ABSTRACT Background and aims Primary lung tumors (PLTs) in children are rare, and surgery remains the key to ensure remission. Here we describe the PLTs clinical characteristics, their management, and the pulmonary outcome following surgery. Methods We carried out a French national cohort of pediatric PLTs from 2013 to 2023 from the FRACTURE rare pediatric tumors national database. We included children under 18 years at diagnosis who underwent surgery for a histologically proven PLT, with a minimum of 6 months of follow‐up (FU) post surgery. Results Sixty‐two patients were included. The median age at diagnosis was 3.6 years [3; 11], sex ratio 1.07. Pleuropulmonary blastoma was the most frequent tumor retrieved ( n = 31). Sixty patients underwent surgery: 32 lobectomies, 15 wedges, five segmentectomies, and five pneumectomies. A thoracoscopic approach was carried out in 14% of the cases. At 6 months post surgery and at the last follow‐up (median time of 5.7 years [3.4; 7.6]), respectively, 11 and eight patients presented with pulmonary symptoms, and 10 and three patients presented with surgical complications. During the post‐surgery period, 22 children benefited from an evaluation of their respiratory function by pulmonary function tests, and four of them remained with abnormal results. Conclusions Surgery is key to ensure remission in PLTs and seems secure. However, respiratory symptoms are noted in 13% of children during the FU, and this rate is probably underestimated. Therefore, we suggest a systematic pulmonary FU to optimize postoperative pulmonary rehabilitation and, therefore, the child's pulmonary outcome.

Introduction: This study compares various surgical approaches for treating congenital diaphragmatic eventration (CDE) in children to identify the most effective and safest method. Methods: we conducted a retrospective analysis of a multicentric cohort of pediatric patients operated on for CDE between 2010 and 2021. The different surgical approaches, including robot-assisted thoracoscopic surgery (RATS), and their outcomes were compared. (Clinical Trials NCT04862494). Results: 112 patients, aged 12 [5 – 21] months, underwent diaphragmatic plication. Thoracoscopy or RATS was performed in 69 (62%) cases, postero-lateral thoracotomy (PLT) in 15 (13%) and an abdominal approach in 28 (25%), based on surgeons’ choice. Symptom relief was achieved in 88% of patients, and 90% showed radiographic improvement. There were 31 peri- or early postoperative complications (28%), mainly including pleural effusions, infections and lobar atelectasis, and eight recurrences of eventration (7%), with no significant correlation between these complications and the surgical approach. Compared to other approaches, thoracotomy multiplied the duration of intravenous analgesia by three (96 vs 36h, p<0.0001), and hospital stay length by two (8 vs 4d, p = 0.002). RATS, although comparable to thoracoscopy in short-term outcomes, had a higher incidence of perioperative hepatic injuries and long-term complications, including persistent symptoms in all 5 patients and chest wall deformities in two. Conclusions: Diaphragmatic plication via a minimally invasive thoracic approach may be the best treatment option for cases of symptomatic CDE. Further research is required to establish potential added risks of RATS as compared to thoracoscopy in this indication.

Background Diaphragmatic plication is the most widely used surgical approach for treating congenital diaphragmatic eventration (CDE) in children. This study aims to assess current surgical practice for this pathology in children.Methods Retrospective data analysis of a multicentric cohort of pediatric patients operated on for CDE between 2010 and 2021. Comparative description of the different surgical approaches and their outcomes, including robot-assisted thoracoscopic surgery (RATS). (Clinical Trials [NCT04862494][1]).Results 112 patients, aged 12 [5 – 21] months, were operated on for CDE. Diaphragmatic plication was performed using thoracoscopy or RATS in 69 (62%) cases, postero-lateral thoracotomy (PLT) in 15 (13%), and using an abdominal approach in 28 (25%). Relief of symptoms and improvement in the diaphragmatic level on chest radiographs were obtained in 88% and 90% of the cases, respectively. We recorded 32 peri- or early postoperative complications (29%) and eight recurrences of eventration (7%), but found no correlation between these complications and the surgical approach used. Compared to other approaches, PLT multiplied the duration of intravenous analgesia by three (96 vs 36h, p<0.0001), and the length of hospital stay by two (8 vs 4d, p = 0.002). Compared to thoracoscopy, RATS provided more perioperative hepatic injuries and equivalent short-term results, but all five patients remained symptomatic and two of them experienced chest wall deformities in long-term follow-up.Conclusions Diaphragmatic plication via a minimally invasive thoracic approach may be the best treatment option for cases of symptomatic CDE. RATS emerges as a promising surgical approach, but further is required to confirm that it is, at least, not inferior to thoracoscopy.### Competing Interest StatementThe authors have declared no competing interest.### Funding StatementThis study did not receive any funding### Author DeclarationsI confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.YesThe details of the IRB/oversight body that provided approval or exemption for the research described are given below:The ethics committee of the University Hospital Center of Angers gave ethial approval for this workI confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as [ClinicalTrials.gov][2]. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).YesI have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.YesAll data produced in the present study are available upon reasonable request to the authors [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT04862494&atom=%2Fmedrxiv%2Fearly%2F2024%2F02%2F15%2F2024.02.15.24302855.atom [2]: http://ClinicalTrials.gov

Total nephrectomies for the treatment of Wilms’ tumor (WT) are more and more performed by laparoscopy, although indications for this approach following the UMBRELLA guidelines are currently very restrictive. The purpose of this study was to assess the compliance to the criteria of the UMBRELLA protocol for minimally invasive approach of WT. This retrospective multicenter study included children operated on by laparoscopic total nephrectomy for suspected WT before 2020. Imaging was reviewed centrally. Fifty-six patients (50 WT and 6 nephrogenic rests) were operated on at a median age of 3.3 ± 2.6 years. Thirteen (23

Contexte et objectifs Les tumeurs pulmonaires primaires (TPP) chez les enfants sont rares, et la chirurgie reste le traitement principal. L’objectif est de décrire leurs caractéristiques cliniques et thérapeutiques, ainsi que l’impact respiratoire au décours du traitement. Méthodes Nous avons réalisé une cohorte nationale française de TPP pédiatriques de 2013 à 2023. Résultats et discussion Soixante-deux patients ont été inclus. L’âge médian au diagnostic était de 3,6 ans, avec des symptômes chez 54 patients. Soixante patients ont eu une résection chirurgicale : 32 lobectomies, 15 wedges, 5 segmentectomies et 5 pneumectomies. Un abord par thoracoscopie n’a été réalisé que dans 14 % des cas. Le pleuropneumoblastome représente 50 % de la cohorte. Les autres histologies sont principalement des tumeurs neuroendocrines, des carcinomes mucoépidermoïdes, des tumeurs inflammatoires myofibroblastiques. Six mois après la chirurgie et au dernier suivi, respectivement 11 puis 8 patients avaient des symptômes respiratoires ; et respectivement 10 puis 3 patients ont eu des complications chirurgicales. Au dernier suivi, seulement 20 enfants ont eu des EFR. Conclusions La chirurgie est essentielle pour assurer la rémission complète dans les TPP et semble bien tolérée. Cependant, un suivi pneumologique accru après la chirurgie semble nécessaire pour optimiser la rééducation pulmonaire post-chirurgie et donc la qualité de vie de l’enfant.

The purpose of this study is to assess quality of life (QoL) after laparoscopic anti-reflux surgery (LARS) in children with gastroesophageal reflux disease (GERD) and to evaluate GERD symptoms and their impact on daily life and school. From June 2016 to June 2019, all children with GERD from 2 to 16 years of age, without neurologic impairment or malformation-related reflux, were prospectively included in a monocentric study. Patients (or their parents according to the age of the child) answered the Pediatric Questionnaire on Gastroesophageal Symptoms and QoL (PGSQ) before surgery and 3 and 12 months after surgery. Variables were compared by paired, bilateral Student t-test. Twenty-eight children (16 boys) were included. The median age at surgery was 77 months (IQR: 59.2–137) with median weight of 22 kg (IQR: 19.8–42.3). All had a laparoscopic Toupet fundoplication. Median duration of follow-up was 14.7 months (IQR: 12.3–22.5). One patient (4

The Summary Background Data: EA is the most frequent congenital esophageal malformation. Long gap EA remains a therapeutic challenge for pediatric surgeons. A case case-control prospective study from a multi-institutional national French data base was performed to assess the outcome, at age of 1 and 6 years, of long gap esophageal atresia (EA) compared with non-long gap EA/tracheo-esophageal fistula (TEF). The secondary aim was to assess whether initial treatment (delayed primary anastomosis of native esophagus vs. esophageal replacement) influenced mortality and morbidity at ages 1 and 6 years. Methods: A multicentric population-based prospective study was performed and included all patients who underwent EA surgery in France from January 1, 2008 to December 31, 2010. A comparative study was performed with non-long gap EA/TEF patients. Morbidity at birth, 1 year, and 6 years was assessed. Results: Thirty-one patients with long gap EA were compared with 62 non-long gap EA/TEF patients. At age 1 year, the long gap EA group had longer parenteral nutrition support and longer hospital stay and were significantly more likely to have complications both early post-operatively and before age 1 year compared with the non-long gap EA/TEF group. At 6 years, digestive complications were more frequent in long gap compared to non-long gap EA/TEF patients. Tracheomalacia was the only respiratory complication that differed between the groups. Spine deformation was less frequent in the long gap group. There were no differences between conservative and replacement groups at ages 1 and 6 years except feeding difficulties that were more common in the native esophagus group. Conclusions: Long gap strongly influenced digestive morbidity at age 6 years. (c) 2022 Elsevier Inc. All rights reserved.

Background: This study assessed the potential cost-effectiveness of high (80–100%) vs low (21–35%) fraction of inspired oxygen (FiO2) at preventing surgical site infections (SSIs) after abdominal surgery in Nigeria, India, and South Africa. Methods: Decision-analytic models were constructed using best available evidence sourced from unbundled data of an ongoing pilot trial assessing the effectiveness of high FiO2, published literature, and a cost survey in Nigeria, India, and South Africa. Effectiveness was measured as percentage of SSIs at 30 days after surgery, a healthcare perspective was adopted, and costs were reported in US dollars ($). Results: High FiO2 may be cost-effective (cheaper and effective). In Nigeria, the average cost for high FiO2 was $216 compared with $222 for low FiO2 leading to a −$6 (95% confidence interval [CI]: −$13 to −$1) difference in costs. In India, the average cost for high FiO2 was $184 compared with $195 for low FiO2 leading to a −$11 (95% CI: −$15 to −$6) difference in costs. In South Africa, the average cost for high FiO2 was $1164 compared with $1257 for low FiO2 leading to a −$93 (95% CI: −$132 to −$65) difference in costs. The high FiO2 arm had few SSIs, 7.33% compared with 8.38% for low FiO2, leading to a −1.05 (95% CI: −1.14 to −0.90) percentage point reduction in SSIs. Conclusion: High FiO2 could be cost-effective at preventing SSIs in the three countries but further data from large clinical trials are required to confirm this.

Objectives: Necrotizing enterocolitis (NEC) is a severe neonatal surgical condition, associated with a prolonged pro-inflammatory state, leading to high mortality and morbidity rates. Carbon dioxide (CO2) insufflation during laparoscopy may have an anti-inflammatory effect. We aimed to evaluate the effects of CO2-insufflation on experimental colitis. Methods: Acute colitis was induced in 6-week-old Balb/c mice by the administration of 2%-dextran sulfate-sodium (DSS) during 7 days (n = 45). On Day 4, two groups received intraperitoneal insufflation (duration: 30 mn, pressure: 5 mmHg) of CO2 ("DSS+CO2") or air ("DSS+air"). A group received no insufflation ("DSS"). Groups were compared for clinical severity using the disease activity index (DAI-body weight loss, stool consistency, and bleeding), histological severity (histopathological activity index, colon length, and ulcerations), colonic mucosecretion, and inflammation. Results: DAI was significantly decreased in DSS+CO2 group, compared to DSS (p < 0.0001) or DSS+air (p < 0.0001) groups. Colon length was increased in DSS+CO2 treated mice compared to DSS (p = 0.0002). The histopathological activity index was lower in DSS+CO2 (vs. DSS, p = 0.0059/vs. DSS+air, p = 0.0389), with decreased ulcerations (3.77 vs. 10.7, p = 0.0306), and persistent mucosecretion with increased mucin-secreting cells. Conclusions: CO2-insufflation attenuates DSS-induced colitis and improves both clinical and histological scores. Laparoscopy with CO2 insufflation represents a therapeutic anti-inflammatory strategy for NEC.

PURPOSE:Neuroblastoma management in children is multimodal and depends on multiple factors, including the possibility of complete surgical resection. Image-defined risk factors (IDRFs) are used to assess the feasibility of primary surgery. We studied the changes in IDRFs after neoadjuvant chemotherapy for thoracic neurogenic tumors.METHODS:We performed a multicenter review of 27 patients presenting with unresectable thoracic neurogenic tumors. Patients received neoadjuvant chemotherapy, according to their risk group. IDRF at diagnosis and before surgery were retrospectively analyzed by a radiologist and a surgeon, blind to the initial assessment. Surgical and oncologic outcomes were reviewed.RESULTS:None of the patients presented MYCN amplification, and 78 IDRFs were identified at diagnosis. Vascular IDRFs were the most frequent, with 28 vascular IDRFs detected in 18 patients, 22 of which disappeared after chemotherapy. Reductions of tumor volume were associated with a regression of IDRFs. Patients undergoing minimally invasive surgery had smaller tumor volumes than those undergoing open surgery, and no vascular IDRF. Two patients received two additional courses of chemotherapy to reduce tumor volume sufficiently for surgery. One patient with ganglioneuroblastoma underwent early surgery due to a lack of response to initial chemotherapy.CONCLUSION:Tumor volume reduction with neoadjuvant chemotherapy eliminates most IDRF in thoracic neurogenic tumors. Vascular IDRF are rapidly resolved at this site, making surgical resection and minimally invasive surgery possible.

INTRODUCTION:Surgical site infection (SSI) is one of the most common healthcare-associated infections (HAIs). However, there is a lack of data available about SSI in children worldwide, especially from low-income and middle-income countries. This study aimed to estimate the incidence of SSI in children and associations between SSI and morbidity across human development settings.METHODS:A multicentre, international, prospective, validated cohort study of children aged under 16 years undergoing clean-contaminated, contaminated or dirty gastrointestinal surgery. Any hospital in the world providing paediatric surgery was eligible to contribute data between January and July 2016. The primary outcome was the incidence of SSI by 30 days. Relationships between explanatory variables and SSI were examined using multilevel logistic regression. Countries were stratified into high development, middle development and low development groups using the United Nations Human Development Index (HDI).RESULTS:Of 1159 children across 181 hospitals in 51 countries, 523 (45·1%) children were from high HDI, 397 (34·2%) from middle HDI and 239 (20·6%) from low HDI countries. The 30-day SSI rate was 6.3% (33/523) in high HDI, 12·8% (51/397) in middle HDI and 24·7% (59/239) in low HDI countries. SSI was associated with higher incidence of 30-day mortality, intervention, organ-space infection and other HAIs, with the highest rates seen in low HDI countries. Median length of stay in patients who had an SSI was longer (7.0 days), compared with 3.0 days in patients who did not have an SSI. Use of laparoscopy was associated with significantly lower SSI rates, even after accounting for HDI.CONCLUSION:The odds of SSI in children is nearly four times greater in low HDI compared with high HDI countries. Policies to reduce SSI should be prioritised as part of the wider global agenda.

To evaluate the impact of the COVID-19 pandemic-related lockdown on management and outcomes of children with acute appendicitis. A retrospective cohort study was conducted, including children treated for acute appendicitis (January 20th–May 11th, 2020). The data regarding the severity of appendicitis and outcome were collected and compared for two time periods, before and after the nationwide lockdown (March 17th, 2020). The number of cases of acute appendicitis increased by 77% during the lockdown (n = 39 vs. n = 69, p = 0.03). During the lockdown, children treated for appendicitis were older (11.1 vs. 8.9 years, p = 0.003), and were more likely to live more than 5 km away from our institution (77% vs. 52%, p = 0.017). Less children had previously consulted a general practitioner (15% vs. 33%, p = 0.028), whereas more children were transferred from other hospitals (52% vs. 31%, p = 0.043). There was no difference in terms of length of hospital stay, rate of postoperative intra-abdominal abscess, ER visits, and readmissions between both periods. Three children (4%) were diagnosed with COVID-19 and appendicitis. Despite an increase in the number of children with appendicitis managed at our hospital during the COVID-19-related lockdown, management, and outcome remained similar. Although our pediatric center was strongly affected by this pandemic, maintaining our prior practice strategies for acute appendicitis avoided the occurrence of collateral damage for those children.

Medical care in rectal cancer is subject to social inequality. According to the last French guidelines, a 1-cm distal margin below the lower pole of the rectal tumor is now considered sufficient. This extends the limits of the current sphincter preservation gold standard. Like for other innovative technics, the dissemination of such technics is often subject to social and geographical inequalities. The objective was to analyze whether sphincter preservation in rectal cancer is subject to social or geographical inequality. The odds of sphincter preservation was modeled by logistic regression among the 1453 patients in the Calvados digestive cancer registry between 1 January 1997 and 31 December 2015 by examining some of the variables that could influence it: social inequalities and geographical remoteness, sex, age, and stage. A total of 69.4% of the population received sphincter preservation. Patients in the more deprived quintiles had a significantly higher probability of having sphincter amputation (odds ratio (OR) = 1.469 (1.046–2.064)). This result was no longer significant after adjustment on stage and travel time. There was a dose-effect pattern of geographical remoteness on likelihood of sphincter preservation with a progressive increase in OR between patients living the nearest and the furthest from the reference center (p-trend = 0.0178). This study shows that the probability of receiving sphincter preservation is influenced by the social environment and strongly influenced by remoteness. Although management guidelines have had a huge impact on the rates of sphincter preservation, they have not reduced the influence of the social and geographical environment on sphincter preservation.

A 4-year-old boy was referred with recurrent pneumonia and aspiration of liquids. Clinical examination, complete blood count and sweat test were normal. A tracheo-oesophageal fistula (TEF) was suspected as a differential diagnosis. Barium swallow was unremarkable. Tracheoscopy showed a small mucous irregularity on the posterior wall, but intra-oesophageal instillation of methylene blue was not perceived in the trachea. Tracheoscopy was interrupted prematurely due to poor respiratory tolerance. Finally, chest CT scan showed a millimetre-wide TEF originating from the trachea …

Rapporter notre expérience de la voie scrotale seule dans les reprises chirurgicales d’orchidopexie après chirurgie inguinale ou chirurgie de testicules non descendus. Trente-six patients opérés de janvier 2003 à septembre 2015 dans notre service de chirurgie pour abaissement testiculaire après orchidopexie ou chirurgie inguinale préalable ont été inclus. L’intervention de reprise était conduite par un abord scrotal premier de type Bianchi. En cas de difficulté par cette voie un abord inguinal reprenant la cicatrice précédente était réalisé. Les patients ont été répartis en deux groupes : un groupe 1 de 10 enfants opérés d’une hernie inguinale et présentant un testicule ascensionné ; et un groupe 2 de 26 enfants présentant un testicule ascencionné après une orchidopexie première. A été considéré bon résultat un testicule en position scrotale sans atrophie ou hypotrophie au contrôle postopératoire. La voie scrotale seule a permis de traiter tous les patients du groupe 1. Dans le groupe 2, une incision inguinale complémentaire a été réalisée pour 7 patients (19 %). Un patient opéré par voie scrotale seule a présenté un hématome postopératoire qui a mené à une atrophie testiculaire secondaire. Un bon résultat était obtenu pour 35/36 patients (97 %). L’incision scrotale unique est efficace et facile à réaliser pour une chirurgie d’orchidopexie secondaire à une cure de hernie inguinale. Après une orchidopexie préalable pour testicule non descendu, l’abaissement du testicule par voie scrotale seule ne peut pas être une approche unique, la combinaison avec une voie inguinale classique peut être nécessaire. 5. To report our experience of the unique scrotal incision for the redo cases of orchiopexy after previous inguinal surgery or orchiopexy for undescended testis with a special attention regarding the place of the single scrotal approach. Thirty-six patients operated between January 2003 and September 2015 in our surgical unit for secondary orchiopexy after previous inguinal surgery or orchiopexy for undescended testis (UDT) were included in a retrospective study. The secondary surgical procedure was initiated by a scrotal incision (Bianchi). In cases of difficulty by the scrotal incision an inguinal approach by the prior skin inguinal incision was performed. Patients were divided in two groups a group 1 of 10 patients with reascending testis following inguinal hernia repair and a group 2 of 26 patients with reascending testis after previous orchiopexy for UDT. A good result was defined as testis in scrotal position without evidence of atrophy. All the patients of group 1 were treated by a unique scrotal incision. In group 2, seven patients required a complementary inguinal approach. One hematoma complicated a scrotal procedure leading to a testicular atrophy. A good result was achieved in 35/36 patients (97%). Single scrotal incision is an efficient and easy way to perform secondary orchiopexy after hernia repair. After surgery for UDT, as for primary cases, it cannot be an exclusive approach, higher testis need a combined or an inguinal approach. 5.

Objective. - To report our experience of the unique scrotal incision for the redo cases of orchiopexy after previous inguinal surgery or orchiopexy for undescended testis with a special attention regarding the place of the single scrotal approach.Patients and methods. - Thirty-six patients operated between January 2003 and September 2015 in our surgical unit for secondary orchiopexy after previous inguinal surgery or orchiopexy for undescended testis (UDT) were included in a retrospective study. The secondary surgical procedure was initiated by a scrotal incision (Bianchi). In cases of difficulty by the scrotal incision an inguinal approach by the prior skin inguinal incision was performed. Patients were divided in two groups a group 1 of 10 patients with reascending testis following inguinal hernia repair and a group 2 of 26 patients with reascending testis after previous orchiopexy for UDT. A good result was defined as testis in scrotal position without evidence of atrophy.Results. - All the patients of group 1 were treated by a unique scrotal incision. In group 2, seven patients required a complementary inguinal approach. One hematoma complicated a scrotal procedure leading to a testicular atrophy. A good result was achieved in 35/36 patients (97%).Conclusion. - Single scrotal incision is an efficient and easy way to perform secondary orchiopexy after hernia repair. After surgery for UDT, as for primary cases, it cannot be an exclusive approach, higher testis need a combined or an inguinal approach. (C) 2017 Elsevier Masson SAS. All rights reserved.