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Introduction The highest percentage of female surgeons is found in pediatric surgery but most departments are led by men. The aim of this study is to evaluate gender-related career goals, perceived career opportunities, and reasons for differences. Materials and Methods An online questionnaire was created and distributed to pediatric surgeons in Germany, Switzerland, and Austria between July and September 2020. Participants were asked to state current position, career goals, and perceived career opportunities in comparison to a colleague of the opposite gender. Reasons for gender-related differences were asked for as free-text comments. Results A total of 182 questionnaires were analyzed. The overall gender ratio was balanced but junior positions were predominantly held by women, while there were more men in leading positions. Most women pursued a position as a consultant, while the majority of men aimed for a leading position. Men mostly regard both genders to have the same career opportunities, whereas most women believe the chances of men to be better. From the free-text answers, three following categories for gender-related differences in career chances were derived: (1) absences due to maternity, (2) differing support and bias arising from gender-related stereotypes, and (3) assumed personality traits. Conclusion There are gender-related differences in career opportunities in pediatric surgery. Gender equality is needed not only to overcome injustice but also to maximize team efficiency and collaboration. Career support needs to be gender-independent and (unconscious) bias needs to be recognized and eradicated.

Introduction Inguinal procedures in children are frequent and typically performed in an outpatient setting. We aimed to analyze whether there is a difference in postoperative pain scores and setup time (start of anesthesia management to incision time) when comparing caudal block (CB) with local wound infiltration. Materials and Methods We enrolled pediatric outpatients scheduled for inguinal procedures. Patients were randomized to receive either preincision CBs or end-of-procedure local wound infiltration. Postoperative pain scores until 24 hours postoperatively and setup time were analyzed. Results Fifty-two patients were included in the study. Thirty patients received a CB, and 22 patients received local infiltration (LI). There was no significant difference in postoperative pain scores. Setup time was significantly higher in the CB group: median 22.5 minutes IQR (16–46 minutes) compared with 17 minutes in the LI group IQR (10–35 minutes), p-value of 0.0026. Conclusion Both CB and LI result in good postoperative pain control after inguinal procedures in pediatric outpatients. Since LI is less time consuming and has lower risks for complications, we recommend this technique for inguinal procedures in pediatric outpatients. Our findings will need to be confirmed in larger cohorts, but we believe the evidence generated with this study has the potential to positively influence patient care, operating room efficiency, and costs.

ZusammenfassungDie Hydronephrose beim Kind ist zumeist bedingt durch eine (kongenitale) intrinsische Ureterabgangsstenose. Die von Anderson und Hynes etablierte „dismembered“ Nierenbeckenplastik stellt den Goldstandard in der operativen Therapie dar, sei es über einen offenen Zugang oder laparoskopisch (auch robotisch assistiert) bzw. retroperitoneoskopisch durchgeführt. Weniger häufig findet man – zumeist bei Patienten jenseits des Säuglingsalters − eine extrinsische Stenose als Ursache einer – dann zumeist – intermittierenden bzw. dynamischen Hydronephrose. Diese wird verursacht durch ein oder mehrere aberrierende Unterpolgefäße, welche den uretero-pelvinen Übergang obstruieren. Hierfür ist die operative Verlagerung des Gefäßes durch eine Tunnel-Plastik am Nierenbecken, die sog. „vascular hitch“-Operation, von Hellström beschrieben, in zunehmender Weise wieder etabliert worden. Die beiden Möglichkeiten der operativen Therapie werden nach wie vor kontrovers diskutiert. In der Literatur findet sich Evidenz dafür, dass bei Vorliegen eines Polgefäßes in bis zu 57 % zusätzlich eine intrinsische Stenose ist, in bis zu 100 % zumindest histologische Alterationen wie bei einer intrinsischen Stenose vorhanden sind. Der intraoperative Aspekt erlaubt keine Diskriminierung zwischen intrinsischer und extrinsischer Stenose, diese kann nur histologisch objektiviert werden. Bei der Durchführung eines „vascular hitch“ besteht daher das Risiko einer verbleibenden intrinsischen Stenose mit konsekutiver Abflussstörung und der Gefahr einer Partialfunktionsminderung. Auch kann durch den „vascular hitch“ selbst die Durchblutung der Niere kompromittiert werden. Die sog. „dismembered“ Nierenbeckenplastik vermeidet hingegen ein falsches Selektionieren der Patienten. Zudem ist sie mit hinreichender Evidenz belegt als ein Verfahren mit niedriger Komplikationsrate von 2 – 3 % und funktionell sehr guten Ergebnissen hinsichtlich des Erhalts der Partialfunktion und der Verbesserung der Abflussdynamik. Im Vergleich besteht in der Literatur kein vermehrtes Komplikationsrisiko gegenüber der „vascular hitch“-Operation. Daher bevorzugen wir die "dismembered" Nierenbeckenplastik als Methode der Wahl bei der Hydronephrose und dem Vorliegen eines aberrierenden Polgefäßes.

The surgical correction of craniostenosis in children is a time-consuming and taxing procedure. To facilitate this procedure, especially in infants with complex craniostenosis, we refined the computer-aided design and manufacturing technique (CAD/CAM) based on computed tomography (CT)-generated DICOM data. We used cutting guides and molding templates, which allowed the surgeon to reshape and fixate the supraorbital bar extracorporeally on a side table and to control the intracorporal fit without removing the template. To compare our traditional concept with the possibility of preoperative virtual planning (PVP) technique, the surgical treatment and courses of 16 infants with complex craniostenosis following fronto-orbital advancement (FOA) (age range 8–15 months) were analyzed in two groups (group 1: traditional, control group n = 8, group 2: CAD/CAM planned, n = 8). While in both groups, the head accurately reshaped postoperatively during the follow-up; the CAD group 2 showed a significantly shorter operating time with a mean of 4 h 25 min compared with group 1 with a mean of 5 h 37 min (p = 0.038). Additionally, the CAD group 2 had a significantly lower volume of blood loss (380 ml vs. 575 ml mean, p = 0.047), lower blood transfusion volume (285 ml vs. 400 ml mean, p = 0.108), lower fresh frozen plasma (FFP) volume (140 ml vs. 275 ml mean, p = 0.019), shorter stay in the pediatric intensive care unit (PICU) (3 vs. 5 days mean (p = 0.002), and shorter total length of hospital stay (6 days vs. 8 days mean, p = 0.002). CAD/CAM cutting guides and templates offer optimizing operative efficiency, precision, and accuracy in craniostenosis surgery in infants. As shown in this single-center observational study, the use of on-site templates significantly accelerates the reconstruction of the bandeau. The virtual 3D planning technique increases surgical precision without discernible detrimental effects.

No abstract available., + ID der Publikation: unilu_51609 + Sprache: Englisch + Letzte Aktualisierung: 2021-11-04 11:45:42

Background Entrustable Professional Activities (EPAs) are being implemented worldwide as a means to promote competency-based medical education. In Switzerland, the new EPA-based curriculum for undergraduate medical education will be implemented in 2021. The aim of our study was to analyze the perceived, self-reported competence of graduates in 2019. The data represent a pre-implementation baseline and will provide guidance for curriculum developers. Methods Two hundred eighty-one graduates of the Master of Human Medicine program of the University of Zurich who had passed the Federal Licensing Exam in September 2019 were invited to complete an online survey. They were asked to rate their needed level of supervision (“observe only”, “direct, proactive supervision”, “indirect, reactive supervision”) for 46 selected EPAs. We compared the perceived competence with the expected competence of the new curriculum. Results The response rate was 54%. The need for supervision expressed by graduates varied considerably by EPA. The proportion of graduates rating themselves at expected level was high for “history taking”, “physical examination” “and documentation”; medium for “prioritizing differential diagnoses”, “interpreting results” and “developing and communicating a management plan”; low for “practical skills”; and very low for EPAs related to “urgent and emergency care”. Conclusions Currently, there are significant gaps between the expectations of curriculum developers and the perceived competences of students. This is most obvious for practical skills and emergency situations. The new curriculum will either need to fill this gap or expectations might need to be revised.

Background Little is known about the timeframe in which acquired undescended testes occur. To guide recommendations for screening examinations, we aimed to (1) specify the ratio of acquired undescended testes in orchiopexy cases and to (2) identify a predisposing age for the development of acquired undescended testis. Methods Three-hundred-forty cases of orchiopexy were retrospectively analyzed and classified as congenital or acquired cases of undescended testis. In acquired cases, the time of the last documented physiological testicular position was obtained. The time of testicular ascent was approximated by calculating the mean between the last physiological finding and orchiopexy. Results In 151 cases (44.4%) prior physiological position of testes was documented and acquired undescended testis was assumed. In 115 of these cases (76.2%) details on the age at last physiological position were available. Ascent occurred between the age of one and fourteen. The 50th, 75th, 85th, 90th and 95th percentile for the estimated age at ascent was 5.8, 7.3, 8.4, 8.7 and 11.1 years, respectively. Conclusions Acquired undescended testes are a common cause of cryptorchidism. Ascent occurs throughout all prepubertal ages, emphasizing the need to regular follow-up of testicular position until puberty. Type of Study Prognosis study. Level of Evidence Level II.

The results of studies comparing two-dimensional (2D) and three-dimensional (3D) laparoscopy have shown variable results. We aimed to review the literature and develop an appropriate instrument to compare 2D and 3D laparoscopy. We further aimed to use the data extracted to perform a pilot study.Sixty-seven recent articles on 3D laparoscopy were reviewed and data extracted on factors influencing outcome variables. These variables were used to design a pilot study of 28 novices using a randomized crossover design. The results were analyzed using descriptive statistics and the Wilcoxon signed-rank tests.Seven themes were identified to influence the outcome of 3D studies: applied technique (1), experience of subjects (2), study design (3), learning curve (4), subjective qualitative reports (5), laparoscopic tasks (6), and chosen outcome variables (7). The consecutively developed five laparoscopic simulation tasks contained placing a rubber band over hooks, ring and pearl transfer, threading a pipe cleaner through loops, and placing a suturise. The pilot study showed a primary benefit of 3D laparoscopy that was unrelated to repetition. Two tasks served well to assess first-time performance, and two tasks promise to serve well to assess a learning curve if performed repeatedly.We were able to identify important issues influencing the outcome of studies analyzing 3D laparoscopy. These may help evaluate future studies. The developed tasks resulted in meaningful data in favor of 3D visualization, but further studies are necessary to confirm the pilot test results.

Introduction Sagittal synostosis leading to scaphocephaly is the most common type of craniostenosis being operated. Different treatment options are known, but the optimal treatment method is still controversial. Head growth indicated by measurements of the head´s circumference and cephalic index (CI) are valid surrogate parameters for normal head shapes in children. The aim of the study was to analyze if osteoclastic craniectomy (OC) in scaphocephaly children at four to ten months of age results in normal head shapes. Patients and methods Twenty-seven patients with scaphocephaly underwent OC between 2003 and 2011. The mean patient age at the time of surgery was 6.75 months. The body weight was between 6.1 and 9.3 kg, mean 8.0 kg. The average duration of surgery was 108 minutes. The mean blood loss during the procedure was 168 ml and the mean amount of erythrocyte transfusion was 152 ml. The mean time spent on the ICU was 1.48 days and the mean of total hospital stay was 5.81 days. The operative method is described. During the mean follow-up time of 6.3 years (min 3.8, max 10.4, median 7.1) focus was set on the patient´s head growth and cephalic index (CI) following OC. For statistical reason the follow up period was divided into three groups: follow up 2-4 years, 5-7 years and 8-10 years. Results For all cases the total head growth was 9.5cm (mean) during the follow up period of 6.3 years. Analyzing the mean head growth by bootstrapping analysis, the three observational groups showed a significant increase of the head circumference in all cases being analyzed: group 1 p=0.003, group 2 p=0.005 and group 3 p=0.028 Evaluation of the CI showed a statistically significant change from a pathologic value of 0.67 (mean) preoperatively to a normal value of 0.78 (mean) postoperatively during the follow up analyzing all patients. To precise these findings, the bootstrapping analysis showed in the first period an increase of the mean CI not reaching statistical significance (p=0.351). Analyzing the second and third period the CI significantly increased in both groups (p=0.016 and p=0.037). All patients showed a nearly complete re-ossification during the follow up period. No secondary operation was necessary in any patient of this cohort. Conclusion As shown in this single-center observational study, the surgical intervention significantly improved the cephalic index and resulted in a symmetric head shape with excellent aesthetic appearance. The results were not dependent on postoperative helmet therapy, and compliance of caregivers. Re-ossification reached 100% within the observation period. According to these data, we recommend osteoclastic craniectomy as the method of choice in infants six to twelve months of age.

Varicocele is defined as an abnormal dilation and tortuosity of the internal spermatic veins found within the pampiniform plexus. It is a common finding in adolescents and adult men alike, however its diagnosis in the adolescent population poses different dilemmas in regard to indications for treatment than in adults. Failed Paternity is a clear-cut indication for repair in adult men attempting to father children. In adolescents, the physicians, family and patients must consider potential for future fertility problems which may or may not actually become of concern. Assessing the degree of negative effect of the varicocele on an adolescent's testicular health can also be difficult as teenagers typically are not asked to provide semen for analysis and thus surrogate markers for testicular health such as testicular size differentials must be used. Treatment options for the adolescent varicocele are similar to options in adult populations. While risks and benefits of various techniques can be considered, the gold standard for varicocele repair in adolescents has not been clearly defined. We aim to discuss diagnosis of varicocele, considerations for initiating treatment of varicocele in the adolescent, and techniques for management.

Uretero-pelvic junction obstruction (UPJO) is the most common cause of hydronephrosis in infants and children. Historically, this condition has been approached surgically through a retroperitoneal approach as described by Anderson and Hynes aiming for an open dismembered pyeloplasty. A true evolution of laparoscopy in pediatric urology took place within the last 30 years. Laparoscopy developed from a merely diagnostic tool for non-palpable testes to “interventional” laparoscopy for extirpative surgery. Finally the era of reconstructive pediatric laparoscopic urology started, when in 1995 Peters described the first laparoscopic pyeloplasty in a child. Laparoscopic dismembered pyeloplasty now has become the preferred surgical treatment of UPJO. It offers excellent visualization of the anatomy, accurate anastomotic suturing, thus the precise reconstruction of the UPJ along with good functional outcome. This article aims to provide the current status, indication and operative technique of laparoscopic dismembered pyeloplasty for UPJO in infants and children.

Hintergrund: In der Unfallchirurgie besteht ein gravierender Nachwuchsmangel, welcher sich in den letzten Jahren verscharft hat. Die Ursachen hierfur sind vielschichtig. Studien haben gezeigt, dass das Interesse am Fach Chirurgie im Verlauf des Medizinstudiums deutlich abnimmt. Um dem Nachwuchsmangel in der Klinik entgegenzuwirken, sollte schon im Studium das Interesse, insbesondere auch durch gute Lehrveranstaltungen, fur das Fach Unfallchirurgie geweckt werden. Ziel dieser Untersuchung war es, die aktuelle Form des Blockpraktikums der Unfallchirurgie unserer Universitat als curriculare Pflichtveranstaltung aller Medizinstudenten prospektiv zu evaluieren. Material und Methoden: Das untersuchte Praktikum der Unfallchirurgie findet im 5. klinischen Semester statt. Das Praktikum hat einen strukturierten Ablauf, wobei praktische Kurse, Beobachtungsmodule und Vorlesungen kombiniert werden. Fur das Praktikum steht in der Klinik ein eigenes Lehr- und Schulungszentrum fur die Durchfuhrung der praktischen Anteile zur Verfugung. Es wurde mit einem anonymen Fragebogen nach der Gesamtbeurteilung, dem Lernerfolg der praktischen und theoretisch orientierten Module und dem spezifischen Interesse an der Unfallchirurgie gefragt. Ergebnisse: Das evaluierte Blockpraktikum zeigte in der Gesamtbewertung dieser Studie ein sehr gutes Ergebnis mit einer Gesamtbewertung von 1,53 (Mittelwert) auf einer 6-Punkt-Likert-Skala. Es konnte gezeigt werden, dass Studenten, die sich vor dem Blockpraktikum nicht vorstellen konnten, in der Unfallchirurgie zu arbeiten, nach dem Praktikum signifikant mehr Interesse am Fach hatten. Die einzelnen praktischen Blocke wurden von den Studierenden insgesamt sehr gut bewertet. Schlussfolgerung: Wir konnten zeigen, dass es mit intensiver, qualitativ hochwertiger Lehre moglich ist, auch bei fur Orthopadie und Unfallchirurgie primar wenig aufgeschlossenen Studierenden, das Interesse an diesem Fach zu wecken.

Objectives A change in German licensing legislation imposed a portfolio for surgical clerks. We aimed to analyze whether the implementation of the portfolio changed the amount of clinical exposure and activities during surgical clerkships. Design The study was conducted with a modified pre-post design at the University Hospital of Tuebingen, Germany. Before and after the implementation of the portfolio on April 1, 2013, final-year students ( n = 557) who had just finished their surgical clerkship were interviewed with an online questionnaire. A total of 21 basic surgical skills were evaluated. Results Overall, 230 questionnaires were returned and analyzed; 51% were preintervention. Overall clinical activity for the whole study cohort varied for different activities between 98% and 32%. For 16 of 21 parameters, there was more clinical activity in the postintervention (portfolio) group. This difference was statistically significant for the following 7 activities: discharge, analgesia, local infiltration, patient positioning, drain in, blood transfusion, and emergency diagnostics. Conclusion The implementation of the portfolio did enhance clinical activity for surgical clerks in the study cohort. Nevertheless, overall exposure is still unsatisfactory low for some activities. Additional changes and studies are necessary to further improve surgical education.

In children, ureteropelvic junction obstruction (UPJO) is mostly caused by intrinsic factors (IUPJO); extrinsic UPJO are rare and often due to crossing vessels (CVs). We retrospectively reviewed all data of children with UPJO that underwent surgery in our institution from 2004 to 2011. Analyses included age at surgery, gender, preoperative and postoperative results of ultrasound and renal scans [differential renal function (DRF); signs of obstruction], and pathology reports. Available histological specimens of cases with CV were compared to a random selection of intrinsic cases in a blinded fashion. After additional Masson’s trichrome staining, the specimens were scored for fibrosis, muscular hypertrophy, and chronic inflammation. Out of 139 patients with UPJO, 39 cases were associated with CV. Median age at surgery was 68 months (range 2–194) in the CV group and 11.5 months (range 0–188) in IUPJO group. Laparoscopic dismembered pyeloplasty (LDMP) was carried out in 134 and open DMP in five patients. Preoperative ultrasound identified 28/39 cases with CV. DRF below 40 % was more frequently seen in CV patients (p = 0.020). Histological analyses revealed no differences between the CV and IUPJO specimens in total. CV patients with higher grades of muscular hypertrophy had lower preoperative DRF, compared to those with higher preoperative DRF (p = 0.026). Functional recovery after (L)DMP was excellent in both groups. We could not find any significant histological differences between CV and IUPJO in children. To obtain excellent functional recovery, surgical procedures with a definite correction of the UPJ should be preferred in paediatric patients with CV.

Padiatrische Fieberkrampfe treten bei fiebernden Kindern im Alter zwischen 6 Monaten und 6 Jahren auf. Der einfache Fieberkrampf ist generalisiert, dauert 15 min andauert, fokal beginnt, mit postiktalen Paresen einhergeht oder mehrmals innerhalb von 24h auftritt.Eine Lumbalpunktion oder zerebrale Bildgebung ist primar nicht indiziert, ist jedoch bei komplizierten Fieberkrampfen oder febrilem Status epilepticus immer in Erwagung zu ziehen. Bei Meningismus-Zeichen ist eine Lumbalpunktion zum Ausschluss einer Meningitis als wichtigster Differenzialdiagnose obligat. Eine Anfallsdauer von > 3–5 min ist eine Indikation zur medikamentosen Unterbrechung mit Benzodiazepinen als Mittel der ersten Wahl. Ein febriler Status epilepticus ist nach dem gleichen therapeutischen Stufenplan wie ein afebriler konvulsiver Status epilepticus zu behandeln.Eine antikonvulsive Prophylaxe ist bei einfachen Fieberkrampfen nicht notig, bei komplexen rekurrierenden Fieberkrampfen jedoch zu erwagen. Nach aktueller Datenlage senkt eine fruhe antipyretische Therapie das Rezidivrisiko fur weitere Fieberkrampfe nicht.

Patients with cystic fibrosis (CF) lung disease have chronic airway inflammation driven by disrupted balance of T-cell (Th17 and Th2) responses. Regulatory T cells (Tregs) dampen T-cell activation, but their role in CF is incompletely understood.To characterize numbers, function, and clinical impact of Tregs in CF lung disease.Tregs were quantified in peripheral blood and airway samples from patients with CF and from lung disease control patients without CF and healthy control subjects. The role of Pseudomonas aeruginosa and CF transmembrane conductance regulator (CFTR) in Treg regulation was analyzed by using in vitro and murine in vivo models.Tregs were decreased in peripheral blood and airways of patients with CF compared with healthy controls or lung disease patients without CF and correlated positively with lung function parameters. Patients with CF with chronic P. aeruginosa infection had lower Tregs compared with patients with CF without P. aeruginosa infection. Genetic knockout, pharmacological inhibition, and P. aeruginosa infection studies showed that both P. aeruginosa and CFTR contributed to Treg dysregulation in CF. Functionally, Tregs from patients with CF or from Cftr(-/-) mice were impaired in suppressing conventional T cells, an effect that was enhanced by P. aeruginosa infection. The loss of Tregs in CF affected memory, but not naive Tregs, and manifested gradually with disease progression.Patients with CF who have chronic P. aeruginosa infection show an age-dependent, quantitative, and qualitative impairment of Tregs. Modulation of Tregs represents a novel strategy to rebalance T-cell responses, dampen inflammation, and ultimately improve outcomes for patients with infective CF lung disease.

Necrotizing fasciitis (NF) is a severe, life-threatening infectious condition. Diagnosis is difficult due to unspecific symptoms yet crucial for favorable outcomes. We report a case of a 1 year old, previously healthy boy, where early suspicion of NF led to prompt aggressive therapy and consecutive restitutio ad integrum.

Early differentiation between sepsis and systemic inflammatory response syndrome (SIRS) is useful for therapeutic management in neonates and infants after surgery.To compare the early (first 2 days) diagnostic value of interleukin-6 (IL-6), procalcitonin (PCT), and C-reactive protein (CRP) after surgery in the differentiation of subsequent SIRS and septic complications.IL-6, PCT, and CRP were measured 0, 24, and 48 hours after surgery in neonates and infants with clinical suspicion of postoperative sepsis. Sensitivity, specificity, and predictive values for SIRS/septic complications were calculated.A total of 31 out of 205 neonates and infants showed clinical signs for postoperative sepsis and underwent sepsis work-up. Nine patients developed septic complications, sixteen patients met criteria for SIRS, and six patients showed an uneventful postoperative course during the first five postoperative days. IL-6, PCT, and CRP levels increased in all subgroups after surgery and were significantly higher in the sepsis group (p 0.05). IL-6 peaked immediately, CRP at 24 to 48 hours, and PCT at 24 hours after surgery. Sensitivity and specificity (area under the curve) for IL-6 (cutoff 673 ng/dL) were 94.4 and 75% (86.2%), for CRP (cutoff 1.48 mg/dL) 76.2 and 75.0% (88.1%), and for PCT (cutoff 16.1 mg/L) 66.7 and 57.1% (65.6%).IL-6 appears to be an early marker for severe bacterial infections with high sensitivity. IL-6 and CRP were the most reliable markers for the discrimination between SIRS and sepsis within the postoperative period.

Background Early orchidopexy (OP) around the age of 1 year is recommended in boys with congenital undescended testis (UDT) worldwide since decades. Former retrospectives studies did not distinguish congenital from acquired UDT with a consecutive negative bias concerning the age at surgery. Methods In a retrospective analysis, data of all boys who underwent OP in eight pediatric surgery institutions from 2009 to 2015 were analyzed. Congenital or acquired UDT were differentiated. Patients were categorized into 3 groups of age at surgery: (1) 24 months. Data of one institution were analyzed in detail: exact age of first referral, exact age at surgery, intraoperative findings. Results Out of 4448 boys, 3270 boys had congenital UDT. In 81% (2656 cases) surgery was performed beyond the age of 1 year, in 54.4% (1780) beyond the age of 2 years. chi-Square statistics showed a higher rate of early operations in hospitals compared to outpatient services and in Germany compared to Switzerland. In 694 congenital detailed cases, median age at referral was 13 months [range 0–196], median age at surgery was 15 months [range 0–202]. Conclusion Delayed referral is the main reason for guideline non-conform delayed surgery in UDT. Type of Study Clinical Research paper. Level of evidence Level III: Treatment Study.

Verletzungen von Milz und Leber im Kindesalter werden durch alterstypische Sturze, Sport- oder Verkehrsunfalle verursacht. Bei isolierten Verletzungen hat sich die nicht operative Therapie (NOM) etabliert und es stehen evidenzbasierte Leitlinien zur Verfugung. Die Kompression der Organe durch die geschlossene Bauchdecke im begrenzten intraabdominellen Raum ist die pathophysiologische Erklarung fur das Sistieren der Blutung. Voraussetzung fur eine nichtoperative Therapie ist die bildgestutzte Klassifikation der Verletzungen nach der Organ Injury Scale (OIS) und ein hamodynamisch stabiler Patient. Die Kreislaufstabilitat des Patienten wird – falls notwendig – durch Bluttransfusionen, Volumensubstitution und Katecholamine gewahrleistet. Bei Gefasstielabrissen, kompletten Devaskularisierungen mit fehlendem Perfusionsnachweis oder bei instabilen Patienten – trotz Ausreizung der konservativen Therapiemasnahmen – ist die notfallmasige operative Therapie zwingend. Bei dieser hat die organerhaltende Chirurgie fur Milz und Leber einen hohen Stellenwert. Insbesondere im Wachstumsalter ist die Milz essenziell fur die Ausbildung der immunologischen Kompetenz. Die Leberruptur kann durch Verletzungen der Gallengangstrukturen kompliziert sein, die einer operativen Rekonstruktion bedurfen. Handelt es sich um eine Milz- oder Leberverletzung im Rahmen einer Mehrfachverletzung oder eines Polytraumas, so muss eine individuelle Therapieentscheidung getroffen werden. Hierfur existieren keine evaluierten Therapierichtlinien und die Rate der operativen Masnahmen steigt. Fur alle Verletzungsarten gilt, dass der kindertraumatologisch spezialisierte Chirurg durch seine Kenntnisse uber anatomische und altersspezifische Besonderheiten des verletzten Kindes im multidisziplinaren Team die besten Therapieergebnisse erzielt.

Summary Neonates show an impaired anti-microbial host defence, but the underlying immune mechanisms are not understood fully. Myeloid-derived suppressor cells (MDSCs) represent an innate immune cell subset characterized by their capacity to suppress T cell immunity. In this study we demonstrate that a distinct MDSC subset with a neutrophilic/granulocytic phenotype (Gr-MDSCs) is highly increased in cord blood compared to peripheral blood of children and adults. Functionally, cord blood isolated Gr-MDSCs suppressed T cell proliferation efficiently as well as T helper type 1 (Th1), Th2 and Th17 cytokine secretion. Beyond T cells, cord blood Gr-MDSCs controlled natural killer (NK) cell cytotoxicity in a cell contact-dependent manner. These studies establish neutrophilic Gr-MDSCs as a novel immunosuppressive cell subset that controls innate (NK) and adaptive (T cell) immune responses in neonates. Increased MDSC activity in cord blood might serve as key fetomaternal immunosuppressive mechanism impairing neonatal host defence. Gr-MDSCs in cord blood might therefore represent a therapeutic target in neonatal infections.

Purpose We set out to evaluate how residents in pediatric surgery learn and how they teach. We hypnotized that European residents learn as much from their peers and teach as much as their fellows worldwide, but that they receive comparably less educational training. Methods An online questionnaire was distributed to the participants of the combined annual meeting for German, Swiss and Austrian residents in pediatric surgery. Participants were asked whom they learn from in different workplace environments (ward, operating room, emergency department), how, when and why they adopt the role of teacher and how they were prepared for this role. Results Response rate was 48%. 65 questionnaires were analyzed. Residents stated that they predominantly learn from each other on wards and in the emergency department, less frequently in the operating room. They ranked fellow residents as first or second most important source of instruction. 53% of participants have never had any educational training, for another 33% the instruction was being done by fellow residents without any set curriculum. 93% of the participating residents had no or did not know about any resident as teacher training program available to them. Nevertheless, motivation to teach was stated to be high and interest in educational training was assured. Conclusions Our data delivers evidence that peer teaching during residency is the rule rather than the exception in Central Europe. Educational training however is scarce. Resident as teacher-training programs need to be introduced. Next to local initiatives, we strongly recommend national initiatives powered by regulatory authorities and surgical associations. Type of study Research paper. Level of evidence II.

Introduction Pediatric necrotizing fasciitis (NF) is a rare but severe, life-threatening infection. Early diagnosis is crucial to reduce morbidity and mortality, but initial symptoms are nonspecific. Little sound data exists on factors aiding clinicians to recognize NF in children. With a systematic literature review, we aimed to better characterize pediatric NF. We focused on triggers, symptoms, and laboratory and microbiological findings and differences between pediatric adult patients. Materials and Methods A literature research was conducted according to the guidance of the “Preferred Reporting Items for Systematic Reviews and Meta-Analyses.” Articles published between January 2010 and October 2015 were included. Data extraction was performed as an iterative process. Results A total of 32 articles describing 53 pediatric patients with NF were included in the analysis. Overall mortality was 15.4%. Frequency peaks were found for neonates and children aged between 1 and 2 years. These two age groups were predominantly affected on the torso. Another frequency peak was found in patients aged around 10 years of age. These patients were predominantly affected on the extremities and face. In general, early symptoms were found to be fever, erythema, localized selling, and tenderness or pain. “Pain out of proportion” was not mentioned as a typical symptom. Fever and leukocytosis were more common in teenage patients. Monomicrobial necrotizing (type 2) fasciitis was much more common than polymicrobial (type 1) fasciitis. Next to Streptococci and Staphylococci, Pseudomonas aeruginosa was often isolated. Early aggressive surgical treatment was the treatment of choice. Conclusions Pediatric NF has distinguishing features that differ from adult NF. Knowledge of these details should increase early diagnosis and improve treatment.

Background and Methods We conducted a focus group analysis with students and surgeons on factors which influence medical school students’ education in the operating room (OR). The interviews were analyzed using grounded theory. Results The analysis resulted in 18 detailed and easily applyable themes, which were grouped into the four categories: “Students’ preparation and organizational aspects”, “Learning objectives”, “Educational strategies for the teacher”, and “Social–environmental aspects”. Conclusion By including students and surgeons, we were able to extend existing knowledge and enable better understanding of factors influencing teaching in the OR.

Objective To demonstrate a rare case of urological pathology, we report a combination of a single kidney and ureteral atresia. The treatment concept and outcome are outlined. Patient and method Antenatal ultrasound had revealed urinary ascites which lead to caesarean section in the 34th gestational week. Persisting anuria was confirmed postnatally and peritoneal dialysis started on the second day of life. Subsequent laparotomy revealed ureteral atresia after 3 cm of patent ureter. We created an ileum conduit after discussing various other therapeutic options. Result and conclusion A follow up of 12 months has shown steady function of the stoma with stable renal parameters. An ileal conduit represents a good option if high drainage is necessary in early childhood.

Pseudomonas aeruginosa persists in patients with cystic fibrosis (CF) and drives CF lung disease progression. P. aeruginosa potently activates the innate immune system, mainly mediated through pathogen-associated molecular patterns, such as flagellin. However, the host is unable to eradicate this flagellated bacterium efficiently. The underlying immunological mechanisms are incompletely understood. Myeloid-derived suppressor cells (MDSCs) are innate immune cells generated in cancer and proinflammatory microenvironments and are capable of suppressing T cell responses. We hypothesized that P. aeruginosa induces MDSCs to escape T cell immunity. In this article, we demonstrate that granulocytic MDSCs accumulate in CF patients chronically infected with P. aeruginosa and correlate with CF lung disease activity. Flagellated P. aeruginosa culture supernatants induced the generation of MDSCs, an effect that was 1) dose-dependently mimicked by purified flagellin protein, 2) significantly reduced using flagellin-deficient P. aeruginosa bacteria, and 3) corresponded to TLR5 expression on MDSCs in vitro and in vivo. Both purified flagellin and flagellated P. aeruginosa induced an MDSC phenotype distinct from that of the previously described MDSC-inducing cytokine GM-CSF, characterized by an upregulation of the chemokine receptor CXCR4 on the surface of MDSCs. Functionally, P. aeruginosa–infected CF patient ex vivo–isolated as well as flagellin or P. aeruginosa in vitro–generated MDSCs efficiently suppressed polyclonal T cell proliferation in a dose-dependent manner and modulated Th17 responses. These studies demonstrate that flagellin induces the generation of MDSCs and suggest that P. aeruginosa uses this mechanism to undermine T cell–mediated host defense in CF and other P. aeruginosa–associated chronic lung diseases.

Summary Background Undescended testis in boys is common. Guidelines recommend surgical treatment between the ages of 6 months and 2 years; nevertheless, orchidopexy is frequently performed at later ages. One reason is the belated diagnosis due to a perceived difficulty in the physical examination (PE) and correct localization of the testis. Objectives We aimed to find an effective method for teaching the physical examination of the testis in a child. Study design An interdisciplinary team developed teaching sessions, including an educational video and a simulator. Medical students (n = 133) were randomized into three groups: self-study only, video, and video and simulator. The sessions were carried out and quantitative feedback was collected from the teachers and students. The learning achievements of the different groups were assessed with an objective structured clinical examination (OSCE). The differences in mean OSCE results between all three groups were tested using one-way analysis of variance (ANOVA). For multiple pairwise comparisons, a closed testing procedure was performed using unpaired t-tests. Results The self-study only group acquired the poorest results in the OSCE, with a mean score of 5.1 out of 10. The video-only-group reached a mean of 6.7, and the video-and-simulator group performed best with a mean score of 8.5. The differences between all three groups were found to be statistically significant, with P = 0.007. The attached figure illustrates this data. If analyzed in pairs, this difference was particularly apparent between the groups self-study only vs video and simulator, with P = 0.002. Qualitative feedback revealed doubtful effectiveness for educational videos, but positive reactions to training on a simulator. Discussion The poor results of the self-study-only group were in accordance with the literature, where textbook learning was found not to increase OSCE results. The effectiveness of video tutorials remains doubtful; studies focusing on this teaching method are divergent and the present students' feedback supports this data. The effective teaching with the simulator has been proven for other skills (i.e. ultrasound skills). The analyzed cohort for this study was small, and the study should be repeated at different institutions and with larger numbers of students to assure generalizability. Conclusions Low-fidelity pediatric simulators with palpable testis are available and are able to improve examining skills in medical students. We hope the presented study inspires medical educators in their teaching of the PE of the pediatric testis. Download : Download high-res image (134KB) Download : Download full-size image Summary Figure . One-way analysis of OSCE results by group.

Traumatic posterior dislocation of the elbow is often associated with significant morbidity and incomplete recovery. The aim of this study was to retrospectively analyse the outcome of 33 children (median age 10.8 years). Patients underwent reduction and assessment of stability under general anaesthesia. Pure dislocations (n=10) were immobilized, whereas unstable fractures (n=23) were stabilized. Refixation of ligaments was performed if stability was not achieved by fracture stabilization alone. Immobilization was continued for 26 (pure dislocations) or 35 days (associated injuries), respectively. Results were excellent (n=9) or good (n=1) after pure dislocation. Results were excellent (n=15), good (n=7) or poor (n=1) in children with associated injuries. Accurate diagnosis, concentric stable reduction of the elbow as well as stable osteosynthesis of displaced fractures are associated with good results in children with acute posterior elbow dislocations. Language: en

Thoracoscopic approach for repair of esophageal atresia (EA) and tracheo-esophageal fistula (TEF) has become a standard procedure in many pediatric surgical centers. Thoracoscopic surgery in a newborn is demanding from both the surgeon and the patient. The potential benefits for the newborn are still discussed by neonatologists, pediatric intensive care physicians, and also parents. The aim of our investigation was to clearly define perioperative outcome and complication rates in children undergoing thoracoscopic versus open surgery for EA and TEF repair.We reviewed the records of 68 newborns undergoing surgery for EA and TEF between March 2002 and February 2010. Patient data of open versus thoracoscopic approach were compared regarding operating time, intraoperative as well as postoperative pCO(2)max values, postoperative ventilation time, and complications. Specific patient data are reported with the median and range. Data analysis was done with the JMP(®) 7.0.2 statistical software (SAS Institute, Cary, NC).For the 68 patients, the mean gestational age was 35 weeks (28-41), the median birth weight was 2720 g (1500-3510 g) in the thoracoscopic group and 2090 g (780-3340 g) in the open group. There were 36 girls and 32 boys. Thirty-two children had associated anomalies. Twenty-five children were undergoing a thoracoscopic procedure. In 8 cases, the operation was converted to open thoracotomy. Another 32 children received a thoracotomy. In 11 newborns, a cervical esophagostomy was performed because of long-gap EA and these patients were excluded from the study. Operating time was 141 minutes (77-201 minutes) in the thoracoscopic group and 106 minutes (48-264 minutes) in the thoracotomy group, with significant difference (P=.014). Values of pCO(2)max during operation were 62 mm Hg (34-101 mm Hg) in the thoracoscopic group and 48 mm Hg (28-89 mm Hg) in the open group, with significant difference (P=.014). Postoperative ventilation time was 3 days (1-51 days) in all groups, with no significant difference (P=.79). Early complications were noticed in 9 children undergoing thoracoscopy and in 8 patients of the thoracotomy group, again with no significant difference (P.05).Thoracoscopic repair of EA with TEF is justified because of a comparable perioperative outcome to open surgery, competitive operating times, decreased trauma to the thoracic cavity, and improved cosmesis despite skeptical considerations. Complication rates are not higher than in children operated on through a thoracotomy. However, a learning curve has to be taken into account and large experience in minimal invasive surgery is mandatory for this procedure. Larger series have to be expected for a more objective evaluation of perioperative as well as long-term outcomes. To our opinion, the thoracoscopic approach appears to be favorable and could be a future standard.

We report a case of Hirschsprung disease associated with total colonic agenesis and high-type imperforate anus in a newborn girl. The patient also presented with uterus bicornis and a single kidney. The treatment procedure is presented together with a review of literature. The presented combination of pathologies has never been described before.

Background It is unknown what aspects of undergraduate surgical curricula are useful for future non-surgeons. We aimed to define relevant, enduring learning achievements for this subgroup to enable student-centered teaching. Methods An online questionnaire using open ended questions was distributed to physicians of non-surgical specialties at the University Hospital of Tuebingen, Germany and its associated teaching hospitals. Participants were asked to describe knowledge and skills that endured from their surgical clerkship and which of these are used in daily practice. Textual responses were initially coded using content analysis and the frequency of recurrent categories was calculated. Results Sixty-seven of 153 questionnaires were returned; participants belonged to six different non-surgical specialties and had received their training at 22 different medical schools. Sustaining learning achievements included basic skills (suturing and working under sterile conditions), learning about professionalism and appreciating working conditions in surgery. Two learning techniques were valued: witnessing of rare cases or complications and working autonomously. Conclusion Integration of our findings in undergraduate surgical teaching may focus teaching on students’ interests and improve surgical teaching.