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Leukemic cutaneous T-cell lymphomas (L-CTCL) are lymphoproliferative disorders of skin-homing mature T-cells causing severe symptoms and high mortality through chronic inflammation, tissue destruction, and serious infections. Despite numerous genomic sequencing efforts, recurrent driver mutations have not been identified, but chromosomal losses and gains are frequent and dominant. We integrated genomic landscape analyses with innovative pharmacologic interference studies to identify key vulnerable nodes in L-CTCL. We detected copy number gains of loci containing the STAT3/5 oncogenes in 74% (n = 17/23) of L-CTCL, which correlated with the increased clonal T-cell count in the blood. Dual inhibition of STAT3/5 using small-molecule degraders and multi-kinase blockers abolished L-CTCL cell growth in vitro and ex vivo, whereby PAK kinase inhibition was specifically selective for L-CTCL patient cells carrying STAT3/5 gains. Importantly, the PAK inhibitor FRAx597 demonstrated encouraging anti-leukemic activity in vivo by inhibiting tumor growth and disease dissemination in intradermally xenografted mice. We conclude that STAT3/5 and PAK kinase interaction represents a new therapeutic node to be further explored in L-CTCL., (© 2022 The Authors. Published under the terms of the CC BY 4.0 license.)

Introduction: Shifting the training from the operating room (OR) to simulation models has been proven effective in enhancing patient safety and reducing the learning time to achieve competency and increase the operative efficiency. Currently the field of pediatric surgery only offers few low-cost trainers for specialized training and these feature predominantly artificial and often unrealistic tissue. The aim of this study was to develop an easy access low-cost tissue-realistic simulation model for open training of esophageal atresia and to evaluate the acceptance in trainees and junior pediatric surgeons., Materials and Methods: The model is fashioned using reconfigured chicken skin from a chicken leg. To create a model of esophageal atresia, the chicken skin is dissected off the muscle and reconfigured around a foley catheter balloon to recreate the proximal pouch and a feeding tube to recreate the distal pouch. Surrounding structures such as the tracheo-esophageal fistula and the azygos vein can be easily added, obtaining a realistic esophageal atresia (Type C) prototype. Evaluation of model construction, usage and impact on user were performed by both a self-assessment questionnaire with pre- and post-training questions as well as observer-based variables and a revised Objective Structured Assessment of Technical Skills (OSATS) score., Results: A total of 10 participants were constructing and using the model at two different timepoints. OSATS score for overall performance was significantly higher ( p = 0.005, z = -2.78) during the second observational period [median (MD): 4,95% confidence interval CI: 3.4, 5.1] compared to the first (MD: 3, 95% CI 2.4, 4.1). Self-reported boost in confidence after model usage for performing future esophageal atresia (EA) repair and bowel anastomosis (BA) in general was significantly higher (EA: U = 1, z = -2.3, p = 0.021, BA: U = 1, z = -2.41, p = 0.016) in participants with more years in training/attending status (EA MD:5, BA MD: 5.5) compared to less experienced participants (EA MD: 1.5, BA: 1)., Conclusion: Our easy access low-cost simulation model represents a feasible and tissue realistic training option to increase surgical performance of pediatric surgical trainees outside the OR., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer KS declared a shared affiliation with the authors to the handling editor at the time of review., (Copyright © 2022 Palmisani, Sezen, Haag, Metzelder and Krois.)

Introduction: In patients with anorectal malformations (ARM), the sacral ratio (SR) serves as an established predictive marker for functional prognosis and is derived from conventional radiographs. More recently, magnetic resonance imaging (MRI) has emerged as a diagnostic alternative for preoperative/baseline assessment of patients with ARM. With this study we aimed to evaluate if the SR could be reliable be measured from MRI images and if it correlated to SR measurements obtained from radiographs., Methods: Two raters analyzed MRI data and conventional radiographs from thirty-one subjects (n = 17 with ARM; n = 14 controls). We calculated intra-class correlation coefficients (ICCs) to test inter-rater reliability and applied paired t-tests to examine if SR parameters from MRI were comparable with those from pelvic radiograph. We further computed Pearson's correlation coefficients to test the linear relationship between SR calculated from MRI and conventional radiographs., Results: The ARM and control groups did not statistically differ in their age and weight on the day of the MRI scan. Reliability analysis revealed an excellent inter-rater agreement for SR from radiograph parameters with an intraclass correlation coefficient (ICC) of 0.94, respectively of 0.86 for MRI (frontal plane), and of 0.84 for MRI (sagittal plane). The correlation coefficient between SR calculated from the sagittal MRI and SR calculated from radiograph images was significant and high (r = 0.80, P < 0.001). The SRs from MRI images did not significantly differ from SRs from radiographs, but were also not statistically equivalent., Conclusion: Our results demonstrate that the SR can be derived from MRI images with good inter-rater reliability. The SR value is marginal higher when calculated on MRI, presumably due to inclusion of cartilaginous yet unossified structures., Competing Interests: Declaration of Competing Interest All authors have no disclosures or conflicts of interest., (Copyright © 2021 The Author(s). Published by Elsevier Inc. All rights reserved.)

Assessment of discomfort as a sign for early postoperative complications in neurologically impaired (NI) children is challenging. The necessity of early routine upper gastrointestinal (UGI) contrast studies following laparoscopic Nissen fundoplication in NI children is unclear. We aimed to evaluate the role of scheduled UGI contrast studies to identify early postoperative complications following laparoscopic Nissen fundoplication in NI children. Data for laparoscopic Nissen fundoplications performed in NI children between January 2004 and June 2021 were reviewed. A total of 103 patients were included, with 60 of these being boys. Mean age at initial operation was 6.51 (0.11-18.41) years. Mean body weight was 16.22 (3.3-62.5) kg. Mean duration of follow up was 4.15 (0.01-16.65 years) years. Thirteen redo fundoplications (12.5%) were performed during the follow up period; eleven had one redo and two had 2 redos. Elective postoperative UGI contrast studies were performed in 94 patients (91%). Early postoperative UGI contrast studies were able to identify only one complication: an intrathoracal wrap herniation on postoperative day five, necessitating a reoperation on day six. The use of early UGI contrast imaging following pediatric laparoscopic Nissen fundoplication is not necessary as it does not identify a significant number of acute postoperative complications requiring re-intervention.

Introduction: Training in laparoscopic surgery seems to be an important aspect in gaining and maintaining professional competency. In experimental settings, camera navigation skills improved after simulation-based training, but the effect of camera work on the surgeon's performance is not well studied. The aim of this study was to investigate whether a fixed camera or an operated camera, as well as the experience of the camera operator has an effect on the performance of the surgeon. Materials and Methods: The study was performed on the LapSim laparoscopic training system. The task was to tie an intracorporal knot in a static surgical environment with three different camera conditions: fixed camera, camera operated by an inexperienced person (inexpert camera), and camera operated by an experienced surgeon (expert camera). The camera conditions were counterbalanced across trials. Performance variables were completion time in seconds and the extend of movements in path length and angular pathway. Gaze behavior was measured with eye-tracking glasses worn by the surgeon as well as the camera operator and was evaluated for performance-harming effects. Results: Completion time varied across conditions, with participants performing significantly longer in the fixed camera condition than in the expert or the inexpert condition. The expert and inexpert conditions did not differ. The performance-harming effect of non-focusing on the tissue was especially visible in the fixed camera condition but disappeared in the expert camera condition. Neither the camera operators' gaze behavior nor the surgeon-camera operator fixation agreement predicted task performance. Discussion: A camera operator can potentially eliminate performance-harming effects of maladaptive gaze behavior and promote optimal visual behavior of a surgeon. In our experimental task, there was no significant difference in whether the camera operator had previous training in laparoscopic surgery or not.

Introduction: Short-term international medical service trips (MST) are established means to access specialized medical aid in resource-limited areas. The field of pediatric colorectal surgery is a subspecialty in pediatric surgery that mainly treats anorectal malformations (ARM) and Hirschsprung disease (HD). This study aimed to investigate the impact of MST on the donors' perception of competency concomitantly to the impact on patients in the donors' home country. We also wanted to investigate whether the donors' pre-existing experience in the field of ARM and HD affects the experience they gain during the MST, and the subjective perception in treating patients in their base country., Methods: We created a questionnaire for the international medical staff participating in MSTs on the unique topic of pediatric colorectal diseases. The questionnaire was split into three parts: essential experience (1) in the field of colorectal surgery of the participant, the experience and impact on patient care in the home country during and after the MST in ARM (2), and in HD (3)., Results: We collected data from 20 participants (6 female, 14 male). The majority of them had prior experience with the MST program (75%) and came from institutions specialized in the treatment of pediatric colorectal disorders (80%). Participants felt that MST improved patient care in both the host country (p < 0.001) and their home country (p < 0.001). Experienced and less experienced participants did not differ in the overall MST evaluation (ps > 0.08). They reported that their competencies to treat ARM and HD improved significantly in response to the MST (ps < 0.001). Improvements in ARM and HD treatment were associated with the number of supervised HD surgeries during MST, while the other forms of participation were unrelated to the improvements., Conclusion: The results of our questionnaire indicate that participation in MST in the specialized field of pediatric colorectal surgery helps to improve confidence in the care and treatment of affected patients in both the host and donor countries, independent of previous surgical experience., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2020 The Author(s).)

Background:  Infants are likely to develop anuria during laparoscopy which is uncommon in older patients. The reason for this susceptibility remains unknown. We compared the impact of CO 2 pneumoperitoneum on renal perfusion and urine production in piglets compared with adolescent pigs. We furthermore investigated the effects of different resuscitation strategies., Materials and Methods:  Male piglets ( n  = 21) were divided into four groups: (a) infant controls ( n  = 5), (b) infants with crystalloid restitution ( n  = 6), (c) infants with colloidal restitution ( n  = 5), and (d) adolescents with crystalloid restitution ( n  = 5). Animals were ventilated, the central vessels and ureters were cannulated, and the animals were subjected to a 3-hour, 10 mm Hg CO 2 pneumoperitoneum followed by 2-hour resuscitation. Renal perfusion was assessed by fluorescent microspheres and the rate of urine flow was measured., Results:  Urine production significantly decreased after insufflation only in the infant crystalloid and adolescent group, but not in controls or infants treated with colloids. In the infant crystalloid group, urine production remained at levels below 20% of baseline throughout the experiment. In this group, the renal perfusion dropped significantly after the beginning of the capnoperitoneum and remained significantly reduced throughout the experiment., Conclusion:  Our data indicates that capnoperitoneum impairs renal perfusion and urine production in infants. In moderate-pressure capnoperitoneum, this effect cannot be compensated by application of crystalloids but with colloids., Competing Interests: None declared., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Symptoms at suspicion of necrotizing enterocolitis (NEC) are often nonspecific and several biomarkers have been evaluated for their discriminative power to both diagnose and predict the course from NEC suspicion to complicated disease requiring surgical intervention. Thus, we aimed to assess the utility of interleukin-6 (IL-6) to predict surgical intervention in infants suffering from NEC and, furthermore, to discriminate infants with starting NEC or late-onset sepsis (LOS)., Methods: IL-6 serum levels at disease onset were retrospectively analyzed in 24 infants suffering from NEC as well as 16 neonates with LOS., Results: IL-6 serum levels at disease onset were significantly higher in infants suffering from NEC necessitating surgical intervention in the disease course compared to infants with medical NEC (5000 [785-5000] vs. 370 [78-4716] pg/ml, p = 0.0008) as well as gram-positive LOS (5000 [785-5000] vs. 84 [12-269] pg/ml, p = 0.0001). Infants suffering from gram-negative LOS exhibited elevated IL-6 serum levels at disease onset comparable to infants with surgical NEC (5000 [1919-5000] vs. 5000 [785-5000] pg/ml, p = 1.00)., Conclusion: The proinflammatory cytokine IL-6 appears to be a promising marker to distinguish surgical NEC from medical NEC at the onset of disease but cannot discriminate between surgical NEC and gram-negative LOS., Level of Evidence: II., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Bladder augmentation is a demanding surgical procedure and exclusively offered for selected children and has only a small spectrum of indications. Paediatric bladder voiding dysfunction occurs either on a basis of neurological dysfunction caused by congenital neural tube defects or on a basis of rare congenital anatomic malformations. Neurogenic bladder dysfunction often responds well to a combination of specific drugs and/or intermittent self-catheterization. However, selected patients with spinal dysraphism and children with congenital malformations like bladder exstrophy and resulting small bladder capacity might require bladder augmentation. Ileocystoplasty is the preferred method of bladder augmentation to date. Because of the substantial long-and short-term morbidity of augmentation cystoplasty, recent studies have tried to incorporate new techniques and technologies, such as the use of biomaterials to overcome or reduce the adverse effects. In this regard, homografts and allografts have been implemented in bladder augmentation with varying results, but recent studies have shown promising data in terms of proliferation of urothelium and muscle cells by using biological silk grafts.

Background: Clinical and experimental data indicate that neonates are sensitive to the CO 2 pneumoperitoneum. An impaired splanchnic perfusion during laparoscopy in adults has been reported. We recently confirmed that intravenous colloids improve macrocirculatory function in neonates. We aimed to determine the impact of CO 2 pneumoperitoneum on the perfusion of splanchnic organs in the young including effects of colloid application., Methods: Male piglets (n = 25) were divided into four groups: (1) neonatal controls, (2) neonates with crystalloid restitution, (3) neonates with colloidal restitution, and (4) adolescents with crystalloid restitution. Animals were ventilated and subjected to a 3-h, 10 mmHg CO 2 pneumoperitoneum followed by 2 h resuscitation. Hepatic, splanchnic, and arteriovenous shunt perfusion was assessed via central and portal venous catheters. Capillary organ flow was detected by fluorescent microspheres. The rate of bile flow was measured., Results: The neonatal crystalloid group showed a significant decrease in the intestinal capillary perfusion at the end of the recovery period. This was not detectable in the adolescent and colloid group. There was a significant increase in microcirculatory arterioportal shunt flow during the CO 2 pneumoperitoneum in both neonatal groups but not in the sham and adolescent groups (p < 0.05). Hepatic arterial perfusion increased after insufflation in all groups and dropped during capnoperitoneum to levels of about 70% baseline. There was no significant impairment of splanchnic perfusion or bile flow as a result of the pneumoperitoneum in all groups., Conclusions: Capillary perfusion of the abdominal organs was stable during capnoperitoneum and recovery in adolescents and neonates with colloid restitution, but not with crystalloid restitution. Significant arterioportal shunting during capnoperitoneum could affect hepatic microcirculation in neonates. Our data confirm that moderate pressure capnoperitoneum has no major effect on the perfusion of abdominal organs in neonates with adequate substitution.

Introduction: To describe the social impact of a colostomy on indigent families and affected children with anorectal malformations (ARM) or Hirschsprung's disease (HD) in San Pedro Sula, Honduras, we specifically targeted very low-income households that attended an international medical brigade for ARM and HD in 2016., Methods: The impact of a colostomy on the families and children's daily life was analyzed by personal interviews with a questionnaire., Results: Twenty families with children were included in the study. Children's age ranged from 5 months to 27years (median 2.31). Annual income was reported to be less than $500 USD in 42.8%. Impairment of daily family life by the colostomy was reported in 85%. Parents of preschool children younger than 7 years are more affected than parents of older children, whereas children older than 7 years reported on more social problems. Moreover, 50% of the school-aged children did not attend school owing to issues directly related to their colostomy., Discussion: Colostomies for children in the low middle-income country Honduras have significant social and economic implications for low-income families. In ARM and HD, medical brigades can offer help for definitive surgical repair to overcome and shorten the period of a colostomy presence to improve physical and psychosocial impairment, especially when performed before the children reach the school age., Type of Study: Cost Effectiveness Study., Level of Evidence: II., (Copyright © 2017 Elsevier Inc. All rights reserved.)

In LT, the common policy is to allocate pediatric liver grafts to pediatric recipients. Pediatric organs are also offered to adults if there is no pediatric recipient. However, they are rarely accepted for adult recipients. So far, there is no information available reporting outcome of LT in adult recipients using pediatric livers from donors ≤ 6 yr. In this study, we included nine adult recipients (seven females and two males) who received grafts from children ≤ 6 yr from January 2008 to December 2013. We evaluated the graft quality, the GBWR and analyzed the recipients' perioperative course. Laboratory samples and graft perfusion were analyzed. Nine adults with a median age of 49 yr (range: 25-65) and a median weight of 60 kg (range: 48-64) underwent LT with a pediatric donor graft. Median donor age was five yr (range: 3-6). Median GBWR was 1.02 (range: 0.86-1.45). After a median follow-up of 3.9 yr (range: 11 months-6.6 yr), patient survival was 100%; graft survival was 89%. One patient needed re-transplantation on the second postoperative day due to PNF. Eight recipients were discharged from the ICU after 2-9 days with a regular graft function. Doppler scans revealed regular flow patterns at any time. Only if denied for pediatric recipients, the use of pediatric livers from donors ≤ 6 yr for adult recipients is a considerable option., (© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Aim: A series study mainly from Asia suggests that ABO-incompatible (ABOi) living-related liver transplantation (LRLT) for pediatric recipients is associated with excellent short- and long-term graft and patient survival. Until now, ABOi LRLT has been rarely performed in Europe. The aim of this study was to analyze the safety and early results of an ABOi LRLT in a German high-volume pediatric liver transplant center., Methods: Six consecutive pediatric patients (four males and two females) were included in this prospective study from January, 2010 to January, 2013 with a median age of 13 months (range, 6-30 months) receiving ABOi LRLT and were matched with six patients receiving ABO-compatible LRLT in the same period. In the ABOi group, titers of IgG and IgM isoagglutinins against the donor's blood group were determined at day 14 before the transplantation and from day 1 to 14 after the transplantation, and then twice a week for another 8 weeks. The titer results were determined as the reciprocal number of the highest serum dilution that caused macroscopical reaction., Results: The patients receiving ABOi and those receiving ABO-compatible LRLT were comparable regarding the recipient's preoperative pediatric end-stage liver disease (PELD), age, gender, and technical aspects of transplantation. The median follow-up was 2.6 years (range, 1-4.5 years). At the time of operation, the mean body weight was 7.7 kg (range, 5.7-16 kg) in ABO-compatible LRLT recipients and 8.8 kg (range, 5.5-18 kg) in ABOi LRLT recipients. In each group, the median PELD score was 28 (range, 28-35), respectively. All recipients received tacrolimus plus mycophenolate mofetil-based standard immunosuppression and four ABOi transplanted patients received intravenous immunoglobulins at days 1, 3, and 5 after liver transplantation. Patient and graft survival in this group was 83%. One female patient died within 24 hours due to fulminant gram-negative sepsis. Another patient developed acute cellular rejection at the 8th postoperative day, which responded to steroid treatment. No further complications occurred. In the ABO-compatible group, patient survival was 100% and graft survival was 83%; one patient in this group received retransplantation after 4 days. During follow-up, two patients of the ABOi group had maximum alloantibody titers of four against the donor's blood group; all other patients had titers below four., Conclusion: ABOi LRLT seems to be safe without an escalation of immunosuppression and should be considered as an additional option to timely facilitate the transplantation., (Georg Thieme Verlag KG Stuttgart · New York.)

The current literature provides fundamental insights regarding the neurotoxic potency of various general anesthetic drugs in neonates and small infants. Therefore, considerations to minimize the use of general anesthetic drugs in this age group are required. The use of caudal and epidural anesthesia under sedation is one possibility to minimize the use of general anesthetic drugs. A large number of surgical procedures can be managed with this anesthetic concept. Training, practical hand skills, good infrastructure, a well-defined indication, and a team approach including the entire operation room staff are the major prerequisites to implement these techniques in the daily clinical practice. This review article discusses all present aspects and possible future evolutions of caudal and epidural anesthesia under sedation., (© 2014 John Wiley & Sons Ltd.)

Fast-track concepts in pediatric surgery were established in a university hospital in consecutive studies within several years. They significantly reduced the length of hospitalization compared with German institutions without fast-track protocols. The aim of this study was to assess the implementation process of fast-track in a German nonacademic department of pediatric surgery without previous fast-track experience. All patients undergoing four types of operations (appendectomy, hypospadias repair, pyloromyotomy, and fundoplication) from February 2011 to January 2012 were included in this prospective study. Fast-track included detailed clinical pathways and specific pain treatment protocols using validated pain scales according to age. Mobilization and oral nutrition were started 2 hours postoperatively and documented with established scores. The length of hospital stay was compared with data from other hospitals with conventional treatment using information from the German reimbursement system (German diagnosis-related groups [G-DRG]) and with the hospital stay of patients from the corresponding university hospital undergoing fast-track treatment for the same procedures during the same study period. Two weeks after discharge, a questionnaire was completed by the patients/parents. A total of 143 patients with a mean age of 7.9 ± 5.0 years underwent fast-track treatment. The mean pain intensity during the immediate postoperative period was 1.7 ± 2.1 in patients < 4 years and 2.3 ± 2.1 in patients ≥ 4 years on a 10-point scale. Full mobilization was reached after a mean duration of 2.3 ± 2.0 days while full oral nutrition was completed after a mean duration of 1.8 ± 1.4 days. There were no complications associated with fast-track. The mean hospital stay was 5.8 ± 3.4 days which was not significantly different compared with G-DRG data from other hospitals without fast-track. This was in contrast to the mean hospital stay of patients from the corresponding university hospital (5.6 ± 3.0 days vs. G-DRG 6.9 ± 3.2 days, p < 0.05). After 2 weeks, patients/parents were highly satisfied with fast-track (mean score of 8.6 ± 1.4 on a 1-10-point scale) and 95.2% claimed that they would choose it again. Fast-track concepts can be applied in a nonacademic department of pediatric surgery without previous fast-track experience and with excellent patient/parent satisfaction. However, the G-DRG system interferes with concepts of early discharge of patients. Modifications of the reimbursement modalities within the German health care system seem to be mandatory., (Georg Thieme Verlag KG Stuttgart · New York.)

During LTX, there may be a risk that pathogens of the native liver are released into the systemic circulation. No investigations on incidence/spectrum of pathogens in native livers have been published. We hypothesized that pathogens are found in the native liver of a large proportion of pediatric patients during LTX and investigated the microbiology of native livers. These data may help optimize antibiotic therapy. Twenty-two consecutive pediatric patients (median age 14 months, range, 5 months-15 yr) receiving LTX in our department from October 2010 to October 2011 were included in this prospective study. Tissue and bile were collected from the explanted liver and were cultivated on different media. All liver tissues were investigated using a broad-range PCR (SepsiTest(®)). In 16 patients, blood cultures were collected post-transplantation. Eleven patients (50%) had at least one pathogen detected; nine of these patients had an underlying diagnosis of biliary atresia. SepsiTest(®) was positive in seven patients. In four patients it was the only test detecting any pathogen. In detail, the positivity rate for liver tissue in all patients was 41% (n = 9); for bile 25% (n = 3); and for blood 25% (n = 4). Thirteen different pathogens (69% bacterial, 31% fungal) were isolated. A highly-sensitive broad-range PCR appears to be an effective method to detect pathogens in native livers of patients undergoing LTX. A high number and variety of microbes, including a high proportion of fungal pathogens, were detected., (© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Introduction: Management of appendicitis in children has changed remarkably over the last decade. The proven benefits of laparoscopic appendectomy (LA) over the open operation have made LA increasingly popular for pediatric patients. To date, no national clinical practice guideline is available for pediatric LA in Germany and the operation is not standardized. Thus, the aim of our study was to evaluate the current status of pediatric LA in Germany., Materials and Methods: An internet-based survey was conducted on pediatric LA among all 98 registered pediatric surgical units in Germany, comprising 22 questions with regard to utilization and subjective appraisal of LA, technical standards, perioperative treatment, and training aspects., Results: The survey was completed by 71 of the 98 units (72%). Technical infrastructure for LA was provided in all units, but only in 79% of the units was LA, the standard approach for appendectomy. Overall quality of LA was rated better compared with open appendectomy by 52% units, equivalent by 38% and worse by 3%. The three-port technique was used by 90% of the units; 10% used a single-port approach. Dissection of the mesoappendix was done with bipolar coagulation in 55%, monopolar coagulation in 24%, harmonic knife in 6%, and endostaplers in 11% of the units. Closure of the appendiceal stump was performed using endoloops in 57%, ligations in 3%, endostaplers in 39%, and harmonic knife in 1%. Removal of the appendix was done through the port by 79%, using a retrieval bag by 18%, whereas in 3% it was removed directly through laparotomy. In case of appendiceal perforation, an intra-abdominal drain was placed in 65%. Perioperative antibiotic treatment for nonperforated appendicitis was given as a single shot in 33% of the units, for 24 hours in 17%, for 3 days in 39%, and for 5 to 7 days in 11%. LA was performed by a trainee under supervision in 87%, by a board approved pediatric surgeon in 2%, by an attending pediatric surgeon in 7%, and by the surgeon-in-chief in 4% of the units. For 93% of the sample, LA was an essential part of pediatric surgical training., Conclusion: LA is the favored surgical method for pediatric appendectomy in Germany. However, technical details, perioperative therapy and implementation into training programs remain inconsistent. An effort has to be made to establish national clinical practice guidelines to achieve standardization of LA., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: The size of congenital pulmonary malformation (CPM) in infants might interfere with the feasibility of thoracoscopic resection. This study was undertaken to evaluate the impact of the size of CPM on the applicability of video-assisted thoracic surgery (VATS) in infants., Methods: Twenty-two infants were operated on for CPM from November 2000 to June 2009. The intra- and postoperative course was analyzed retrospectively from patient charts. Preoperative scans were evaluated blindly by a radiologist to calculate the relation between the maximum size of the lesion and the thoracic diameter in VATS and open procedures., Results: VATS was performed in 14 (64%) of the 22 patients and thoracotomy in 8. VATS was successfully performed in 11 (79%) of the 14 patients, whereas VATS was converted to thoracotomy due to lack of overview in 3 (21%). The mean relative size of CPM at preoperative imaging was 0.34 ± 0.05 (range: 0.3-0.4) in patients who received successful VATS, 0.57 ± 0.06 (range: 0.5-0.6) in converted cases, and 0.68 ± 0.10 (range: 0.5-0.8) in infants who underwent thoracotomy. The relative CPM size was significantly lower in successful VATS than in cases of conversion (P<0.01) and thoracotomy (P<0.01)., Conclusions: The relative size of CPM at preoperative imaging might be useful information for a decision-making on the use of VATS in infants. A relative CPM size below 0.5, which is less than half of the thoracic diameter, indicates a good feasibility for thoracoscopic resection of CPM. A larger size may indicate that VATS might be technically difficult.

Background: We recently demonstrated that minimally invasive repair of pectus excavatum (MIRPE) achieves a lasting patient satisfaction after bar removal. This correlated with parent ratings. It has been postulated that patient ratings may be biased by high preoperative patient expectations. The aim of this study was to compare patient self-assessment with general practitioners (GPs) assessment., Methods: Of the 39 patients who underwent bar removal after MIRPE between 2002 and 2006, 39 GPs were asked to answer a modified version of a former single-step questionnaire to evaluate their opinion on psychosocial and physical well-being of their patients. The subjective patient ratings were compared with the GP ratings., Results: Of the 39 GPs, 22 (56%) completed a questionnaire and assessed the outcome of the Nuss procedure. There was a highly significant correlation between GP and patient ratings (p<0.001; correlation coefficient=0.437). Mean total scores obtained from GPs were similar to patient scores (63.4±2.6 SEM vs. 67.5±2.4 SEM; not significant [NS]). Detailed analysis revealed that GPs scored several items differently to their patients: GPs scored social activity (p<0.05) and preoperative self-esteem (p<0.05) significantly lower, but pain episodes (p<0.05) and impairment of daily activities (p<0.05) during the period with the implanted bar significantly higher than their patients. Comparison of the 17 nonassessed cases, with the self-assessment of 22 patients with GP assessment, revealed no significant difference, making an analytical bias unlikely (67.5±2.4 SEM vs. 67.3±2.8 SEM; NS)., Conclusion: GPs found a higher impairment of patient well-being during the period with an implanted bar, which might be related to the high patient motivation to cope with bar impairment. However, the all over GP and patient satisfaction was similar and excellent., (Copyright © 2012 by Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background/purpose: The surgical treatment for patients with progressive familial intrahepatic cholestasis (PFIC) is either liver transplantation (LTX) or partial external biliary diversion (PEBD). Both procedures achieve a good short-term outcome. However, the treatment strategy for these children remains controversial because the long-term outcome after PEBD is unknown. The aim of our study was to assess the long-term outcome and complications after PEBD in our institution., Methods: We retrospectively analyzed the characteristics of all patients with PFIC undergoing PEBD in our department from 1994 to 2008. The course of serum bile acids, pruritus, and liver enzymes was assessed in a regular follow-up., Results: Twenty-four patients underwent PEBD. Thirteen patients (54%) improved significantly, with a normalization of serum bile acids (P < .001 vs postoperatively) and lessened pruritus (P < .05 vs preoperatively) at 12 months after PEBD. None of these patients showed progression of cholestasis during a median follow-up of 9.8 years (range, 1.6-14.3 years). Partial external biliary diversion failed to normalize bile acids in 11 patients, of whom 9 required secondary LTX at a 1-year follow-up, with a median interval of 1.9 years (range, 0.5-3.8 years). All 7 patients (100%) with liver cirrhosis at the time of PEBD and 2 of 17 patients without cirrhosis (12%) required secondary LTX (P < .001)., Conclusions: Clinical improvement with normalization of serum bile acids within 1 year was associated with an excellent long-term outcome in patients with PEBD. The presence of liver cirrhosis at the time of PEBD indicated an unfavorable outcome. Thus, we recommend primary LTX only in PFIC patients with liver cirrhosis., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Aim: To assess the role of minimally invasive surgery (MIS) to diagnose post-transplantation lymphoproliferative disorder (PTLD) in pediatric patients., Methods: Thirty-four patients (20 male, 14 female) underwent organ transplantation (14 liver, 14 kidney, 3 heart, 2 lung, 1 heart-lung) from May 1992 to November 2008 (mean age at transplantation, 66 months; range, 5-277), in whom a biopsy was performed for suspected PTLD from May 1993 to September 2009. The time point of onset, type of PTLD, rate of intraabdominal manifestations with need of MIS, and its accuracy were assessed., Results: Twenty-four of 34 patients (70%) had biopsies of superficial lymph nodes (9), oropharyngeal biopsy (5), gastrointestinal endoscopy or bronchoscopy (5), ultrasound-guided biopsies (3), biopsy of the bone marrow (1), or of the orbita (1). Data of the technique used were unavailable in 3 (9%). Due to lack of superficially located lesions, 6 of 34 patients (18%) had laparoscopic biopsy, of which 4 had abdominal organ graft. Laparoscopic biopsy was successful in 5 of 6 cases (83%). Abscess formation at area of transplanted kidney led to conversion in 1. Tumor extension to the abdominal wall led to a primary biopsy via a mini-laparotomy in another case. One patient with abdominal Burkitt's lymphoma developed a trocar metastasis, successfully treated by systemic chemotherapy. No other complications were observed after MIS. Accuracy of MIS biopsies was 100%. The onset of PTLD was significantly later diagnosed in cases of explicit intraabdominal PTLD (81 ± 6.3 versus 28 ± 5.3 months; P < .001). Morbidity and mortality were not influenced by biopsy technique or time point of PTLD onset., Conclusions: In 20% of pediatric PTLD cases an intraabdominal biopsy is required due to explicit intraabdominal manifestation. As laparoscopic surgery was even feasible in patients after prior abdominal organ transplantation, we suggest laparoscopic biopsy as a safe tool for diagnosing PTLD.

Background: Long-lasting minimally invasive procedures are increasingly used for children. However, the hemodynamic effects of a prolonged carbon dioxide (CO(2)) pneumoperitoneum (PP) on small infants are poorly understood and may differ from the effects on adolescents. This study aimed to detect and compare these effects in neonatal and adolescent pigs., Methods: Six neonatal pigs weighing 5.6-6.4 kg and six adolescent pigs weighing 51-57 kg underwent a prolonged CO(2) PP of 180 min. Five neonatal pigs weighing 5.7-6.6 kg underwent sham PP as an additional control group. All the animals received crystalloid electrolyte solution at 10 ml/kg/h during the experiments. After CO(2) decompression, all the animals were monitored for a further 120 min. The end points of the study were mean arterial pressure (MAP), central venous pressure (CVP), and cardiac index (CI). The parameters were assessed after a 60-min resting phase (i.e., after initial placement of catheters in the jugular vein, the carotid artery, and the femoral artery four times during CO(2) PP and three times afterward., Results: The comparison of neonates and adolescent pigs showed that neonates had a significantly more pronounced decrease in MAP during CO(2) PP (88.1 +/- 2.7% of baseline vs 95.1 +/- 1.6%; p < 0.05) and the recovery period (71 +/- 5.1% vs 86.4 +/- 1.4%; p < 0.05). Differences in CVP changes between the neonatal and adolescent pigs during and after CO(2) PP were not significant. For the neonates, the decrease in CI was most pronounced during the recovery period after decompression of the CO(2) PP and significantly less than in adolescents (84.3 +/- 3.3% of baseline vs 97.4 +/- 4.5%; p < 0.05). The neonates with sham PP did not show any significant MAP, CVP, or CI changes during the experiments., Conclusions: A prolonged CO(2) PP induces hypotension and cardiac depression in neonatal but not in adolescent pigs. Thus, intensive monitoring during prolonged laparoscopic procedures and particularly afterward may be mandatory for neonates.

Background: Caudal anesthesia (CA) is widely recommended due to excellent analgesia in distal hypospadia repairs, but its potential side effect on urinary retention interferes with patient comfort. To objective is to determine the impact of CA versus penile block (PB) on postoperative micturition., Methods: Sixty distal hypospadia repairs performed over a 48-month period were analyzed concerning the impact of applicated analgesia on postoperative micturition. Inclusion criteria were Mathieu or Snodgrass procedures, use of a non-dribbling urethral stent, CA or PB. Endpoint was first postoperative micturation (<6 h), or treatment of delayed postoperative micturation (>6 h)., Results: CA was used in 27 and PB in 33 cases. Compared groups had similar age (mean: 31 months, range 12-68 vs. 28 months, range: 14-145), weight (mean: 13 kg, range 9-18 vs. 15 kg, range 8-59), operation duration (mean 61 min, range 30-105 vs. mean 67 min, range 35-120) and surgical technique (Mathieu/Snodgrass: 7/20 CA vs. 19/14 PB). Micturation was significantly less impaired in the PB than CA group (5/33 vs. 15/27; p < 0.05). Delayed or non-micturation was successfully treated in 4 and 14 patients, respectively, by cholinergic agonists. One patient of each group required a suprapubic drain on the first operative day after unsuccessful medical treatment., Conclusions: In our series, children undergoing distal hypospadia repair experienced significantly less impaired micturition when using penile block instead of caudal anesthesia. We recommend penile block as the first choice perioperative analgesia, when spontaneous postoperative micturition must be guaranteed.

In recent years minimally invasive surgical techniques in children have made substantial progress. The feasibility and safety of a wide spectrum of laparoscopic and thoracoscopic procedures have been confirmed in numerous studies. Moreover, it was reported that minimally invasive pediatric surgery is associated with lower morbidity, a shorter hospital stay, lower costs, better cosmetics and clinical results similar to those achieved by open surgery. The present article reviews information on established as well as feasible but not yet established surgical procedures. The discussion of potential hemodynamic, respiratory and organ perfusion effects of the CO(2) pneumoperitoneum and the notation of special logistic aspects should support the reader in the process of decision-making to schedule infants and children for minimally invasive surgery.

Background: Natural orifice transluminal endoscopic surgery (NOTES) was introduced to reduce scars and the surgical trauma. The feasibility of this technique in children is unknown. Our study was designed to determine the feasibility of various procedures via a transurethral-assisted approach in an animal model., Materials and Methods: Specially designed Aesculap-Braun (Tuttlingen, Germany) instruments and Endo-Ligasure (Valleylab, Boulder, CO) were used in 12 female piglets (mean weight, 15.2 kg; range, 14-17). A modified 12-mm device, including a 0-degree optic and a working channel, was used for the umbilical approach and for CO(2) insufflation (8 mm Hg, flow 5L/min). A 3-mm trocar, including a 2-mm optic, was introduced via the urethra and the urinary bladder dome into the abdominal cavity. The end-point of the study was the feasibility of nephroureterectomy (n = 8) and bilateral tuboovariectomy (n = 4)., Results: All nephroureterectomies and bilateral tuboovariectomies were performed successfully. Closure of the urinary bladder was safely performed with Endoloops (Ethicon Endosurgery, Cincinnati, OH) via the umbilical "two in one system." Intracorporal suturing, knotting, and placement of Endoclips (Ethicon Endosurgery) during nephrectomy were time-consuming due to the restricted motion of the two in one system. The use of a vessel-sealing device allowed a safe, fast, and easy nephroureterectomy., Conclusions: Modifications of instruments and approaches are mandatory for NOTES and must be tested in animal models before being used in infants and children. We showed that nephroureterectomy and tuboovariectomy can be performed safely via a transurethral and umbilical approach in female piglets. The use of vessel-sealing devices is essential in two in one systems with limited view and range of motion.

Introduction: The lack of young physicians in Germany, who are willing to train in surgery, is caused by several factors. Due to the demographic development and the specialisation in paediatric surgery in university institutions, attracting trained paediatric surgeons became difficult for non-specialised rural paediatric surgical departments, which is often also complicated by economic pressures. Strategies, such as cooperation between hospitals or departments, are required. We present a mid-term analysis of the first paediatric surgical cooperation between a university clinic and a rural paediatric surgical department in Lower Saxony., Methods: The Department of Pediatric Surgery, Hannover Medical School (MHH), is a university centre with a case load of about 1,700 surgical procedures per year with a case mix index (CMI) of 1.3. The Department of Paediatric Surgery, St. Bernward Hospital Hildesheim (BK), is a peripheral institution with about 1,200 surgical procedures per year and a CMI of 0.5. A cooperation project was inaugurated in October, 2004, between the two departments. The aim of the cooperation was to support the head of the paediatric surgical department at the BK by rotating trained paediatric surgeons from the MHH. Simultaneously, it was planned to offer attractive conditions for research at MHH for participating surgeons. The cooperation further included sufficient economic cover of 1.5 posts for rotating medical staff by the BK., Results: Three trained paediatric surgeons have so far been included in the rotation programme between the two cooperating paediatric surgical departments. The rotating medical staff costs were covered by the BK. Over a period of 2.5 years, MHH surgeons performed about 50 % of all surgical procedures at BK, while undertaking two-thirds of on-call duties there. Analysis of academic research revealed 3 accomplished experimental and 4 clinical studies, as well as 10 published articles., Conclusions: The paediatric surgical cooperation was rated as a success by the rotating trained paediatric surgeons, the heads of both departments and the hospital administrations. The academic link to a university clinic also increased the attractiveness to work in a paediatric surgical department at a rural hospital.

Minimally invasive techniques are well established in numerous paediatric surgical departments. They are safely applied to children of all age groups. Numerous types of procedures have been established specifically for children and, therefore, the necessary expertise cannot be derived from general surgical experience. Advantages in postoperative symptoms, convalescence and cosmesis have been confirmed. However, data or recommendations concerning the use outside of centres of paediatric surgery are lacking. In the opinion of the authors, minimally invasive paediatric surgery should only be considered for departments with a volume of paediatric specialty operations similar to that of paediatric surgical centres. In addition, an adequate number of operations, specific expertise of the surgeons in minimally invasive paediatric surgery, and specific expertise of anaesthesiologists is mandatory. Today, these prerequisites can only be assumed for non-paediatric specialty operations, such as laparoscopic appendectomy. In conclusion, before recommendations can be made for minimally invasive techniques in specialty paediatric operations outside of paediatric surgical centres, the feasibility and safety under these conditions has to be investigated.

Lung biopsy is necessary for establishing the diagnosis in patients with otherwise unclassified diffuse or localized parenchymal lung disease. This study aimed to assess the safety and accuracy of video-assisted thoracoscopic (VATS) lung biopsy in children with diffuse parenchymal lung disease (DPLD). In addition we aimed to evaluate the value of this technique with respect to the spectrum of diseases encountered, correlating histological diagnosis with treatment decisions and subsequent clinical outcome. Data from all patients (n = 21) who underwent surgical lung biopsy for suspected DPLD between March 2001 and August 2006 were collected prospectively. Median age was 3 years, 8 months (range 11 days to 15 years, 2 months). All lung biopsies were performed by VATS under general anesthesia. Median operative time was 45 min (range 25-100 min). Conversion to minithoracotomy due to cardiorespiratory difficulties was necessary in two young infants. There were no further intraoperative complications. In 8/21 children, a chest tube was inserted postoperatively for a median of 2 days (range 1-5 days). In one patient, prolonged air-leakage was managed thoracoscopically on postoperative day 9. There were no other postoperative complications. The specimens were of adequate volume and quality and a histopathological diagnosis was obtained for all patients. There was a broad spectrum of different diagnoses which led to specific therapeutic decisions. Subsequent medical treatment was beneficial in the majority of the patients. In conclusion, VATS is a safe and effective procedure for diagnosis of children with suspected DPLD. Diagnostic accuracy is high, morbidity rates are low, and patients may benefit from avoiding thoracotomy., ((c) 2008 Wiley-Liss, Inc.)

Background: Carbon dioxide (CO(2)) insufflation during laparoscopy has been shown to dampen the systemic stress response to surgery. This is related to a suppression of peritoneal macrophage functions. In vivo data suggest that CO(2) can also affect neutrophils (polymorphonuclear cells, PMNs), the most abundant cell type in the inflamed peritoneal cavity. Nonetheless, the direct effects of CO(2) on PMNs have not yet been investigated., Method: PMNs were isolated from peripheral blood of healthy volunteers and incubated with (1) CO(2) (100% CO(2), pH 6.2), (2) hypoxic control (95% helium/5% CO(2), pH 7.4), and (3) control (95% air/5% CO(2), pH 7.4). Spontaneous and IL-8-induced migrations (chemokinesis and chemotaxis) during 2 h of exposure to different gases were measured with a transwell chamber system. The release of reactive oxygen species (ROS, luminometry) was determined after 15-min and 2-h exposures. In other sets of experiments, PMNs were exposed for 2 h or 4 h and kept under normal conditions for 18 h with lipopolysaccharide (LPS) stimulation thereafter. Final viability and apoptosis were assessed with fluorometry., Results: Exposure to 100% CO(2) completely blocked spontaneous and IL-8 induced migration of PMNs (p < 0.001 vs. controls). Neutrophil migration was slightly diminished in the hypoxic control group. PMA-stimulated ROS production was reduced even after short exposure to 100% CO(2)(p < 0.05). We observed a slight increase of caspase-3/7 activity after exposure to 100% CO(2) and/or hypoxia; however, total viability was not affected., Conclusions: CO(2) incubation directly and temporarily suppresses the proinflammatory functions of PMNs; this is caused only partially by the concomitant hypoxia. This effect will contribute to the dampened inflammatory response to laparoscopic surgery. Further studies are needed to investigate whether the temporary suppression of neutrophil functions could affect the clearance of bacterial contaminations.

Background: This study aimed to analyze the feasibility of subsequent minimally invasive pectus repair, particularly modified Nuss procedure, combined with simultaneous thoracic procedures for different underlying intrathoracic diseases and conditions., Methods: A total of 110 patients, who underwent minimally invasive pectus repair in Nuss technique over a 5-year period, were retrospectively analyzed concerning complications, cosmetic results, and satisfaction. Six patients (5%) underwent the Nuss procedure with concomitant thoracic interventions. Patients with prior cardiac surgery or planned redo pectus repair were not examined and were excluded. The mean age of 6 patients (3 male and 3 female) was 11 years (range, 5.5-17.2). Two patients with former left-sided transabdominal diaphragmatic hernia repair and 1 with former lobectomy of the left lower lobe underwent thoracoscopic adhesiolysis. Two underwent thoracotomy: one for closure of a recurrent left-sided diaphragmatic hernia with fundoplication owing to a large hiatal hernia, another for lobectomy of the right middle lobe owing to recurrent infections and bronchodysplasia. One patient presented with anterior mediastinal mass, which was suspected to be benign, and underwent thoracoscopic complete resection. All patients underwent a 1-stage procedure with subsequent simultaneous Nuss procedure., Results: Simultaneous Nuss procedure was feasible without intraoperative complications in all patients (100%). Thoracoscopic adhesiolysis did not affect the feasibility of the Nuss procedure in 3 patients with former diaphragmatic hernia repair, particularly former lobectomy in one. Thoracotomy with middle-lobe lobectomy, as well as repair of recurrent diaphragmatic hernia and fundoplication in 2, did not affect modified Nuss technique and dispensed thoracoscopic guidance. Histopathologic analysis in one patient with a removed anterior mediastinal mass revealed Hodgkin lymphoma (stage IA), and the patient received multiagent chemotherapy. The postoperative course was uneventful in 5 of 6 patients. One patient required intermittent drainage of pleural effusion after simultaneous lobectomy. At follow-up (6 months-5 years), 6 patients had excellent cosmetic results and good quality of life confirmed by a questionnaire. There was no evidence of recurrent malignancy in one patient after 6 months., Conclusions: Thoracic surgery and subsequent Nuss procedure can be performed simultaneously. Underlying conditions, such as prior repair of congenital diaphragmatic hernia or diaphragmatic eventration, as well as former lobectomy, had no impact on feasibility. Open thoracotomy can be combined with Nuss procedure dispensing thoracoscopy.

Exclusive lower pole pelvi-ureteric junction obstruction (PUJO) in double collecting systems in children is a rare condition requiring reconstructive surgery. We report on the feasibility of laparoscopic transabdominal dismembered pyeloplasty in two cases. Two children with duplicated collecting systems presented with hydronephrosis of lower pole moiety due to exclusive PUJO. Isotope renography revealed impaired drainage of affected lower kidney pole. A four-trocar transabdominal technique was used. No stent was used in one patient with bilateral duplication (male, 6 years) while a 4 Fr. double-J stent was placed laparoscopically in another with unilateral duplication (male, 9 months). Both patients had uneventful laparoscopic transabdominal dismembered pyeloplasty. The operation time was 115 and 155 min, respectively, and was comparable to our previously reported patient series undergoing laparoscopic pyeloplasty for singular collecting systems. After a mean follow-up of 21 months (range 12-42), both patients were asymptomatic and showed improved pelvi-ureteric drainage on isotope renography and improved hydronephrosis on ultrasound scan. Laparoscopic transabdominal dismembered pyeloplasty is safe and effective in children with rare lower pole PUJO in double collecting systems.

Background: The use of minimally invasive surgery (MIS) in pediatric cancer is a matter of debate. The diagnostic and ablative roles of MIS were evaluated in a consecutive series of children with malignancies., Methods: A prospective study, including all patients, who underwent abdominal and thoracic surgery for confirmed or highly suspected pediatric cancer was performed from September, 2000, to December, 2005. An interdisciplinary panel approved the indication for minimally invasive or conventional surgery., Results: At a single institution, 301 operations were performed on 276 children with cancer. A minimally invasive approach was attempted in 90 of these patients (30%) and successfully employed in 69 (77%) of the operations. However, 21 operations (23%) were converted to an open approach. Regarding the abdominal operations attempted laparoscopically, 41 abdominal operations for biopsy or staging purposes were attempted laparoscopically (53%), but 6 were converted. In all, 139 abdominal resections were performed and 24 were attempted laparoscopically. Ten of these (42%) were converted. In 34 thoracic operations requiring biopsy, thoracoscopy was attempted in 14 (41%) and was successful in all but 1 (93%). Fifty-one thoracic tumors were resected and the thoracoscopic approach was attempted in 11 (22%) and successful in 7 (14%). Conversions from a minimally invasive operation to an open procedure occurred mainly due to limited visibility. Three bleeding complications occurred with 1 patient requiring a blood transfusion. In addition, 1 small bowel injury occurred with immediate laparoscopic closure. There were no port site recurrences after a median of 39 months., Conclusions: MIS is a reliable diagnostic tool for pediatric abdominal and thoracic malignancy. The role of ablative MIS in pediatric cancer remains limited., ((c) 2007 American Cancer Society.)

Background: Improvement of quality of life by minimally invasive repair of pectus excavatum (MIRPE) has been demonstrated only for the period with implanted pectus bar. The aim of this study was to demonstrate the effects of MIRPE on psychosocial and physical well-being after removal of the pectus bar., Methods: Forty patients (26 boys and 14 girls; mean age, 17 years; range, 10 to 24 years) were assessed. Follow-up was performed for a mean of 54 months after pectus repair (range, 25 to 73 months). Patients were interviewed at 6 months after MIRPE with the bar in place, and patients and parents were assessed a mean of 23 months after bar removal (range, 2 to 48 months). A single-step questionnaire that evaluates psychosocial and physical well-being was independently used by patients and their parents., Results: There was a high level of persistent satisfaction with MIRPE after bar removal (mean total score = 67; maximal score = 80) and a highly significant correlation between self and external assessment (p < 0.001; Spearman correlation coefficient = 0.77). Analysis of specific and total scores revealed a significant improvement of psychosocial and physical well-being after bar implantation, which persisted up to 4 years after bar removal (p < 0.001). Age and sex had no significant impact on the mean specific and total scores either in patients or in parents. Persistent pectus excavatum was noticed in 1 patient after bar removal (2.5%) as a result of treatment failure., Conclusions: The positive impact of MIRPE on psychosocial and physical well-being in children and adolescents persists after bar removal. Thus we consider MIRPE to be justified for cosmetic reasons.

Numerous human macrophage (mphi) subpopulations with different behavior have been identified in adults. It is well known that peritoneal mphi are activated by abdominal surgery and subsequently contribute to a systemic inflammatory response that leads to immune suppression, increased morbidity and mortality. Information on the role of pleural mphi in adults is scarce and information on their role in children is lacking. We investigated the behavior of pleural versus peritoneal mphi in children and adolescents. As a first step, we compared the cellular composition of the pleural and peritoneal surface in children and adolescents. Pleural and peritoneal lavages were performed in 21 patients undergoing non-contaminated laparoscopic and thoracoscopic surgical procedures. We observed a significantly higher percentage of mphi in the pleural compared to the peritoneal cavity with less lymphocytes, a small amount of polymorphonuclear cells (PMNs) and other cells. To further study the mphi inflammatory response, we measured the spontaneous and LPS triggered cytokine release of isolated pleural versus peritoneal mphi (IL-1beta, IL-6, and IL-10). The pattern of cytokine release was similar in both, pleural and peritoneal mphi. Directly after lavage, they showed a strong activation, with no difference between stimulated and non-stimulated cells. After 24 h resting, mphi of both compartments reacted to LPS with a similar significant increase in the cytokine release. In conclusion, our results demonstrate that pleural mphi represent the dominant cell population in the pleural cavity of the young. They show a similar inflammatory response as peritoneal mphi and should be considered to play a major role in the local inflammatory response to thoracic surgery.

Background: Superoxide anions released by activated macrophages during surgery are considered to be responsible for local cellular damage. Application of CO2 pneumoperitoneum during laparoscopy affects superoxide anion release, but the underlying mechanism remains unclear and the data reported are conflicting. We investigated the direct and pH-mediated impact of CO2 and air on macrophage superoxide anion production., Methods: Cells of the NR 8383 rat macrophage cell line were incubated for 2 hours in 5% CO2, 100% CO2, and room air or pH 7.4, pH 6.5, and pH 5.5. The extracellular pH was monitored during incubation. At 0, 2, and 6 hours after incubation, the release of superoxide anions was determined fluorometrically. The mitochondrial activity was determined via the conversion of MTT [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide] during and after incubation., Results: Extracellular pH decreased to 6.4 during incubation in a CO2 atmosphere. The release of superoxide anions was significantly reduced immediately after CO2 incubation. It was restored at all other time-points. Decreasing the extracellular pH to 6.5 had no effect on superoxide anion release, whereas acidification of the extracellular milieu to pH 5.5 significantly suppressed subsequent superoxide release. Mitochondrial activity was significantly decreased by CO2 up to 2 hours and by acidic milieu up to 6 hours. Incubation in room air had no effect., Conclusions: Incubation in CO2 can directly suppress macrophage superoxide anion production. This effect is of short duration, fully reversible, and not correlated to changes in extracellular pH or mitochondrial activity. Air contamination does not affect macrophage superoxide anion release. We speculate that CO2 pneumoperitoneum could attenuate the intraoperative free radical production by directly inhibiting superoxide anion release of macrophages without long-lasting suppression of macrophages and their capacity to release superoxide anions postoperatively.

Background: There are varying data regarding the degree and extent of abdominal acidification during laparoscopy. The aim of this study was to determine the extent of peritoneal acidification during carbon dioxide insufflation and the effects of different pressures, insufflation rates, and free intraperitoneal fluids., Materials and Methods: Sixteen male Sprague-Dawley rats weighing 250-300 g were anesthetized and a two-point pH probe was inserted in the abdominal cavity. After closure of the abdominal wall, each group of 4 rats was subjected to one of four insufflation regimens: low pressure (2 mm Hg, no leakage); high pressure (10 mm Hg, no leakage); leakage (2 mm Hg, leakage 0.5 mL/min); and fluid (2 mm Hg, 10 mL intraperitoneal 0.9% NaCl). During insufflation peritoneal pH was continuously measured., Results: Carbon dioxide insufflation significantly decreased the peritoneal pH to <7.0 only in areas exposed to the insufflation gas. Neither changes in pressure nor insufflation rate had major effects on the peritoneal pH. The addition of 10 mL normal saline into the abdominal cavity significantly enhanced the pH change during insufflation. conclusion: Acidification associated with carbon dioxide pneumoperitoneum is limited to the area of inspection and manipulation. The increased acidification following injection of normal saline could offer a useful mechanism to alter the inflammatory response.

Background: This study aimed to determine the impact of prior surgery on the feasibility of laparoscopic surgery for children., Methods: A prospective study analyzed 471 consecutive children who underwent laparoscopic surgery over a 4-year period. Laparoscopic procedures were classified "easy," "difficult," or "demanding." The end points of the study were conversion rate, intraoperative events, and duration of operation., Results: A total of 89 patients (19%) had undergone previous abdominal surgery. The conversion rate was 18% for the patients with prior surgery versus 9% for those without a prior operation (16/89 vs 35/382; p < 0.05). This difference reflects a significantly higher conversion rate for "easy" procedures among patients with than among those without prior surgery, but not for "difficult" and "demanding" procedures. The type of prior surgery had no significant impact on the mean duration of the operation. Of 71 procedures, 12 (17%) after prior conventional surgery were converted, as compared with 4 (22%) of 18 after prior laparoscopy (p > 0.05). Intraoperative events, mainly attributable to adhesions and lack of overview, occurred in 8% of patients with prior procedures, as compared with 2% without former surgery (7/89 vs 9/382; p < 0.05). Relevant complications were not significantly more frequent after prior surgery. The incidence of conversions decreased with increased time between current and previous surgery. It was 64% for surgeries less than 1 year later, 25% for surgeries 1 to 5 years later, and 5% for surgeries more than 5 years later (7/11 vs 6/24 vs 3/54; p < 0.001)., Conclusions: Prior surgery has a limited impact on the feasibility of laparoscopic surgery for children. The conversion rate and the incidence of intraoperative events, mainly because of adhesions and lack of overviewing, is increased, but not the incidence of relevant complications. The feasibility improves considerably with increased time between surgery and prior surgery. The authors consider laparoscopy to be the first-choice technique after prior surgery.

Background: This study was conducted to evaluate the feasibility of using the LigaSure vessel sealing system (Valleylab, Boulder, CO) in laparoscopic transperitoneal vs. open retroperitoneal heminephroureterectomy in children., Materials and Methods: Seven consecutive patients with impaired renal duplex systems underwent laparoscopic heminephroureterectomies using LigaSure between April 2003 and April 2005. The operative time, complications, and hospital stay were analyzed prospectively. The data of 7 consecutive patients who had undergone open retroperitoneal heminephroureterectomy from 2001 to 2003 were analyzed for comparison purposes. The mean ages, underlying disease, and location of the affected kidney pole were not significantly different between these groups., Results: There were no intraoperative complications during laparoscopic heminephroureterectomy and all procedures were completed laparoscopically. The mean operative time of 144 minutes (range, 90-210 minutes) for laparoscopic heminephroureterectomy was somewhat longer than in open heminephroureterectomy-mean time 110 minutes (range, 60-165 minutes) (P = 0.5). Complications of open retroperitoneal heminephroureterectomy included bleeding of the surface of the remaining kidney pole in one patient, requiring extensive hemostatic suturing. Postoperative recovery was uneventful in all laparoscopic procedures, whereas intermittent retention of urine was noticed in one patient undergoing the open procedure., Conclusion: Laparoscopic heminephroureterectomy using LigaSure is feasible in children and has a similar operative time compared to conventional heminephroureterectomy.

Purpose: We analyzed the feasibility of laparoscopic nephroureterectomy in children younger than 1 year, with regard to size of impaired kidney., Materials and Methods: A total of 40 consecutive children underwent transperitoneal laparoscopic nephrectomy during a 4-year period. Of the patients 19 (48%) were younger than 1 year and were analyzed in detail. Nine of these patients (47.4%) had a multicystic dysplastic kidney, 9 (47.4%) had reflux nephropathy and 1 (5.3%) had obstructive nephropathy. The duration of operation, reasons for conversion, and intraoperative and postoperative complications were prospectively documented., Results: Mean operative time was 133 minutes (range 60 to 240), and did not differ significantly between patients up to age 12 months compared to children 1 year and older (126 vs 148 minutes, NS). Nephroureterectomy was completed laparoscopically in 17 of 19 children (89%) up to age 12 months vs 20 of 21 (95%) 1 year and older (NS). In 1 child younger than 1 year suture dislocation at the renal artery required laparoscopic resuturing. No further complications were seen. In children younger than 1 year the mean operating time was not significantly different for resection of multicystic dysplastic kidney (8 patients, 113 minutes) compared to reflux nephropathy (9, 134 minutes, NS). Mean operating time did not differ significantly for kidney volumes less than 10 cc (8 patients, 119 minutes) compared to kidney volumes greater than 10 cc (9, 129 minutes, NS)., Conclusions: The feasibility of transperitoneal laparoscopic nephroureterectomy in children younger than 1 year is excellent. The duration of operation is not affected by patient age, underlying disease or kidney size.