Hypercapnia and acidosis during open and thoracoscopic repair of congenital diaphragmatic hernia and esophageal atresia: results of a pilot randomized controlled trial

Outcomes After Thoracoscopic and Open Repair of Esophageal Atresia With Tracheoesophageal Fistula at US Children's Hospitals

BACKGROUND

Thoracoscopic repair of esophageal atresia with tracheoesophageal fistula (EA/TEF) has been reported to have superior outcomes to the open approach. We sought to evaluate adoption of thoracoscopic repair at US children's hospitals and compare outcomes to open repair.

METHODS

The Pediatric Health Information System database was used to identify patients with EA/TEF who underwent repair between 2016 and 2023. Patients with birthweight less than 1800g and/or repair after the first 3 days of life were excluded. Postoperative complications, length of stay, and opioid requirements were assessed.

RESULTS

Inclusion criteria were met in 618 patients. Eighty thoracoscopic repairs were reported (13 %). The proportion of thoracoscopic operations did not change over the study period. Infants managed with a thoracoscopic or open approach were demographically similar. Thoracoscopic repair was associated with a higher incidence of anastomotic stricture (39 % vs. 26 %, p = 0.02), recurrent laryngeal nerve (RLN) injury (11 % vs 3 %, p = 0.001), and fewer days of postoperative opioid (5.2 vs. 6.5, p = 0.04). Other operative complications, LOS, and duration of TPN did not differ based on operative approach.

CONCLUSION

A small proportion of EA/TEF repairs in US children's hospitals were completed thoracoscopically and adoption of this approach did not increase between 2016 and 2023. Anastomotic stricture and RLN injury were significantly more likely after thoracoscopic repair. Although opioids were administered for one day fewer after thoracoscopic operations, no other metrics favored this approach. These data contrast with recent literature and suggest that the experience of high-volume hospitals may underestimate the morbidity of thoracoscopic EA/TEF repair and overestimate its benefits.

LEVEL OF EVIDENCE: 3

Respiratory Support Strategies for Surgical Neonates: A Review

Neonates with congenital conditions which require surgical management frequently experience respiratory distress. This review discusses the management of pulmonary complications and the respiratory support strategies for four conditions: oesophageal atresia-tracheoesophageal fistula (OA-TOF), congenital diaphragmatic hernia (CDH), congenital lung malformations (CLM), and anterior abdominal wall defects (AWD). Mechanical ventilation techniques which can reduce the risk of ventilator-induced lung injury (VILI) are discussed, as well as the use of non-invasive respiratory support modes. While advances in perioperative respiratory support have improved outcomes in infants with OA-TOF, managing respiratory distress in premature OA-TOF neonates remains a challenge. In CDH infants, a randomised trial has suggested that conventional ventilation may improve outcomes compared to high-frequency ventilation. Echocardiographic assessment is essential in the management of CDH infants with pulmonary hypertension. Lung-protective ventilation settings may lower the rate of postoperative complications in symptomatic CLM infants, but there remains debate regarding the choice of expectant versus surgical management in neonates with asymptomatic CLMs. Infants with AWDs can require ventilation due to pulmonary hypoplasia, but the effects of this on their long-term respiratory health are poorly understood. As surgical techniques continue to evolve and novel ventilation techniques become available, prospective multi-centre studies will be required to define the optimal respiratory support strategies for neonatal surgical conditions that affect lung function.

Minimally Invasive Approach Versus Traditional Approach for Treating Congenital Diaphragmatic Hernia: A Systematic Review and Meta-Analysis

Congenital diaphragmatic hernia (CDH) is a rare but critical surgical disorder that can be managed using either open or thoracoscopic surgical approaches. However, the optimal approach remains a topic of debate. This study aimed to evaluate the efficacy and safety of thoracoscopic repair compared to open repair in patients with CDH. An extensive literature search was conducted across four databases (PubMed, Web of Science, Scopus, and Cochrane Library) from inception to May 2024, including all relevant studies comparing the two surgical modalities. Key outcomes assessed were hospital stay duration, operation time, mortality, and recurrence. Categorical outcomes were analyzed using the risk ratio (RR) with 95% confidence intervals (CI), while continuous outcomes were analyzed using the mean difference (MD) with 95% CI. Data analysis was performed using Review Manager (RevMan, Version 5.3). A total of 35 studies involving 1,680 individuals with CDH were included in our analysis. The pooled results revealed that thoracoscopic repair was associated with a shorter hospital stay (MD=-6.80, 95% CI [-9.39, -4.21], p< 0.0001) but a longer operation time (MD=23.30, 95% CI [7.22, 39.38], p=0.005) compared to the open approach. Additionally, thoracoscopic repair demonstrated lower mortality rates (RR=0.43, 95% CI [0.24, 0.76], p=0.004) but higher recurrence rates (RR=2.24, 95% CI [1.56, 3.21], p<0.0001) than open repair. Our findings suggest that thoracoscopic repair offers shorter hospital stays and lower mortality rates but involves longer operation times and higher recurrence rates compared to the open approach. These results highlight the need for further large, multicenter, randomized controlled trials to validate our findings and guide clinical decision-making.

Birth weight and thoracoscopic approach for patients with esophageal atresia and tracheoesophageal fistula-a retrospective cohort study

BACKGROUND

This study aimed to analyze the results, feasibility and safety of the thoracoscopic approach for patients with esophageal atresia with tracheoesophageal fistula (EA/TEF) depending on the patient's birth weight.

METHODS

The study involved only type C and D EA/TEF. Among the analyzed parameters were the patients' characteristics, surgical treatment and post-operative complications: early mortality, anastomosis leakage, anastomosis strictures, chylothorax, TEF recurrence, and the need for fundoplication or gastrostomy.

RESULTS

145 consecutive newborns underwent thoracoscopic EA with TEF repair. They were divided into three groups-A (N = 12 with a birth weight < 1500 g), B (N = 23 with a birth weight ≥ 1500 g but < 2000 g), and C-control group (N = 110 with a birth weight ≥ 2000 g). Primary one-stage anastomosis was performed in 11/12 (91.7%) patients-group A, 19/23 (82.6%)-group B and 110 (100%)-group C. Early mortality was 3/12 (25%)-group A, 2/23 (8.7%)-group B, and 2/110 (1.8%)-group C and was not directly related to the surgical repair. There were no significant differences in operative time and the following complications: anastomotic leakage, recurrent TEF, esophageal strictures, and chylothorax. There were no conversions to an open surgery. Fundoplication was required in 0%-group A, 4/21 (19.0%)-group B, and 2/108 (1.9%)-group C survivors. Gastrostomy was performed in 1/9 (11.1%)-group A, 3/21 (14.3%)-group B and 0%-group C.

CONCLUSION

In an experienced surgeon's hands, even in the smallest newborns, the thoracoscopic approach may be safe, feasible, and worthy of consideration. Birth weight seems to be not a direct contraindication to the thoracoscopic approach.

Comparison of the Efficacy and Safety of Thoracoscopic Surgery and Conventional Open Surgery for Congenital Diaphragmatic Hernia in Neonates: A Meta-analysis

Background

Thoracoscopic surgery is an increasingly popular surgical technique for the repair of congenital diaphragmatic hernias. We performed a meta-analysis to compare the efficacy, safety of thoracoscopic surgery and the conventional open surgical approach for congenital diaphragmatic hernia in neonates.

Materials and Methods

A systematic search of electronic databases such as PubMed, Google, and Web of Science was performed to identify studies comparing thoracoscopic surgery and open surgery for congenital diaphragmatic hernia. A total of 6 studies with 3348 patients were found. Parameters such as operation time, hospital stay, recurrence rate, postoperative mortality, and postoperative complications were pooled and compared by meta-analysis.

Results

Of the 3348 children with congenital diaphragmatic hernia included in the 6 studies, 615 underwent thoracoscopic surgery and 2733 underwent open surgery. All studies were nonrandomized controlled trials. The operation times were shorter for thoracoscopic surgery than for open surgery in three studies, but there was no significant difference (standard mean difference = 1.25, confidence interval [CI] = [-0.48-2.98], P = 0.16). In the thoracoscopic surgery group, the rate of postoperative deaths was significantly lower (95% CI = 1.24-2.75), but the occurrence of recurrences was more frequent (95% CI = 0.08-0.23). The hospital stay varied significantly across studies. There was a statistically significant difference (standard mean difference = -1.47, CI = [-2.24--0.70], P < 0.001) in the overall effect between the groups. The complication rate was significantly lower with thoracoscopic surgery compared to open surgery (odds ratio = 0.26, CI = [0.10-0.66], P = 0.004) for the overall effect between the groups. The thoracoscopic procedure, however, was planned for milder and stable cases.

Conclusion

Thoracoscopic repair of congenital diaphragmatic hernia in neonates is associated with a shorter length of hospital stay, fewer complications, and less postoperative mortality than traditional open repair. However, the rate of recurrence was found to be higher in those who underwent thoracoscopic surgery.

Surgical management of the diaphragmatic defect in congenital diaphragmatic hernia: a contemporary review

Worldwide, 150 children are born each day with congenital diaphragmatic hernia (CDH), a diaphragmatic defect with concomitant abnormal lung development. Patients with CDH with large defects are particularly challenging to treat, have the highest mortality, and are at significant risk of long-term complications. Advances in prenatal and neonatal treatments have improved survival in high-risk patients with CDH, but surgical treatment of large defects lacks standardization. Open repair by an abdominal approach has long been considered the traditional procedure, but the type of defect repair (patch or muscle flap) and patch material (non-absorbable, synthetic or absorbable, biological) remain subjects of debate. Increased experience and improved techniques in minimally invasive surgery (MIS) have expanded selection criteria for thoracoscopic defect repair in cardiopulmonary stable patients with small defects. However, the application of MIS to repair large defects remains controversial due to increased recurrence rates and unknown long-term effects of perioperative hypercapnia and acidosis resulting from capnothorax and reduced ventilation. Current recommendations on the surgical management rely on cohort studies of varying patient numbers and data on the long-term outcomes are sparse. Here, we discuss surgical approaches for diaphragmatic defect repair highlighting advancements, and knowledge gaps in surgical techniques (open surgery and MIS), patch materials and muscle flaps for large defects, as well as procedural adjuncts and management of CDH variants.

Lung-protective ventilation in the management of congenital diaphragmatic hernia

Prioritizing lung-protective ventilation has produced a clear mortality benefit in neonates with congenital diaphragmatic hernia (CDH). While there is a paucity of CDH-specific evidence to support any particular approach to lung-protective ventilation, a growing body of data in adults is beginning to clarify the mechanisms behind ventilator-induced lung injury and inform safer management of mechanical ventilation in general. This review summarizes the adult data and attempts to relate the findings, conceptually, to the CDH population. Critical lessons from the adult studies are that much of the damage done during conventional mechanical ventilation affects normal lung tissue and that most of this damage occurs at the low-volume and high-volume extremes of the respiratory cycle. Consequently, it is important to prevent atelectasis by using sufficient positive end-expiratory pressure while also avoiding overdistention by scaling tidal volume to the amount of functional lung tissue rather than body weight. Paralysis early in acute respiratory distress syndrome improves outcomes, possibly because consistent respiratory mechanics facilitate avoidance of both atelectasis and overdistention-a mechanism that may also apply to the CDH population. Volume-targeted conventional modes may be advantageous in CDH, but determining optimal tidal volume is challenging. Both high-frequency oscillatory ventilation and high-frequency jet ventilation have been used successfully as 'rescue modes' to avoid extracorporeal membrane oxygenation, and a prospective trial comparing the two high-frequency modalities as the primary ventilation strategy for CDH is underway.

Are Low Weight or Cardiopathy Contraindications for Thoracoscopic Repair of Esophageal Atresia with Tracheoesophageal Fistula?

BACKGROUND

 Thoracoscopic repair of esophageal atresia (EA) with tracheoesophageal fistula (TEF) is becoming an increasingly widespread technique; there is still controversy about its indication in certain patients. Our objective is to analyze if potential risk factors such as major congenital heart disease (CHD) or low birth weight (LBW) are a limitation to this approach.

METHODS

 Retrospective study (2017-2021) of patients with EA and distal TEF who underwent thoracoscopic repair were included. Patients with LBW less than 2,000 g or major CHD were compared with the rest.

RESULTS

 Twenty-five patients underwent thoracoscopic surgery. Nine patients (36%) had major CHD. Five of them (20%) were LBW less than 2,000 g, and only 8% (2/25) presented both risk factors. There were no differences in terms of operative time, conversion rate, tolerance evaluated with gasometric parameters (pO2, pCO2, pH) or complications (anastomotic leak and stricture, both early or during follow-up) in patients with major CHD and LBW (1,473 ± 319 vs. 2,664 ± 402 g). One conversion to thoracotomy was performed in a neonate weighing 1,050 g due to anesthetic intolerance. There was no recurrence of TEF. One patient died at the age of 9 months, due to major uncorrectable heart disease.

CONCLUSION

 Thoracoscopic repair of EA/TEF is feasible technique in patients with CHD or LBW, with similar results to other patients. The complexity of this technique warrants individualizing the indication in each case.

LEVEL OF EVIDENCE

 IV.

Surgical approaches to congenital diaphragmatic hernia

Surgical repair of the diaphragm is essential for survival in congenital diaphragmatic hernia (CDH). There are many considerations surrounding the operation - why the operation matters, optimal timing of repair and its relation to extracorporeal life support (ECLS) use, minimally invasive versus open approaches, and strategies for reconstruction. Surgery is both affected by, and affects, the physiology of these infants and is an important factor in determining long-term outcomes. Here we discuss the evidence and provide insight surrounding this complex decision making, technical pearls, and outcomes in repair of CDH.

Comprehensive meta-analysis of surgical procedure for congenital diaphragmatic hernia: thoracoscopic versus open repair

PURPOSE

Previous studies have shown a higher recurrence rate and longer operative times for thoracoscopic repair (TR) of congenital diaphragmatic hernia (CDH) compared to open repair (OR). An updated meta-analysis was conducted to re-evaluate the surgical outcomes of TR.

METHODS

A comprehensive literature search comparing TR and OR in neonates was performed in accordance with the PRISMA statement (PROSPERO: CRD42020166588).

RESULTS

Fourteen studies were selected for quantitative analysis, including a total of 709 patients (TR: 308 cases, OR: 401 cases). The recurrence rate was higher [Odds ratio: 4.03, 95% CI (2.21, 7.36), p < 0.001] and operative times (minutes) were longer [Mean Difference (MD): 43.96, 95% CI (24.70, 63.22), p < 0.001] for TR compared to OR. A significant reduction in the occurrence of postoperative bowel obstruction was observed in TR (5.0%) compared to OR (14.8%) [Odds ratio: 0.42, 95% CI (0.20, 0.89), p = 0.02].

CONCLUSIONS

TR remains associated with higher recurrence rates and longer operative times. However, the reduced risk of postoperative bowel obstruction suggests potential long-term benefits. This study emphasizes the importance of meticulous patient selection for TR to mitigate detrimental effects on patients with severe disease.

Safe thoracoscopic repair of recurrent congenital diaphragmatic hernia after initial open abdominal repair

PURPOSE

The optimal surgical approach for recurrent congenital diaphragmatic hernia (CDH) remains controversial. We compared the surgical outcomes of a thoracoscopic approach versus an open abdominal approach for recurrent CDH after initial abdominal open repair.

METHOD

The subjects of this comparative study were patients who underwent open abdominal or thoracoscopic surgery for recurrent CDH following an initial open abdominal repair.

RESULTS

Among 166 patients with Bochdalek-type CDH, 15 underwent reoperation for recurrent CDH following an open abdominal repair. Seven patients underwent open abdominal surgery (group O) and eight underwent thoracoscopic surgery (group T). The operative duration was similar for the two groups, with less blood loss (17.2 ml/kg vs. 1 ml/kg, P = 0.001) and fewer intraoperative complications in the T group (n = 6 vs. n = 0 cases, P = 0.001). There was no significant difference in the number of postoperative complications (n = 1 vs. n = 1, P = 1.0) or in the number of patients with a second CDH recurrence (n = 2 vs. n = 1, P = 0.569) between the two groups.

CONCLUSION

Thoracoscopic surgery is preferable to the open surgical approach for recurrent CDH following an initial abdominal open repair.

Thoracoscopic Patch Repair of Congenital Diaphragmatic Hernia: Can Smaller Incisions Treat Larger Defects?

INTRODUCTION

Thoracoscopic CDH repair is increasingly performed for Type A and small Type B defects that are amenable to primary repair. However, the thoracoscopic approach is controversial for larger defects necessitating a patch due to technical complexity, intraoperative acidosis, and recurrence risk. We aim to compare clinical outcomes between thoracoscopic and open patch repair of Type B/C defects, using a standardized technique.

METHODS

This is a single-center retrospective review of thoracoscopic and open CDH patch repairs January 2017-December 2021. We excluded primary repairs, Type D hernias, repairs on ECMO, recurrent repairs. Various preoperative, intraoperative, and postoperative variables were compared. Primary outcome was recurrence rate. Secondary outcomes included intraoperative pH and pCO2, operative time, and complication rates.

RESULTS

Twenty-nine patients met inclusion criteria (open = 13, thoracoscopic = 16). The open cohort had lower o/e total fetal lung volume (29 vs 41.2%, p = 0.042), higher preoperative peak inspiratory pressures (24 vs 20 cm H2O, p = 0.007), were more frequently Type C defects (92.3 vs 31%, p = 0.002) and had liver "up" in left-sided hernias (46 vs 0%, p < 0.0001). Intraoperatively, median lowest pH and highest pCO2 did not differ; neither did overall median pH or pCO2. Operative times were similar (153 vs 194 min, p = 0.113). No difference in recurrence rates was identified, however postoperative complications were higher in the open group. There were no mortalities.

CONCLUSIONS

Although we demonstrate higher disease severity of patients undergoing open repair, thoracoscopic patch repair for Type B/C defects is safe and effective in patients with favorable physiologic status, alleviating concerns for intraoperative acidosis, operative length, and risk of recurrence.

LEVEL OF EVIDENCE

II.

Minimally invasive surgical approach in children treated for oesophageal atresia is associated with attention problems at school age: a prospective cohort study

The long-term neurodevelopment of children born with oesophageal atresia (OA) is unclear. Therefore, we assessed the neurocognitive domains and their predictors. Patients born with OA between February 2006 and December 2014, who were routinely seen at eight years as part of a structured prospective longitudinal follow-up program, were included. Main outcome measures were need for school support, performance in various neurocognitive domains and potential predictors of neurocognitive problems. We analysed data of 65 children with a mean (SD) age of 8.1 (0.2) years, of whom 89% with OA type C. Thirty-five (54%) surgical corrections were minimally invasive; the median (interquartile range) duration of exposure to anaesthetics in the first 24 months was 398 (296 - 710) minutes. Forty-four (68%) attended regular education without extra support and intelligence was within normal range (99-108). More than 50% had z-scores ≤ -2 on one or more neurocognitive domains, of which attention was the most frequently affected domain. The speed on the sustained attention task was significantly below normal (z-score -1.48 (2.12), p < .001), as was fluctuation of sustained attention (z-score -3.19 (3.80), p < .001). The minimally invasive approach and a lower socio-economic status (both p = 0.006) proved significant predictors for sustained attention problems in multivariable analyses.  Conclusion: Children who undergo minimally invasive surgery for OA correction are at risk for sustained attention problems at school age. Future studies unravelling the effects of perioperative events on neurodevelopment should lead to optimal surgical, anaesthesiological, and intensive care management in the neonatal period. What is Known: • School-aged children born with oesophageal atresia have normal intelligence but problems with sustained attention at eight years. What is New: • Oesophageal atresia patients, who undergo minimally invasive surgery or who have a background of lower socioeconomic status are at serious risk for sustained attention problems at school age. • Moreover, those who have been intubated for a longer period are at risk for stronger fluctuations in sustained attention.

Open Versus Thoracoscopic Repair of Congenital Diaphragmatic Hernia: A 19-Year Review in a Tertiary Referral Centre in Hong Kong

BACKGROUND

Congenital diaphragmatic hernia (CDH) is a developmental defect that causes herniation of abdominal organs into the thoracic cavity with significant morbidity. Thoracoscopic repair of CDH is an increasingly prevalent yet controversial surgical technique, with limited long-term outcome data in the Asian region. The aim of this study was to compare open laparotomy versus thoracoscopic repair of CDH in paediatric patients in a major tertiary referral centre in Asia.

METHODS

We performed a retrospective analysis of neonatal patients who had open laparotomy or thoracoscopic repair for CDH in our institution between July 2002 and November 2021. Demographic data, perioperative parameters, recurrence rates and surgical complications were analysed.

RESULTS

64 patients were identified, with 54 left sided CDH cases. 33 patients had a prenatal diagnosis and 35 patients received minimally invasive surgical repair. There was no significant difference between open and minimally invasive repair in recurrence rate (13 % vs 17 %, P = 0.713), time to recurrence (184 ± 449 days vs 81 ± 383 days, P = 0.502), or median length of ICU stay (11 ± 14 days vs 13 ± 15 days, P = 0.343), respectively. Gastrointestinal complications occurred in 7 % of neonates in the open group and none in the thoracoscopic group. Median follow-up time was 9.5 years.

CONCLUSIONS

This study is a large congenital diaphragmatic hernia series in Asia, with long term follow-up demonstrating no significant difference in recurrence rate, time to recurrence or median length of ICU stay between open and minimally invasive repair, suggesting thoracoscopic approach is a non-inferior surgical option with avoidance of gastrointestinal complications compared to open repair.

LEVEL OF EVIDENCE: 3

TYPE OF STUDY

Retrospective Cohort Study.

Intraoperative Regional Cerebral Oxygenation During Pediatric Thoracoscopic Surgery: A Systematic Review

Background: Ventilating a pediatric patient during thoracoscopy is challenging. Few studies have highlighted the impact of capnothorax in children by measuring regional cerebral oxygen saturation (rcSO2) with near infrared spectroscopy. In this systematic review, we aimed to summarize the data from relevant studies and assess whether thoracoscopy in children is associated with intraoperative pathological cerebral desaturation. Methods: The authors systematically searched four databases for relevant studies on the measurement of rcSO2 during pediatric thoracoscopic procedures. The primary outcome was the proportion of patients with pathological desaturation, that is, >20% decline in the intraoperative rcSO2. Risk of bias among the included studies was estimated using the Newcastle-Ottawa scale. Results: The systematic search resulted in 776 articles, of which 7 studies were included in the analysis. In total, 88 patients (99 procedures) with an age ranging from 0 days to 8.1 years were included. Of these, 43 (49%) patients were neonates. The included cohort had esophageal atresia and tracheoesophageal fistula (n = 26), long-gap esophageal atresia (n = 5), congenital diaphragmatic hernia (n = 14), and congenital pulmonary airway malformations and other conditions needing lung resection (n = 43). Of the total 99 procedures, pathological desaturation was noticed in 13 (13.1%, 95% confidence interval 7.2-21.4) of them. Upon quality assessment, most of the studies were weaker in the selection and comparability domains. Conclusion: In this review, pathological cerebral desaturation was noticed in 13.1% of the pediatric thoracoscopic procedures. However, due to limited methodological quality of the included studies, further randomized multicentric studies comparing rcSO2 in open versus thoracoscopic surgeries are needed to derive definitive conclusions.

Use of Barbed Sutures for Congenital Diaphragmatic Hernia Repair

BACKGROUND

Congenital diaphragmatic hernia (CDH) repair can be challenging, particularly when a larger defect is present. Barbed sutures prevent the suture from slipping back after approximation of the tissues. Although introduced almost 2 decades ago, barbed sutures have not been widely used for CDH repair. We report our initial experience and pitfalls.

METHODS

All patients presenting with CDH from 2021 onward underwent repair using barbed sutures. Demographics, operative parameters, complications, and outcomes were prospectively recorded.

RESULTS

A total of 13 patients underwent CDH repair during the study interval (median age 6 days, range 3 days to 5.75 years). Median operative time was 89 min (range 46 to 288 min). Five thoracoscopic and eight open procedures were performed. Severe pulmonary hypertension and ECMO (extracorporeal membrane oxygenation) were considered contraindications for thoracoscopic repair. The included patients were compared to a historic controlled group performed without barbed sutures. The barbed suture facilitated easy and quick closure of the defects in most cases and obviated the need for knot tying. One patient in the thoracoscopic group had a patch placed due to high tension after the barbed sutures tore the diaphragm. At a median follow-up time of 15 months (range 2 to 34 months), one patient had died, and one patient with complete diaphragmatic agenesis was home-ventilated. There were no recurrences. Median operative time trended lower (89 min) than in the historic control group repaired without barbed sutures (119 min, p < 0.06) after eliminating outliers with large, complex patch repairs.

CONCLUSIONS

Barbed sutures simplify congenital diaphragmatic hernia repair regardless of whether a minimal-invasive or open approach is performed. Patch repair is not a contraindication for using barbed sutures. The resulting potential time savings make them particularly useful in patients with cardiac or other severe co-morbidities in which shorter operative times are essential. In cases with high tension, though, the barbs may tear through and produce a "saw" effect on the tissue with subsequent damage.

Comprehension of fundamental knowledge about pediatric endoscopic surgery: a cross-sectional study in Japan

BACKGROUND

Pediatric endoscopic surgery has become an alternative to conventional techniques with the development of medical equipment. However, there is no formal, standardized curriculum for pediatric endoscopic surgery, and its requirement remains elusive. The purpose of this study is to determine the baseline knowledge of pediatric surgeons that is considered essential for pediatric laparoscopic and thoracoscopic surgery.

METHODS

Sixteen web-based multiple-choice questions based on the fundamental cognitive knowledge of pediatric endoscopic surgery were administered. The questions were created based on the fields covered by the Fundamentals of Laparoscopic Surgery ™ (FLS) certification examination blueprints and eight specific diseases of pediatric surgery. Pediatric surgeons and pediatric surgical trainees participated in this study voluntarily.

RESULTS

A total of 122 surgeons participated through the Japanese Society of Pediatric Surgeons. The response rate was 95% (122/128). The total mean examination score of all participants was 79.4% (77.3-81.4%). There were no significant differences in total scores between the board-certified pediatric surgeons without an endoscopic surgical skill qualification and the non-board-certified pediatric surgeons (80.4% vs. 77.1%, p = 0.12). The endoscopic surgical skill-qualified surgeons had significantly higher percentages of correct responses in specific subjects than board-certified pediatric surgeons and surgeons without pediatric board certification (94.3% vs. 82.9%, p = 0.02; 94.3% vs. 77.5%, p = 0.0002). The FLS original subjects' scores were not significantly different among them. The mean score of surgeons who had experienced more than 200 cases of endoscopic surgery, including adult cases, was 83.2% (80.4-85.9%).

CONCLUSIONS

A knowledge gap exists between surgeons, board-certified pediatric surgeons, and endoscopic surgical skill-qualified surgeons in Japan. In the field of pediatric surgery, an effective formal curriculum, such as FLS, is required to help address this vast knowledge gap for the safe conduct of endoscopic surgeries.

Thoracoscopic vs open repair of congenital diaphragmatic hernia after extracorporeal membrane oxygenation: a comparison of intra-operative data

PURPOSE

ECMO is an escalation treatment for hypoxic respiratory failure in patients with CDH. Open repair has been advocated after ECMO indicating that physiological changes associated to thoracoscopic repair were not well tolerated.

METHODS

We have performed a retrospective review of all patients who underwent ECMO prior CDH repair over a 7 year period (2015-2021). Outcome measures were intra-operative Ph, PCO2, PO2 and FiO2 at 30 min, 1 h 30 min, and 2 h 30 min of surgery, operative time and recurrence rate. Data are shown in median (range).

RESULTS

Eleven patients required ECMO prior CDH repair. Six of eleven (55%) were done thoracoscopically (Group A) and five of eleven (45%) via laparotomy (Group B). Two of six (33%) patients (Group A) were converted to a laparotomy, one of six (16%) patient developed a recurrence, and there was no recurrence in Group B. Two of five (40%) patients died within the first 60 days of life, whilst there was no death in Group A. Intra-operative values are shown below.

CONCLUSION

Whilst this is a preliminary report of a limited number of patients, there is no obvious difference of intra-operative blood gas parameters during surgical repair in patients after ECMO. Thoracoscopic CDH repair may be considered in patients after ECMO.

Thoracoscopy versus thoracotomy for esophageal atresia and tracheoesophageal fistula: Outcomes from the Midwest Pediatric Surgery Consortium

BACKGROUND/PURPOSE

Controversy persists regarding the ideal surgical approach for repair of esophageal atresia with tracheoesophageal fistula (EA/TEF). We examined complications and outcomes of infants undergoing thoracoscopy and thoracotomy for repair of Type C EA/TEF using propensity score-based overlap weights to minimize the effects of selection bias.

METHODS

Secondary analysis of two databases from multicenter retrospective and prospective studies examining outcomes of infants with proximal EA and distal TEF who underwent repair at 11 institutions was performed based on surgical approach. Regression analysis using propensity score-based overlap weights was utilized to evaluate outcomes of patients undergoing thoracotomy or thoracoscopy for Type C EA/TEF repair.

RESULTS

Of 504 patients included, 448 (89%) underwent thoracotomy and 56 (11%) thoracoscopy. Patients undergoing thoracoscopy were more likely to be full term (37.9 vs. 36.3 weeks estimated gestational age, p < 0.001), have a higher weight at operative repair (2.9 vs. 2.6 kg, p < 0.001), and less likely to have congenital heart disease (16% vs. 39%, p < 0.001). Postoperative stricture rate did not differ by approach, 29 (52%) thoracoscopy and 198 (44%) thoracotomy (p = 0.42). Similarly, there was no significant difference in time from surgery to stricture formation (p > 0.26). Regression analysis using propensity score-based overlap weighting found no significant difference in the odds of vocal cord paresis or paralysis (OR 1.087 p = 0.885), odds of anastomotic leak (OR 1.683 p = 0.123), the hazard of time to anastomotic stricture (HR 1.204 p = 0.378), or the number of dilations (IRR 1.182 p = 0.519) between thoracoscopy and thoracotomy.

CONCLUSION

Infants undergoing thoracoscopic repair of Type C EA/TEF are more commonly full term, with higher weight at repair, and without congenital heart disease as compared to infants repaired via thoracotomy. Utilizing propensity score-based overlap weighting to minimize the effects of selection bias, we found no significant difference in complications based on surgical approach. However, our study may be underpowered to detect such outcome differences owing to the small number of infants undergoing thoracoscopic repair.

LEVEL OF EVIDENCE

Level III.

Surgical treatment of congenital diaphragmatic hernia in a single institution

BACKGROUND

This study aimed to evaluate the effectiveness of video-assisted thoracic surgery for the treatment of congenital diaphragmatic hernia (CDH) in a larger series compared with conventional open surgery. Additionally, we summarized the experience of thoracoscopic surgery in the treatment of CDH in infants.

METHODS

We retrospectively analysed the clinical data of 109 children with CDH who underwent surgical treatment at the Department of Cardiothoracic Surgery of Children's Hospital of Chongqing Medical University from January 2011 to January 2021. According to the surgical method, the children were divided into an open group (62 cases) and a thoracoscopy group (47 cases).Patients who underwent surgical correction had the diaphragmatic defect size graded (A-D) using a standardized system. We compared the operation time, intraoperative blood loss, postoperative mechanical ventilation time, postoperative hospital stay, postoperative CCU admission time and other surgical indicators as well as the recurrence rate, mortality rate and complication rate of the two groups of children.

RESULTS

The index data on the operation time, intraoperative blood loss, postoperative mechanical ventilation time, postoperative hospital stay and postoperative CCU admission time were better in the thoracoscopy group than in the open group. The difference between the two groups was statistically significant (P < 0.05). We compared the number of incision infections, lung infections, atelectasis, pleural effusion, and chylothorax between the two groups. There were more children in the open group than in the thoracoscopy group. The overall incidence of postoperative complications in the open group (51.61%) was higher than that in the thoracoscopy group (44.68%).The recurrence rate of the thoracoscopy group (8.51%) was higher than that of the open group (3.23%). In the open group, 7 patients died of respiratory distress after surgery, and no patients died in the thoracoscopy group.

CONCLUSIONS

Thoracoscopic surgery and open surgery can effectively treat CDH. Compared with conventional open surgery, thoracoscopy has the advantages of shorter operation time, less trauma, faster recovery and fewer complications. We believe that thoracoscopic surgery for type A/B diaphragmatic defect has certain advantages, but there is a risk of recurrence.

Retroperitoneoscopic Surgery in Children Does Not Cause Pathological Desaturation in Cerebral/Renal Oxygenation on Near-Infrared Spectroscopy Compared with Laparoscopic and Thoracoscopic Surgery

Introduction: Cerebral and renal regional oxygen saturation (C-rSO₂ and R-rSO₂, respectively) were monitored using near-infrared spectroscopy in pediatric patients (range: 0.3-14.3 years) during minimally invasive surgery (MIS) taking at least 3 hours performed by laparoscopy (Lap), thoracoscopy (Tho), or retroperitoneoscopy (Ret) from January 2019 to December 2021. Materials and Methods: Criteria compared were operative time, preoperative/intraoperative hemoglobin, blood loss, mean arterial pressure, arterial partial pressure of carbon dioxide (PaCO₂), peripheral oxygen saturation (SpO₂), C-rSO₂, and R-rSO₂. Pathological desaturation (PD) was defined as >20% decrease from baseline, and statistical significance as P < .05. Results: Subjects (n = 79) were similar for gender, age, and body mass index. MIS procedures were: Lap = 45, Tho = 20, Ret = 14; one Lap case required conversion for severe adhesions, not PD. Intraoperative PaCO₂ (mmHg) was significantly higher in Tho (maximum: 59.5 ± 17.0, minimum: 39.9 ± 7.5) versus Lap (maximum: 39.9 ± 5.1, minimum: 34.6 ± 3.9) and Ret (maximum: 37.8 ± 4.2, minimum: 35.0 ± 3.3); P < .0001 (maximum), P = .0013 (minimum). Minimum intraoperative SpO₂ was significantly lower in Tho (P < .0001). Mean operative times were significantly shorter in Tho (259 ± 114 minutes) versus Lap (433 ± 154 minutes) and Ret (342 ± 100 minutes); P < .0001, respectively. PD was absent during Ret (C-rSO₂: 0/14 = 0% and R-rSO₂: 0/14 = 0%). Differences in PD for Lap (C-rSO₂: 7/45 = 15.6% and R-rSO₂: 10/45 = 22.2%) and Tho (C-rSO₂: 9/20 = 45.0%, and R-rSO₂: 7/20 = 35.0%) were significant; P = .0028 for C-rSO₂ and P = .0497 for R-rSO₂. Hemoglobin and blood loss were similar. Conclusions: PD was absent during Ret, despite longer operative times. If Ret is indicated for a procedure, neurodevelopmental sequelae of MIS could be minimized.

Surgical Management of Congenital Diaphragmatic Hernia

Congenital diaphragmatic hernia (CDH) is a challenging surgical disease that requires complex preoperative, perioperative, and postoperative care. Survival depends on successful reduction and repair of the defect, and numerous complex decisions must be made regarding timing and preparation for surgery. This review describes the challenges and controversies inherent to surgical CDH care and provides recommendations for management based on the most recent evidence.

A predictive scoring system for small diaphragmatic defects in infants with congenital diaphragmatic hernia

PURPOSE

To develop a predictive score for small diaphragmatic defects in infants with congenital diaphragmatic hernia (CDH) for determining thoracoscopic surgery indication.

METHODS

The Japanese CDH Study Group cohort was randomly divided into derivation (n = 397) and validation (n = 396) datasets. Using logistic regression, a prediction model and weighted scoring system for small diaphragmatic defects were created from derivation dataset and validated with validation dataset.

RESULTS

Six weighted variables were selected: no hydramnios, 1 point; 1 min Apgar score of 5-10, 1 point; apex type of the lung (left lung is detected radiographically in apex area), 1 point; oxygenation index < 8, 1 point; abdominal nasogastric tube (tip of the nasogastric tube is detected radiographically in the abdominal area), 2 points; no right-to-left flow of ductus arteriosus, 1 point. In validation dataset, rates of small diaphragmatic defects for Possible (0-3 points), Probable (4-5 points), and Definite (6-7 points) groups were 36%, 81%, and 94%, respectively (p < 0.001). Additionally, sensitivity, specificity, positive predictive value, and C statistics were 0.78, 0.79, 0.88, 0.76, and 0.45, 0.94, 0.94, 0.70 for Probable and Definite groups, respectively.

CONCLUSION

Our scoring system effectively predicted small diaphragmatic defects in infants with CDH.

Esophageal Magnetic Anastomosis Device (EMAD) to simplify and improve outcome of thoracoscopic repair for esophageal atresia with tracheoesophageal fistula: A proof of concept study

BACKGROUND

We designed a new Esophageal Magnetic Anastomosis Device (EMAD) for thoracoscopic repair of esophageal atresia (EA) with tracheoesophageal fistula (TEF) without the need of handheld suturing or additional gastrostomy.

METHODS

Synthetic EA-TEF model: Spherical and tubular shaped rubber balloons and a term infant sized plastic doll were used. Medical students (n = 10) and surgical trainees (n = 10) were asked to perform thoracoscopic repair of an "EA" with a hand sutured anastomosis (HA) and with the EMAD. Euthanized animal model: The esophagus in 5 piglets (3-4 kg) was dissected and a thoracoscopic esophageal magnetic anastomosis (EMA) was performed. Bursting pressure (BP) and pulling force (PF): HA and EMA were created on ex vivo New Zealand white rabbit (2.5-3 kg) esophagi (n = 25 in each test series). BP and PF were measured and compared against each other.

RESULTS

Medical students were unable to complete HA, but were successful with the EMAD in 11.1 ± 2.78 min. Surgical trainees completed EMA in 4.6 ± 2.06 min vs. HA 30.8 ± 4.29 min (p<0.001). The BP following a HA (14.1 ± 3.32 cmH₂O) was close to the physiological intraluminal pressure reported in a neonatal esophagus (around 20 cmH₂O), whereas the BP with the EMAD was extremely high (>90 cmH₂O) (p<0.001). The PF of an EMA (1.8 ± 0.30 N) was closer to the safety limits of anastomotic tension reported in the literature (i.e. 0.75 N) compared with the HA (3.6 ± 0.43 N) (p<0.0001).

CONCLUSION

The EMAD could simplify, shorten, and potentially improve the outcome of thoracoscopic repair for EA with TEF in the future. A high BS and a relative low PF following EMAD application may lower the risk of postoperative complications such as esophageal leakage and stricture formation.

Pediatric Minimally Invasive Surgery-A Bibliometric Study on 30 Years of Research Activity

Background: Pediatric minimally invasive surgery (MIS) is a standard technique worldwide. We aimed to analyze the research activity in this field. Methods: Articles on pediatric MIS (1991−2020) were analyzed from the Web of Science™ for the total number of publications, citations, journals, and impact factors (IF). Of these, the 50 most cited publications were evaluated in detail and classified according to the level of evidence (i.e., study design) and topic (i.e., surgical procedure). Results: In total, 4464 publications and 53,111 citations from 684 journals on pediatric MIS were identified. The 50 most cited papers were published from 32 institutions in the USA/Canada (n = 28), Europe (n = 19), and Asia (n = 3) in 12 journals. Four authors (USA/Europe) contributed to 26% of the 50 most cited papers as first/senior author. Hot topics were laparoscopic pyeloplasty (n = 9), inguinal hernia repair (n = 7), appendectomy, and pyloromyotomy (n = 4 each). The majority of publications were retrospective studies (n = 33) and case reports (n = 6) (IF 5.2 ± 3.2; impact index 16.5 ± 6.4; citations 125 ± 39.4). They were cited as often as articles with high evidence levels (meta-analyses, n = 2; randomized controlled trials, n = 7; prospective studies, n = 2) (IF 12.9 ± 22.5; impact index 14.0 ± 6.5; citations 125 ± 34.7; p > 0.05). Conclusions: Publications on laparoscopic pyeloplasty, inguinal hernia repair, appendectomy, and pyloromyotomy are cited most often in pediatric MIS. However, the relevant number of studies with strong evidence for the advantages of MIS in pediatric surgery is missing.

Neurocardiovascular coupling in congenital diaphragmatic hernia patients undergoing different types of surgical treatment

BACKGROUND

The effect of peri-operative management on the neonatal brain is largely unknown. Triggers for perioperative brain injury might be revealed by studying changes in neonatal physiology peri-operatively.

OBJECTIVE

To study neonatal pathophysiology and cerebral blood flow regulation peri-operatively using the neuro-cardiovascular graph.

DESIGN

Observational, prospective cohort study on perioperative neuromonitoring. Neonates were included between July 2018 and April 2020.

SETTING

Multicentre study in two high-volume tertiary university hospitals.

PATIENTS

Neonates with congenital diaphragmatic hernia were eligible if they received surgical treatment within the first 28 days of life. Exclusion criteria were major cardiac or chromosomal anomalies, or syndromes associated with altered cerebral perfusion or major neurodevelopmental impairment. The neonates were stratified into different groups by type of peri-operative management.

INTERVENTION

Each patient was monitored using near-infrared spectroscopy and EEG in addition to the routine peri-operative monitoring. Neurocardiovascular graphs were computed off-line.

MAIN OUTCOME MEASURES

The primary endpoint was the difference in neurocardiovascular graph connectivity in the groups over time.

RESULTS

Thirty-six patients were included. The intraoperative graph connectivity decreased in all patients operated upon in the operation room (OR) with sevoflurane-based anaesthesia ( P  < 0.001) but remained stable in all patients operated upon in the neonatal intensive care unit (NICU) with midazolam-based anaesthesia. Thoracoscopic surgery in the OR was associated with the largest median connectivity reduction (0.33 to 0.12, P  < 0.001) and a loss of baroreflex and neurovascular coupling. During open surgery in the OR, all regulation mechanisms remained intact. Open surgery in the NICU was associated with the highest neurovascular coupling values.

CONCLUSION

Neurocardiovascular graphs provided more insight into the effect of the peri-operative management on the pathophysiology of neonates undergoing surgery. The neonate's clinical condition as well as the surgical and the anaesthesiological approach affected the neonatal physiology and CBF regulation mechanisms at different levels.

TRIAL REGISTRATION

NL6972, URL: https://www.trialre-gister.nl/trial/6972 .

Considerations of single-lung ventilation in neonatal thoracoscopic surgery with cardiac arrest caused by bilateral pneumothorax: A case report

BACKGROUND

Tension pneumothorax of the contralateral lung during single-lung ventilation (SLV) combined with artificial pneumothorax can cause cardiac arrest due to bilateral pneumothorax. If not rapidly diagnosed and managed, this condition can lead to sudden death. We describe the emergency handling procedures and rapid diagnostic methods for this critical emergency situation.

CASE SUMMARY

We report a case of bilateral pneumothorax in a neonatal patient who underwent thoracoscopic esophageal atresia and tracheoesophageal fistula repair under the combined application of SLV and artificial pneumothorax. The patient suffered sudden cardiac arrest and received emergency treatment to revive her. The recognition of dangerous vital sign parameters, rapid evacuation of the artificial pneumothorax, and initiation of lateral position cardiopulmonary resuscitation while simultaneously removing the endotracheal tube to the main airway are critically important. Moreover, even though the sinus rhythm was restored, the patient’s continued tachycardia, reduced pulse pressure, and depressed pulse oximeter waveform were worrisome. We should highly suspect the possibility of pneumothorax and use rapid diagnostic methods to make judgment calls. Sometimes thoracoscopy can be used for rapid examination; if the mediastinum is observed to be shifted to the right, it may indicate tension pneumothorax. This condition can be immediately relieved by needle thoracentesis, ultimately allowing the safe completion of the surgical procedure.

CONCLUSION

Bilateral pneumothorax during SLV combined with artificial pneumothorax is rare but can occur at any time in neonatal thoracoscopic surgery. Therefore, anesthesiologists should consider this possibility, be alert, and address this rare but critical complication in a timely manner.

Clinical trials and outcome reporting in congenital diaphragmatic hernia overlook long-term health and functional outcomes-A plea for core outcomes

Aim

To review the selection, measurement and reporting of outcomes in studies of interventions in Congenital Diaphragmatic Hernia (CDH).

Methods

We searched the Cochrane Central Register of Controlled Trials from 2000–2020 for randomised trials and observational studies. Outcomes reported were classified into seven key domains modelled on the patient journey.

Results

Our search yielded 118 papers; 27 were eligible. The most frequent domains measured were ‘short‐term markers of disease activity’ (17/27), whereas long‐term outcomes (3/27) and outcomes relating to functional health status (8/27) were reported infrequently. There was heterogeneity in the methods and timing of outcome reporting. Primary outcomes were varied and not always clearly stated.

Conclusion

Long‐term health and functional outcomes involving interventional studies in CDH are infrequently reported, which hinders the process of shared decision‐making and evidence‐based healthcare. A CDH core outcome set is needed to standardise outcome reporting that is relevant to both families and healthcare teams.

Remote ischemic conditioning in necrotizing enterocolitis: study protocol of a multi-center phase II feasibility randomized controlled trial

PURPOSE

Remote ischemic conditioning (RIC) is a maneuver involving brief cycles of ischemia reperfusion in an individual's limb. In the early stage of experimental NEC, RIC decreased intestinal injury and prolonged survival by counteracting the derangements in intestinal microcirculation. A single-center phase I study demonstrated that the performance of RIC was safe in neonates with NEC. The aim of this phase II RCT was to evaluate the safety and feasibility of RIC, to identify challenges in recruitment, retainment, and to inform a phase III RCT to evaluate efficacy.

METHODS

RIC will be performed by trained research personnel and will consist of four cycles of limb ischemia (4-min via cuff inflation) followed by reperfusion (4-min via cuff deflation), repeated on two consecutive days post randomization. The primary endpoint of this RCT is feasibility and acceptability of recruiting and randomizing neonates within 24 h from NEC diagnosis as well as masking and completing the RIC intervention.

RESULTS

We created a novel international consortium for this trial and created a consensus on the diagnostic criteria for NEC and protocol for the trial. The phase II multicenter-masked feasibility RCT will be conducted at 12 centers in Canada, USA, Sweden, The Netherlands, UK, and Spain. The inclusion criteria are: gestational age < 33 weeks, weight ≥ 750 g, NEC receiving medical treatment, and diagnosis established within previous 24 h. Neonates will be randomized to RIC (intervention) or no-RIC (control) and will continue to receive standard management of NEC. We expect to recruit and randomize 40% of eligible patients in the collaborating centers (78 patients; 39/arm) in 30 months. Bayesian methods will be used to combine uninformative prior distributions with the corresponding observed proportions from this trial to determine posterior distributions for parameters of feasibility.

CONCLUSIONS

The newly established NEC consortium has generated novel data on NEC diagnosis and defined the feasibility parameters for the introduction of a novel treatment in NEC. This phase II RCT will inform a future phase III RCT to evaluate the efficacy and safety of RIC in early-stage NEC.

Significant neonatal intraoperative cerebral and renal oxygen desaturation identified with near-infrared spectroscopy

INTRODUCTION

Near-infrared spectroscopy (NIRS) was used to monitor intraoperative regional oxygen saturation (rSO₂) during open (Op) and minimally invasive (MI) surgery performed in neonates (N) and children.

MATERIALS AND METHODS

NIRS sensors were applied to the forehead and flanks for cerebral rSO₂ (C-rSO₂) and renal rSO₂ (R-rSO₂), respectively. MI included laparoscopy (La), retroperitoneoscopy (Re) and thoracoscopy (Th). In children, Op and MI were major operations taking at least 3 h (MOp; MMI). Pathological desaturation (PD) was defined as > 20% deterioration in rSO₂.

RESULTS

Mean ages at surgery were N: 5.2 ± 8.2 days, MOp: 2.4 ± 2.9 years, and MMI: 3.8 ± 4.3 years. Despite significantly shorter operative times in N (169 ± 94 min; p < 0.0001), PD was significantly worse; PD(C-rSO₂): N = 14/35 (40.0%) versus MOp = 3/36 (8.3%) and MMI = 7/58 (12.1%); p = 0.0006, and PD(R-rSO₂): N = 27/35 (77.1%) versus MOp = 6/36 (16.7%) and MMI = 7/58 (12.1%); p < 0.0001, respectively. PD(R-rSO₂) occurred immediately with visceral reduction in NOp (Fig. 1) and PD was frequent during NMI(Th) (Fig. 2). rSO₂ was stable throughout MOp and MMI (Fig. 3). Fig. 1 Pathological desaturation in renal rSO₂ after visceral reduction for gastroschisis. Renal rSO₂ deteriorated immediately after viscera were returned to the abdominal cavity rSO₂ regional oxygen saturation Fig. 2 Fragility of tissue perfusion during thoracoscopic lung lobectomy in a neonate. Pathological desaturation occurred frequently during neonatal thoracoscopic surgery rSO₂ regional oxygen saturation Fig. 3 Changes in cerebral and renal rSO₂ according to operative time. Cerebral and renal rSO₂ did not appear to change according to operative time during major open and major minimally invasive surgery in children. rSO₂ regional oxygen saturation CONCLUSIONS: NIRS is a non-invasive technique for monitoring rSO₂ as an indicator of intraoperative stress and vascular perfusion. PD was so significant in neonates that intraoperative NIRS is highly recommended during thoracoscopy and procedures requiring visceral manipulation.

Effect of different mechanical ventilation modes on cerebral blood flow during thoracoscopic surgery in neonates: A randomised controlled trial

Background and Aims:

Infants exposed to major surgery are at risk of injuries to the immature brain because of reduced arterial oxygen saturation. This study compared the effect of volume-controlled ventilation (VCV) versus pressure-controlled ventilation (PCV) on cerebral oxygenation in neonates subjected to repair of tracheoesophageal fistula (TEF) under video-assisted thoracoscopic surgery (VATS).

Methods:

This randomised controlled study included 30 full-term neonates scheduled for VATS for managing TEF under general anaesthesia. They were randomised to either VC group (n = 15), who received VCV, or PC group (n = 15), who received PCV. Cerebral oxygenation (rScO₂) was monitored throughout the surgery with documentation of episodes of cerebral desaturation. Peripheral oxygen saturation, partial pressure of carbon dioxide (PaCO₂), and end-tidal carbon dioxide were recorded at baseline, after induction of anaesthesia, and every 30 min till the end of the surgery.

Results:

rScO₂ was significantly higher in the PC group than the VC group at baseline and was significantly higher in the VC group after 15 min (P = 0.041). Later, it was comparable in both the groups up to 60 min after starting the surgery. Cerebral desaturation was significantly more common in the PC group (80%) compared to VC group (33.3%) (P = 0.010). PC group required higher fraction of inspired oxygen and positive end-expiratory pressure to prevent cerebral desaturation. PaCO₂ was significantly higher in the PC group than the VC group at 30 and 60 min (P = 0.005 and 0.029).

Conclusion:

VCV is safer than PCV for cerebral oxygenation during VATS in neonates.

Risk factors for anesthesia-associated postoperative capillary leakage after thoracoscopic surgery in neonates: A single-center observational study

BACKGROUND

Thoracoscopy is considered the surgical method of choice for addressing a wide range of conditions in neonates. However, there is a lack of experience in anesthesia management for this procedure. On reviewing the newborns who had undergone thoracoscopic surgery at our medical center, some had developed edema after surgery. After excluding other etiologies, these neonates were diagnosed with capillary leakage secondary to thoracoscopy.

AIMS

This study aimed to identify the potential risk factors for capillary leakage secondary to thoracoscopy in neonates and to provide reference information for optimal anesthesia management.

METHODS

This single-center, retrospective, observational study examined neonates who had undergone thoracoscopic surgery between January 1, 2018, and September 31, 2021. Their electronic medical records were analyzed for demographic and clinical characteristics associated with anesthesia, and postoperative capillary leakage occurring within 24 and 48 h of surgery was assessed based on medical records.

RESULTS

A total of 56 neonates that underwent thoracoscopic surgery were included in this study. Postoperative capillary leakage within 24 h was diagnosed in 14 neonates (25%). The partial pressure of carbon dioxide was an independent factor influencing the occurrence of postoperative edema within 24 h (P = 0.021). Overall, 21 cases (37.5%) were diagnosed as postoperative capillary leakage within 48 h, and age was an independent factor influencing the occurrence of postoperative edema within 48 h (P = 0.027).

CONCLUSIONS

According to our findings, we concluded that preventing the elevation of the partial pressure of carbon dioxide may reduce the occurrence of secondary capillary leakage within 24 h after thoracoscopic surgery, and that older newborns are less likely to have secondary capillary leakage within 48 h after thoracoscopic surgery. Our findings provide evidence that directly informs anesthesia management for thoracoscopic surgery in neonates.

CLINICAL TRIAL REGISTRATION

The study was registered in the Chinese Clinical Trial Registry (ChiCTR2100054117).

Thoracoscopic surgery for congenital diaphragmatic hernia in neonates: Should it be the first choice?

OBJECTIVE

Congenital diaphragmatic hernia (CDH) is an uncommon but potentially life-threatening surgical condition in neonates. Surgery can be performed by either open or thoracoscopic techniques. In this study, we compared the clinical efficacy, safety, and effectiveness of thoracoscopic and open CDH repair.

METHODS

A retrospective review of neonates with CDH who underwent operations at our hospital from 2013 to 2021 was performed. The various perioperative parameters were compared between neonates undergoing thoracoscopic and open surgery.

RESULTS

There were 50 neonates in this study (37 in the thoracoscopic group and 13 in the open group). Thoracoscopic surgery was associated with significantly shorter hospital stay (13.32 vs. 18.77 days, p < 0.001); shorter duration of postoperative mechanical ventilation (3.70 vs. 5.98 days, p < 0.001); early feeding (4.34 vs. 7.46 days, p < 0.001); and shorter time to reach optimal feeding (8.21 vs. 13.38 days, p < 0.001). There was one postoperative death in the open group and no death in the thoracoscopic group. The median follow-up time of the two groups was 23.8 months (20.5 months in open group and 25.0 months in thoracoscopic group). Thoracoscopic surgery was associated with lower recurrence rates, but the difference was not statistically significant (2.7% vs. 7.7%, p = 0.456).

CONCLUSION

Thoracoscopy CDH repair, a safe and effective surgical technique for neonates, has better cosmesis, faster postoperative recovery, and a lower recurrence rate than other procedures. It can be considered the first choice for CDH treatment for neonates among experienced surgeons.

Retrospective analysis of pneumothorax after repair of esophageal atresia/tracheoesophageal fistula

Background

To analyze the possible causes, treatment and outcomes of postoperative pneumothorax in patients with Gross type C esophageal atresia/tracheoesophageal fistula (EA/TEF).

Methods

Medical records of patients with Gross type C EA/TEF who were diagnosed and treated in Beijing Children’s Hospital from January 2007 to January 2020 were retrospectively collected. They were divided into 2 groups according to whether postoperative pneumothorax occurred. Univariate and multivariate logistic regression analysis were performed to identify risk factors for pneumothorax.

Results

A total of 188 patients were included, including 85 (45 %) in the pneumothorax group and 103 (55 %) in the non-pneumothorax group. Multivariate logistic regression analysis showed that postoperative anastomotic leakage [P < 0.001, OR 3.516 (1.859, 6.648)] and mechanical ventilation [P = 0.012, OR 2.399 (1.210, 4.758)] were independent risk factors for pneumothorax after EA/TEF repair. Further analysis of main parameters of mechanical ventilation after surgery showed that none of them were clearly related to the occurrence of pneumothorax. Among the 85 patients with pneumothorax, 33 gave up after surgery and 52 received further treatment [conservative observation (n = 20), pleural puncture (n = 11), pleural closed drainage (n = 9), both pleural puncture and closed drainage (n = 12)]. All of the 52 patients were cured of pneumothorax at discharge.

Conclusions

Anastomotic leakage and postoperative mechanical ventilation were risk factors for pneumothorax after repair of Gross type C EA/TEF, but the main parameters of mechanical ventilation had no clear correlation with pneumothorax. After symptomatic treatment, the prognosis of pneumothorax was good.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-021-02948-x.

Anesthesia for thoracic surgery in infants and children

The management of infants and children presenting for thoracic surgery poses a variety of challenges for anesthesiologists. A thorough understanding of the implications of developmental changes in cardiopulmonary anatomy and physiology, associated comorbid conditions, and the proposed surgical intervention is essential in order to provide safe and effective clinical care. This narrative review discusses the perioperative anesthetic management of pediatric patients undergoing noncardiac thoracic surgery, beginning with the preoperative assessment. The considerations for the implementation and management of one-lung ventilation (OLV) will be reviewed, and as will the anesthetic implications of different surgical procedures including bronchoscopy, mediastinoscopy, thoracotomy, and thoracoscopy. We will also discuss pediatric-specific disease processes presenting in neonates, infants, and children, with an emphasis on those with unique impact on anesthetic management.

Novel Device for Endoluminal Esophageal Atresia Repair: First-in-Human Experience

Thoracoscopic esophageal atresia (EA) repair affords many benefits to the patient; however, intracorporeal suturing of the anastomosis is technically challenging. Esophageal magnetic compression anastomosis (EMCA) is a compelling option for endoluminal EA repair, but available EMCA devices have prohibitive rates of recalcitrant stricture. Connect-EA is a new endoluminal EMCA device system that employs 2 magnetic anchors with a unique mating geometry designed to reliably create a robust anastomosis and decrease rates of leak and stricture. We describe our first-in-human experience with this novel endoluminal device for staged EA repair in 3 patients (Gross type A, B, and C) at high risk for conventional surgical repair. First, the esophageal pouches were approximated thoracoscopically. After acute tension subsided, the device anchors were endoscopically placed in the esophageal pouches and mated. Anchors were spontaneously excreted in 2 cases. Endoscopic repositioning and retrieval of the anchors were required in 1 patient because of narrowed esophageal anatomy. There were no perioperative complications. Patients were managed for 14 to 18 months. The strictures that developed in the patients were membranous and responded well to dilation alone, resolving after 4 to 5 outpatient dilations. Gastrostomies were closed between 6 and 11 months and all patients are tolerating full oral nutrition. Early experience with this new endoluminal EMCA device system is highly favorable. The device offers considerable benefit over conventional handsewn esophageal anastomosis and anastomotic outcomes are superior to available EMCA devices.

A Review of History and Challenges of Evidence-Based Pediatric Surgery

PURPOSE

Evidence-based pediatric surgery (EBPS) refers to the use of the best available evidence in making personalized decisions concerning the management of each pediatric surgical patient. This study aims to provide a comprehensive review on past and present evidence-based clinical decision, and challenges in pediatric surgery.

MATERIAL AND METHODS

A literature search was conducted according to a set of criteria in PubMed for historical and current peer-reviewed studies regarding EBPS.

RESULTS

One hundred forty-five full-text published articles focusing on EPBS findings over the past 25 years were included. The rarity of many congenital anomalies, the inability to establish multicenter collaborations, the failure to perform double-blinded studies in children, the pediatric surgeons' reluctance to perform ethically unacceptable sham operations and their skepticism shown in accepting and implementing the documented results instead of applying their personal clinical practice methods and surgical techniques are among problems that hamper the accomplishment of randomized controlled trials (RCTs).

CONCLUSIONS

RCTs remain limited in clinical pediatric surgery practice due to problems in the design and publication of these trials. Moreover, skepticism exists regarding acceptance and implementation of the documented results of RCTs. Notwithstanding, pediatric surgeons must establish evidence-based centers in order to increase the number of well-designed RCTs, properly evaluate clinical research, make effective evidence-based clinical decisions and develop high-quality of pediatric surgeries care in the future.

Associations of perioperative characteristics with motor function in preschool children born with esophageal atresia

BACKGROUND

Children born with esophageal atresia experience long-term neurodevelopmental deficits, with unknown origin.

AIMS

To find associations between perioperative variables during primary esophageal atresia repair and motor function at age 5 years.

METHODS

This ambidirectional cohort study included children born with esophageal atresia who consecutively had been operated on in the Erasmus MC-Sophia Children's Hospital, University Medical Center, Rotterdam, from January 2007 through June 2013. The perioperative data of this cohort were collected retrospectively; the motor function data prospectively.

RESULTS

After exclusion of patients with syndromal congenital diseases (n = 8) and lost to follow-up (n = 10), the data of 53 children were included. The mean (SD) total motor function impairment z-score at 5 years of age was -0.66 (0.99), significantly below normal (p < .001). In multivariable linear regression analysis, number of postoperative days endotracheal intubation (B = -0.211, 95% CI: -0.389 to -0.033, p = .021) was negatively associated with motor outcome, whereas high blood pressure (B = 0.022, 95% CI 0.001 to 0.042, p = .038) was positively associated. Preoperative nasal oxygen supplementation versus room air (B = 0.706, 95% CI: 0.132 to 1.280, p = .016) was positively associated with motor outcome, which we cannot explain.

CONCLUSIONS

Motor function in 5-year-old esophageal atresia patients was impaired and negatively associated with the number of postoperative days of endotracheal intubation and positively associated with high blood pressure. Prospective studies with critical perioperative monitoring and monitoring during stay at the intensive care unit are recommended.

Left congenital diaphragmatic hernia and gastroschisis in a term male infant

A term male infant was born to a healthy 24-year-old mother with antenatally diagnosed liver-up, left congenital diaphragmatic hernia (CDH) and gastroschisis. The infant was stabilised in the neonatal intensive care unit and then underwent primary repair of the CDH via left subcostal incision and silo placement for the gastroschisis. Serial silo reductions were started postoperatively and umbilical flap closure for the gastroschisis was performed on day of life 6. The patient was weaned from respiratory support, started on enteral feeds, and discharged home at 1 month of age. He was weaned from supplemental nasogastric feeds by 6 weeks of age and is currently well and thriving at 11 months of age.

Cerebral Oxygenation by Near-Infrared Spectroscopy in Infants Undergoing Thoracoscopic Lung Resection

Background: Thoracoscopic resection is the standard of care for congenital lung malformations (CLMs) in infants. However, there is rising concern that capnothorax may affect cerebral perfusion and oxygenation, carrying potential long-term effects on neurodevelopmental behavior. The aim of our study was to investigate, using near-infrared spectroscopy (NIRS), the regional cerebral oxygenation (CrSO₂) in infants undergoing thoracoscopic lung resection; the secondary aim was to assess the relationship between rSO₂ and standard monitoring. Methods: In this retrospective study, we reviewed all infants (<1 year old, ASA II) who underwent thoracoscopic CLM resection in double-lung ventilation under fixed capnothorax parameters (5 mmHg of pressure, 1 L/minute flow), standardized anesthetic protocol, standard monitoring, and multisite NIRS in our center. We focused our attention on 8 anesthetic and surgical maneuvers, potentially affecting tissue oxygen saturation. Results: Ten infants met the inclusion criteria. At surgery, median age was 5.5 (4-7) months, median weight 7.2 (6.6-8) kg, median operative time 110 (55-180) minutes, and median capnothorax duration 79 (34-168) minutes. No conversion to open surgery occurred. CrSO₂ values remained within clinically accepted values during thoracoscopy, beside a CrSO₂ drop >20% of basal value in 1 patient, during capnothorax induction. Renal NIRS added very little to standard monitoring, which appeared generally inadequate to consistently appraise end-organ perfusion. ETCO₂ best correlated with CrSO₂ variations, suggesting to be able to realistically predict them. Conclusions: The thoracoscopic treatment of CLMs under the given conditions appears well tolerated in infants, pending the continuous adjustment of ventilator settings by an experienced anesthetist, confident with NIRS technology.

Applications and Limitations of Neuro-Monitoring in Paediatric Anaesthesia and Intravenous Anaesthesia: A Narrative Review

Safe management of anaesthesia in children has been one of the top areas of research over the last decade. After the large volume of articles which focused on the putative neurotoxic effect of anaesthetic agents on the developing brain, the attention and research efforts shifted toward prevention and treatment of critical events and the importance of peri-anaesthetic haemodynamic stability to prevent negative neurological outcomes. Safetots.org is an international initiative aiming at raising the attention on the relevance of a high-quality anaesthesia in children undergoing surgical and non-surgical procedures to guarantee a favourable outcome. Children might experience hemodynamic instability for many reasons, and how the range of normality within brain autoregulation is maintained is still unknown. Neuro-monitoring can guide anaesthesia providers in delivering optimal anaesthetic drugs dosages and also correcting underling conditions that can negatively affect the neurological outcome. In particular, it is referred to EEG-based monitoring and monitoring for brain oxygenation.

Thoracoscopic repair of congenital diaphragmatic hernia in neonates: findings of a multicenter study in Japan

PURPOSE

We compared the efficacy of thoracoscopic repair (TR) with that of open repair (OR) for neonatal congenital diaphragmatic hernia (CDH).

METHODS

The subjects of this multicenter retrospective cohort study were 524 infants with left-sided isolated CDH, diagnosed prenatally, and treated at one of 15 participating hospitals in Japan between 2006 and 2018. The outcomes of infants who underwent TR and those who underwent OR were compared, applying propensity score matching.

RESULTS

During the study period, 57 infants underwent TR and 467 underwent OR. Ten of the infants who underwent TR required conversion to OR for technical difficulties and these patients were excluded from the analysis. The survival rate at 180 days was similar in both groups (TR 98%; OR 93%). Recurrence developed after TR in 3 patients and after OR in 15 patients (TR 7%, OR 3%, p = 0.40). The propensity score was calculated using the following factors related to relevance of the surgical procedure: prematurity (p = 0.1), liver up (p < 0.01), stomach position (p < 0.01), and RL shunt (p = 0.045). After propensity score matching, the multivariate analysis adjusted for severity classification and age at surgical treatment revealed a significantly shorter hospital stay (odds ratio 0.50) and a lower incidence of chronic lung disease (odds ratio 0.39) in the TR group than in the OR group.

CONCLUSIONS

TR can be performed safely for selected CDH neonates with potentially better outcomes than OR.

Clinical guidelines for the treatment of congenital diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) is a birth defect of the diaphragm in which abdominal organs herniate through the defect into the thoracic cavity. The main pathophysiology is respiratory distress and persistent pulmonary hypertension because of pulmonary hypoplasia caused by compression of the elevated organs. Recent progress in prenatal diagnosis and postnatal care has led to an increase in the survival rate of patients with CDH. However, some survivors experience mid- and long-term disabilities and complications requiring treatment and follow-up. In recent years, the establishment of clinical practice guidelines has been promoted in various medical fields to offer optimal medical care, with the goal of improvement of the disease' outcomes, thereby reducing medical costs, etc. Thus, to provide adequate medical care through standardization of treatment and elimination of disparities in clinical management, and to improve the survival rate and mid- and long-term prognosis of patients with CDH, we present here the clinical practice guidelines for postnatal management of CDH. These are based on the principles of evidence-based medicine using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. The recommendations are based on evidence and were determined after considering the balance among benefits and harm, patient and society preferences, and medical resources available for postnatal CDH treatment.

Publication Trends and Global Collaborations on Esophageal Atresia Research: A Bibliometric Study

INTRODUCTION

 Research on esophageal atresia (EA) has been heavily published over the past decades. Herein, we aimed to study the quantity and quality as well as key topics in EA research with regards to global collaborations among countries and authors.

MATERIALS AND METHODS

 Publications on EA from 1945 to 2018 were extracted from the Web of Science core collection database. Productivity (quantity) was assessed by the number of publications. Quality was estimated from the number of citations, citation rate per item and year, h-index, and impact index. Collaborative networks were evaluated using VOSviewer. All measures were analyzed for countries, authors, and journals. The 10 most cited original articles between 1969 and 2018 in 5-year intervals (n = 100) were manually screened to assess the key points of EA research.

RESULTS

 A total of 2,170 publications from 85 countries published in 388 journals were identified yielding 26,755 citations, both significantly increasing over time (p < 0.001). The most productive countries and authors also accounted for high-quality publications and benefited from an active global network. The most productive journals derived from the field of pediatric surgery but accounted only for one-third of EA papers. The best cited journals were unspecific for pediatric surgery. Long-term outcome remained the most important topic in EA research, followed by surgical techniques, epidemiology, associated anomalies, perioperative complications, and postnatal management. In contrast, basic science was underrepresented.

CONCLUSION

 Over the past seven decades, EA publications increased tremendously. Productiveness and quality benefited from global networking. Long-term outcome remains the key interest of EA research.

Thoracoscopic oesophageal atresia/tracheo-oesophageal fistula (OA/TOF) repair is associated with a higher stricture rate: a single institution’s experience

PURPOSE

Thoracoscopic OA/TOF repair was first described in 1999. Currently, less than 10% of surgeons routinely employ minimally access surgery. Our primary aim was to review our immediate-, early- and long-term outcomes with this technique compared with the open approach.

METHODS

A retrospective review of all patients undergoing primary OA/TOF (Type C) repair at our institution from 2009 was conducted. Outcome measures included length of surgery, conversion rate from thoracoscopy, early complications such as anastomotic leak and post-operative complications such as anastomotic strictures needing dilatations. Fisher's exact and Kruskal-Wallis tests were used for statistical analysis.

RESULTS

95 patients in total underwent OA/TOF repair during the study period of which 61 (64%) were completed via an open approach. 34 were attempted thoracoscopically of which 11 (33%) were converted. There was only one clinically significant anastomotic leak in our series that took place in the thoracoscopic group. We identified a significantly higher stricture rate in our thoracoscopic cohort (72%) versus open surgery (43%, P < 0.05). However, the median number of dilations (3) performed was not significantly different between the groups. There was one recurrent fistula in the thoracoscopic converted to open group. Our median follow-up was 60 months across the groups.

CONCLUSION

In our experience, the clinically significant leak rate for both open and thoracoscopic repair as well as recurrent fistula is much lower than has been reported in the literature. We do not routinely perform contrast studies and are, thus, reporting clinically significant leaks only. The use of post-operative neck flexion, ventilation and paralysis is likely to be protective towards a leak. Thoracoscopic OA/TOF repair is associated with a higher stricture rate compared with open surgery; however, these strictures respond to a similar number of dilatations and are no more refractory. Larger, multicentre studies may be useful to investigate these finding further.

Video-Assisted Thoracoscopic or Conventional Thoracic Surgery in Infants and Children: Current Evidence

INTRODUCTION

 The pros and cons of video-assisted thoracoscopic versus conventional thoracic surgery in infants and children are still under debate. We assessed reported advantages and disadvantages of video-assisted thoracoscopy in pediatric surgical procedures, as well as the evidence level of the available data.

MATERIALS AND METHODS

 A systematic literature search was performed to identify manuscripts comparing video-assisted thoracoscopic and the respective conventional thoracic approach in classic operative indications of pediatric surgery. Outcome parameters were analyzed and graded for level of evidence (according to the Oxford Centre of Evidence-Based Medicine).

RESULTS

 A total of 48 comparative studies reporting on 12,709 patients, 11 meta-analyses, and one pilot randomized controlled trial including 20 patients were identified. More than 15 different types of advantages for video-assisted thoracoscopic surgery were described, mostly with a level of evidence 3b or 3a. Most frequently video-assisted thoracoscopic surgery was associated with shorter hospital stay, shorter postoperative ventilation, and shorter time to chest drain removal. Mortality rate and severe complications did not differ between thoracoscopic and conventional thoracic pediatric surgery, except for congenital diaphragmatic hernia repair with a lower mortality and higher recurrence rate after thoracoscopic repair. The most frequently reported disadvantage for video-assisted thoracoscopic surgery was longer operative time.

CONCLUSION

 The available data point toward improved recovery in pediatric video-assisted thoracoscopic surgery despite longer operative times. Further randomized controlled trials are needed to justify the widespread use of video assisted thoracoscopy in pediatric surgery.

Mentoring in Pediatric Thoracoscopy: From Theory to Practice

Introduction: Thoracoscopy represents the most challenging area of pediatric minimally invasive surgery due to its technical difficulty. A standardized training program would be advisable. The aim of this study is to evaluate the results of our surgical training. Materials and Methods: A retrospective, single-center, cohort study was performed. The following four-step program was tested: (1) theoretical part; (2) experimental training; (3) training in centers of reference; (4) personal operative experience. Particular attention was focused on the choice of mentor. Times and modality of adherence to the program were evaluated. The effectiveness and safety of the training were evaluated according to the surgical results of esophageal atresia (EA/TEF) repair and resection of congenital lung malformations (CLM). The study was conducted from January 2014 to May 2020. Attending surgeons with previous experience in neonatal and pediatric laparoscopy were selected for the training program after being evaluated by the head of Department. Results: The training program was fully completed in 2 years. Twenty-four lobectomies, 9 sequestrectomies, 2 bronchogenic cyst resections and 20 EA/TEF repair were performed. Thoracoscopy was always feasible and effective, with no conversion. The operative times progressively decreased. Only three minor complications were recorded, all treated conservatively. Conclusions: A standardized training program is highly desirable to learn how to safely perform advanced pediatric thoracoscopy. The 4-steps design seems a valid educational option. The choice of the mentor is crucial. An experience-based profile for pediatric surgeons who may teach thoracoscopy is advisable.

Feasibility of Doppler Ultrasound for Cortical Cerebral Blood Flow Velocity Monitoring During Major Non-cardiac Surgery of Newborns

Background and Aim: Newborns needing major surgical intervention are at risk of brain injury and impaired neurodevelopment later in life. Disturbance of cerebral perfusion might be an underlying factor. This study investigates the feasibility of serial transfontanellar ultrasound measurements of the pial arteries during neonatal surgery, and whether perioperative changes in cerebral perfusion can be observed and related to changes in the perioperative management. Methods: In this prospective, observational feasibility study, neonates with congenital diaphragmatic hernia and esophageal atresia scheduled for surgical treatment within the first 28 days of life were eligible for inclusion. We performed transfontanellar directional power Doppler and pulsed wave Doppler ultrasound during major high-risk non-cardiac neonatal surgery. Pial arteries were of interest for the measurements. Extracted Doppler ultrasound parameters were: peak systolic velocity, end diastolic velocity, the resistivity index and pulsatility index. Results: In 10 out of 14 patients it was possible to perform perioperative measurements; the others failed for logistic and technical reasons. In 6 out of 10 patients, it was feasible to perform serial intraoperative transfontanellar ultrasound measurements with directional power Doppler and pulsed wave Doppler of the same pial artery during neonatal surgery. Median peak systolic velocity was ranging between 5.7 and 7.0 cm s^-1 and end diastolic velocity between 1.9 and 3.2 cm s^-1. In patients with a vasoactive-inotropic score below 12 the trend of peak systolic velocity and end diastolic velocity corresponded with the mean arterial blood pressure trend. Conclusion: Perioperative transfontanellar ultrasound Doppler measurements of the pial arteries are feasible and provide new longitudinal data about perioperative cortical cerebral blood flow velocity. Trial Registration: https://www.trialregister.nl/trial/6972, identifier: NL6972.

Respiratory Support of Infants With Congenital Diaphragmatic Hernia

Optimisation of respiratory support of infants with congenital diaphragmatic hernia (CDH) is critical. Infants with CDH often have severe lung hypoplasia and abnormal development of their pulmonary vasculature, leading to ventilation perfusion mismatch. It is vital that lung protective ventilation strategies are employed during both initial stabilisation and post-surgical repair to avoid ventilator induced lung damage and oxygen toxicity to prevent further impairment to an already diminished gas-exchanging environment. There is a lack of robust evidence for the routine use of surfactant therapy during initial resuscitation of infants with CDH and thus administration cannot be recommended outside clinical trials. Additionally, inhaled nitric oxide has been shown to have no benefit in reducing the mortality rates of infants with CDH. Other therapeutic agents which beneficially act on pulmonary hypertension are currently being assessed in infants with CDH in randomised multicentre trials. The role of novel ventilatory modalities such as closed loop automated oxygen control, liquid ventilation and heliox therapy may offer promise for infants with CDH, but the benefits need to be determined in appropriately designed clinical trials.