathoracic position of liver (14/15 pts. versus 6/7 pts., p=1.0) and stomach (15/15 pts. versus 6/7 pts., p=0.32) in left-sided CDH, defect-size and need for patch-closure of the diaphragmatic defect (100% both). Significantly less non-surviving neonates underwent surgery (53.5%, p=0.0004) and there was a tendency to a higher survival-rate in right-sided as compared to left-sided CDH after FETO (9/10 pts. versus 15/28 pts., p=0.059).
Conclusion:
Mortality in our intention-to-treat FETO-patients was primarily due to severe pulmonary hypertension and lung hypoplasia. One patient died because of tracheal damage after FETO, one due to severe chylothorax and one due to associated anomalies. Prematurity was not a reason for reduced survival in our FETO-cohort. In a tertiary-care hospital offering ECMO-therapy survival in patients with severe CDH who underwent FETO can reach >60%.
Evaluation of differences between thoracoscopic and open surgery in neonates with congenital diaphragmatic hernia with matched-pair-analysis according to relative fetal lung volume on prenatal MRI
K. Zahn1, U. Jänicke2, T. Schaible1, L. Wessel1
1UMM Mannheim, Mannheim
2Florence-Nightingale Krankenhaus, Düsseldorf
Background:
Neonates with congenital diaphragmatic hernia (CDH) can undergo minimally-invasive or open surgery. There is an ongoing debate about higher recurrence-rates and longer operating times in minimally-invasive surgery. Also the influence of possible intraoperative hypercapnia and acidosis in minimally-invasive surgery raises concerns.
Materials and methods:
To be able to compare results in similarily affected neonates a matched-pair-analysis was performed according to relative fetal lung volume (rFLV) on prenatal MRI, gestational age and birth weight. 22 matched-pairs (44 patients) were identified. In 20 thoracoscopic patients no match could be found due to postnatal diagnosis and thus missing prenatal MRI (17 patients) or high relative fetal lung volume (3 patients).
Results:
There were no statistically significant differences between type of diaphragmatic repair (primary repair: 45% thoracoscopic (TS) versus 59% open surgery (OS), p=0.54), operating time (median 172 min TS versus 141 min OS, p=0.17), postoperative pCO2 (median 35 mmHg TS versus 41.4 mmHg OS, p=0.14) and ventilation time (median 9.5 days TS versus 12 days OS, p=0.82). Also in regards to postoperative complications there were no statistically significant differences between both groups in the first year postoperatively: gastro-esophageal reflux (GERD) (10/22 TS-patients versus 6/21 OS-patients, p=0.35, no fundoplication), chylothorax (3/22 TS-patients versus 2/22 OS-patients, p=1.0) and recurrence (4/22 TS-patients versus 0/21 OS-patients, p=0.11). One patient in the open-surgery-group died due to pulmonary hypertension while all thoraoscopic patients survived.
Conclusion:
According to relative fetal lung volume on prenatal MRI a matched-pair analysis between neonates with thoracoscopic and open surgery was possible and a selection-bias of different severity of CDH in this cohort could be excluded. Thoracoscopic repair was not associated with significant differences as compared to the open-surgery group. There was also no significantly higher incidence of postoperative GERD and chylothorax. Despite recurrences occuring only in the TS group, the difference between TS and OS was not significant.
Surgical procedure and outcome of CDH patients requiring extracorporal membrane oxygenation therapy.A single center experience from 2010-2016
C. Schramm1, V. Meissner1, F. Kipfmueller1, A. Mueller1, A. Heydweiller1
1Universitätsklinikum Bonn, Bonn
Background:
Congential Diaphragmatic Hernia (CDH) is a relatively common and severe birth defect affecting up to 1:3000 live births and, despite improvements in perinatal care, associated with high mortality and morbidity. Pulmonary hypertension and respiratory failure are factors limitating survival during the first days of life. Extracorporal membrane oxygenation (ECMO) therapy offers an opportunity to stabilize patients with respiratory failure under lung-protective ventilation until pulmonary hypertension is treated and the lung recovered.
Materials and methods:
We retrospectively analyse our surgical procedure and outcome in patients with CDH who received ECMO therapy from 2010-2016.
Results:
During 2010-2016 40 neonates with CDH were treated with ECMO therapy in our center. Indication was respiratory or cardiopulmonary failure. In this severely affected group of CDH patients (average o/e LHR below 40%) 33 patients received surgical repair of the CDH. We present the intraoperative findings, surgical techniques we used, surgical complications and the mortality and morbidity of this special study group.
Conclusion:
ECMO therapy is a valuable option for neonates with respiratory or cardiopulmonary failure due to CDH. These critically ill patients often present with severe forms of CDH and therapy remains an interdisciplinary challenge.
© The Author(s) 2017, published by De Gruyter.
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 License.