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Analyzing the recent literature, it seems that the use of irrigation increases the incidence of intra-abdominal abscesses (IAAs) and infectious complications in perforated appendicitis. The aim of this study was to compare peritoneal irrigation and suction versus suction only during laparoscopic appendectomy (LA) for perforated appendicitis in children. MATERIALS AND METHODS: We retrospectively reviewed the records of 699 patients (460 boys and 239 girls, average age 9.8 years) who underwent LA for complicated appendicitis in six international centers of pediatric surgery over a 5-year period. The appendix was perforated with localized peritonitis in 465 cases and diffuse peritonitis in 234 patients. Irrigation + suction was used in 488 cases (group 1 [G1]), whereas suction only was used in 211 cases (group 2 [G2]). RESULTS: No significant difference between the two groups was found in regard to average operative time (P = .23), average time of resumption of oral diet (P = .55), average reprise of gastrointestinal transit (P = .55), and average length of hospital stay (P = .41). As for postoperative complications, the incidence of IAAs was significantly higher in G2 (41/211; 19.4%) compared with G1 (38/488; 7.7%) (P = .0000), whereas no significant difference was found between the two groups in regard to wound infection (G1: n = 2 or 0.4%; G2: n = 4 or 1.8%; P = .05) and small bowel obstruction rates (G1: n = 8 or 1.6%; G2: n = 2 or 0.9%; P = .47). CONCLUSIONS: In contrast with the most recent literature on this topic, our results demonstrated that peritoneal irrigation and suction were associated with a lower rate of postoperative IAA formation compared with the suction-only approach in children with perforated appendicitis. In such cases, peritoneal irrigation and abdominal drainage should be the preferred methods for peritoneal toilette, with no increase in operative time and postoperative morbidity.

This study aimed to assess malpractice in paediatric minimally invasive surgery (MIS), and attitudes, prevention strategies and mechanisms to support surgeons while they are under investigation. An observational, multicentric, questionnaire-based study was conducted. The survey questionnaire was sent via mail, and it comprised four sections. Twenty-four paediatric surgeons (average age 54.6 years), from 13 different countries, participated in this study. The majority had >15 years of experience in MIS. Three (12.5%) surgeons reported a total of five malpractice claims regarding their MIS activity. The reasons for the claims were a postoperative complication in 3/5 (60%) cases, a delayed/failed diagnosis in 1/5 (20%) cases and the death of the patient in 1/5 (20%) cases. The claims concluded with the absolution of the surgeon in all cases, and monetary compensation to the claimant in two (40%) cases. Eleven (45.8%) surgeons were invited as expert counsels in medico-legal actions. Medico-legal aspects have a minimal impact on the MIS activity of paediatric surgeons. In this series, claims concluded with the absolution of the surgeon in all cases, but they had a negative effect on the surgeon’s reputation and finances. A key element in supporting surgeons while they are under investigation is always to choose a surgeon who is an expert in paediatric MIS as legal counsel. A constant update on innovations in paediatric MIS and appropriate professional liability insurance may also play a key role in reducing medico-legal consequences.

Respiratory manifestations of gastroesophageal reflux disease (GERD), particularly chronic cough, are being recognized with increased frequency in children. This survey aimed to investigate the efficacy of laparoscopic Nissen fundoplication for treatment of GERD-related respiratory symptoms not responsive to medical therapy in neurological normal children.We collected data of children with GERD-related respiratory complaints not responsive to medical therapy who underwent laparoscopic Nissen fundoplication in four European centers of Pediatric Surgery over a 10-year period. We excluded children with neurological impairment.A total of 220 laparoscopic Nissen procedures were performed in the period 2005-2015. Twenty-four (12 boys and 12 girls, average age 9.5 years) out of the 220 patients (10.9%) presented with chronic cough and other respiratory manifestations, including asthma, reactive airway disease, and recurrent pneumonia. Average operative time was 65 minutes (range 45-100). As for postoperative complications, two tight wraps requiring endoscopic dilatation (IIIb Clavien) and two relapses of GERD for slipped Nissen requiring reoperation (IIIb Clavien) were recorded. None of these complications occurred in the group of patients with GERD-related respiratory symptoms. At follow-up evaluation, respiratory symptoms disappeared with a significant improvement of quality of life scoring (I Grade Visick) in 22/24 patients (91.6%).Our results confirm that GERD should be investigated as one of the possible etiologic factors in any child with persistent respiratory complaints. In patients with symptoms not responsive to medical therapy, laparoscopic Nissen fundoplication is the treatment of choice with a very high success rate (90% in our series), a very low morbidity, a significant improvement in airway symptoms, and a marked reduction in the need for medications.

BACKGROUND: There is a limited and conflicting evidence about the most appropriate method for appendiceal stump closure during laparoscopic appendectomy (LA). We aimed to compare endoloop (EL) versus endostapler (ES) for stump closure during LA for complicated perforated appendicitis in children. METHODS: We retrospectively reviewed the records of 708 patients (463 boys and 245 girls with an average age of 9.8 years) who underwent LA for complicated appendicitis in 5 international centers of Pediatric Surgery over a 5-years period (January 2011-December 2016). The appendix was perforated with localized peritonitis in 470 cases and diffuse peritonitis in 238 patients. EL was used in 374 cases (G1), whereas ES was adopted in 334 cases (G2). RESULTS: No intra-operative complication occurred in both groups but 5 conversions to open surgery were reported in G1 (1.3%) and 4 in G2 (1.1%) (OR 1.1; 95% CI 0.30-4.19). Use of EL was significantly associated with higher incidence of intra-abdominal abscess (OR 1.36; 95% CI 0.84-2.18), postoperative ileus (OR 3.61; 95% CI 0.76-17.11), and re-operations/readmissions (OR 6.46; 95% CI 1.46-28.62) compared to ES. The average cost of supplies for LA was significantly higher in G2 (€ 915.60) compared to G1 (€ 578.36) (p = 0.0001). The average cost of re-operations/readmissions was significantly higher in G1 (€ 4.091,39) compared to G2 (€ 2.127,88) (p = 0.0001) (OR 1.72; 95% CI 1.47-2.01). CONCLUSIONS: Our study is the first in the pediatric population to demonstrate that the method used for appendiceal stump closure may influence the outcome of LA in complicated appendicitis. Although ES is more expensive compared to EL, our results demonstrated that appendix stump closure should be performed using ES rather than EL in complicated perforated appendicitis since its use was associated with a lower incidence of postoperative intra-abdominal abscess and postoperative ileus and lower re-operations and readmissions rates and costs.

Vocal fold (VF) fibroblasts are the central subject of interest in fibrogenesis and wound healing after VF injury. Scar fibroblasts (SF) exhibit an aberrant production of several extracellular matrix (ECM) components which lead either to VF fibrosis or scarless wound healing. This study aimed to investigate the role of age at the time of injury on ECM production of SF. This is designed as an animal study. VF injury was established unilaterally in eight male Sprague-Dawley rats [3 months of age (n = 4), 11 months of age (n = 4)], while the other side was left intact. Three months after injury the larynges were excised and fibroblasts were extracted from VF [normal fibroblasts (NF)–scar fibroblasts (SF)] and cultured in vitro. After first passage, VF fibroblasts were plated in 24-well plates and levels of hyaluronic acid (HA) and collagen type I were determined enzymatically from supernatant after 24 and 72 h. Cultured SF from younger animals produced significantly higher levels of HA compared to NF fibroblasts from the same animals. HA concentrations of the older animals did not differ significantly between the NF and SF cultures, but the range in SF cultures was large. In contrast to previous studies, we found that even 3 months after VF injury cultured SF from young animals expressed higher levels of HA in comparison to SF from older animals. No difference in collagen levels were observed between the younger and older animals. Age of animals is an essential factor during VF healing and has to be considered for study design.

AIM: This study aimed to report the results of a multicentric survey about laparoscopic treatment of pancreatic tumors in children. MATERIALS AND METHODS: The data of patients operated using minimally invasive surgery (MIS) for a pancreatic tumor in 5 International centers of Pediatric Surgery in the last 5 years were retrospectively reviewed. We recorded data relating to the clinical presentation, diagnostic evaluation, surgical technique, and outcome. RESULTS: Fifteen patients (average age 2.2 years) were identified. The most common symptoms at presentation were related to the hypoglycemic hyperinsulinism, followed by abdominal pain and vomiting. Tumor types were insulinoma (n = 4), congenital hyperinsulinism of infancy (CHI) diffuse type (n = 3), CHI focal type (n = 3), solid pseudopapillary tumor (n = 2), and cystic malformation (n = 3). The diagnostic assessment was completed using ultrasound associated with computed tomography (CT) scan in all centers; 18FDOPA positron emission tomography in combination with CT was adopted in 2 centers. The MIS procedures performed were as follows: tumor enucleation (n = 4), distal pancreatectomy (n = 8), subtotal pancreatectomy (n = 2), and pancreatico-jejunostomy (n = 1). Average operative time was 110 minutes. As for postoperative complications, we recorded 1 persistent hypoglycemia, requiring redo-surgery (IIIb Clavien-Dindo) and 1 thrombosis of splenic vein, not requiring any treatment (I Clavien-Dindo). CONCLUSIONS: Laparoscopic resection can be considered a safe and effective treatment with minimal morbidity and excellent outcomes for most pediatric pancreatic tumors. Suspension of the stomach with a transparietal stitch and use of new hemostatic devices as Starion TLS3 or Ligasure are key factors for the success of the procedure. A long-term follow-up is mandatory in these patients to evaluate postoperative complications and long-term outcome.

Background Surgeons are at risk for developing work-related musculoskeletal symptoms (WMS). The present study aims to examine the physical factors and their association with WMS among pediatric laparoscopic surgeons. Methods A questionnaire consisting of 21 questions was created and mailed to 25 pediatric laparoscopic surgeons (LG). 23/25 surgeons (92%) completed the survey. The questionnaire was analyzed and then split into 2 groups. Group 1 (LG1) included surgeons with greater laparoscopic experience, and group 2 (LG2) included surgeons with less important laparoscopic experience. In addition, we constructed and sent to the same surgeons a similar questionnaire focused on WMS after an open procedure (OG) with the aim to compare results of LG with OG. Results The prevalence rate of WMS with shoulder symptoms was 78.2% in surgeons that performed laparoscopy for more than 10years, with 60.8% also reporting other pain. In 66.6% this pain is evident only after a long-lasting procedure. Forty-four percent of these surgeons require painkillers at least twice a week. Fifty percent of these surgeons also suffer at home. Fifty-five and one half percent of surgeons indicate that this pain is related to their laparoscopic activity. Forty-three and a half percent think that laparoscopy is beneficial only for the patient but has a bad ergonomic effect for surgeons. Sixty-five and two-tenths percent think that robotic surgery can be helpful to improve ergonomics. Comparing the groups, WMS occur more frequently in LG (78.2%) than in OG (56.5%), but this difference was not statistically significant (χ 2 =0.05). In addition, WMS occur more frequently in LG1 (84.6%) than in LG2 (70%), but this difference was not statistically significant (χ 2 =0.05). Conclusions These results confirmed a strong association between WMS and the number of laparoscopic procedures performed. Skilled laparoscopic surgeons have more pain than less skilled laparoscopic surgeons. WMS in the same group of surgeons are more frequent after laparoscopy than after open procedures. The majority of surgeons refer to shoulder symptoms.

PURPOSE: The aim of this paper was to propose structured guidelines for a European pediatric MIS training program created by ESPES. METHODS: A questionnaire, focused on how the pediatric training program in MIS has to be structured, was proposed to all participants at the ESPES Congress in Marseille in 2013. RESULTS: We received 178 questionnaires but only 139 questionnaires were fully completed and analyzed. All respondents agree that the training program has to be divided into 4 steps: (1) theoretical part: 2 theoretical courses in laparoscopy (101/139 respondents, 72.7 %), 1 theoretical course in retroperitoneoscopy (99/139 respondents, 71.2 %) and 1 in thoracoscopy (91/139 respondents, 65.5 %); (2) experimental part: 10-20 h of training on pelvic trainer (103/139 respondents, 74.1 %) and 10 h of training on animal models (91/139 respondents, 65.5 %); (3) stages in European centers of reference for MIS: a 1-3 months stage (96/139 respondents, 69.1 %); (4) personal experience: 30 procedures as cameraman (98/139 respondents, 70.5 %) and >50 basic MIS procedures as main surgeon under supervision (114/139 respondents, 82 %). CONCLUSIONS: On the basis of our survey ESPES MIS training curriculum for pediatric surgeons must contain the following educational components: (1) theoretical knowledge; (2) practice-based learning and improvement in experimental setting; (3) stages in European centers of reference for MIS; (4) personal operative experience. At the end of the training program, ESPES will analyze the candidate training booklet and release for each applicant an ESPES certification after an exam.

Summary Introduction Vocal fold (VF) fibroblasts (VFFs) are the central target in developing new strategies for treatment of VF injury and scarring. Nevertheless, only little is known about the basic biological characteristics of these cells. The aim of this study was to explore the impact of age of VFFs on the response to external growth factor stimulation. Study Design In vitro cell study using a rat model. Methods VFFs were extracted from young and aged rat VF 3 months after establishing unilateral injury. Resulting scar fibroblasts (SFs) and normal fibroblasts (NFs) were subsequently cultured separately with or without the addition of hepatocyte growth factor (HGF). After 24 and 72 hours, the production of hyaluronic acid (HA) was examined in the supernatant culture media using enzyme-linked immunosorbent assay. Results Only cultured SF and NF from young animals could be stimulated significantly in the production of HA by HGF. Within these, average percentage increase was higher in NF compared with SF. Conclusion The response of VFFs in cell culture to growth factors stimulation is highly depending on the age of the animals. This is another step in a nearer characterization of scar VFF and could furthermore be an important point when estimating the success of an intervention. Age-depending effects must be considered as an important factor in developing possible therapeutic agents for VF scarring.

Congenital defects of the esophagus are relatively frequent, with 1 out of 2500 babies suffering from such a defect. A new method of treatment by implanting tissue engineered esophagi into newborns is currently being developed and tested using ovine esophagi. For the reconstruction of the biological function of native tissues with engineered esophagi, their cellular structure as well as their mechanical properties must be considered. Since very limited mechanical and structural data for the esophagus are available, the aim of this study was to investigate the multiaxial mechanical behavior of the ovine esophagus and the underlying microstructure. Therefore, uniaxial tensile, biaxial tensile and extension-inflation tests on esophagi were performed. The underlying microstructure was examined in stained histological sections through standard optical microscopy techniques. Moreover, the uniaxial ultimate tensile strength and residual deformations of the tissue were determined. Both the mucosa-submucosa and the muscle layers showed nonlinear and anisotropic mechanical behavior during uniaxial, biaxial and inflation testing. Cyclical inflation of the intact esophageal tube caused marked softening of the passive esophagi in the circumferential direction. The rupture strength of the mucosa-submucosa layer was much higher than that of the muscle layer. Overall, the ovine esophagus showed a heterogeneous and anisotropic behavior with different mechanical properties for the individual layers. The intact and layer-specific multiaxial properties were characterized using a well-known three-dimensional microstructurally based strain-energy function. This novel and complete set of data serves the basis for a better understanding of tissue remodeling in diseased esophagi and can be used to perform computer simulations of surgical interventions or medical-device applications.