Background: Intrapericardial extralobar pulmonary sequestration (ELPS) is an exceptionally rare congenital malformation. The location may mimic neoplastic lesions and poses diagnostic and surgical challenges. We present a new case and a systematic review of the literature. Case Presentation: A 3-month-old male infant was referred for evaluation of a congenital intrathoracic mass suspected to be an extralobar sequestration. However, intrapericardial location was not recognized. MRI and CT demonstrated a circumscribed lesion with arterial supply from the right pulmonary artery. Thoracoscopic exploration was attempted but converted to sternotomy. The mass was excised en bloc. Histopathological analysis confirmed extralobar pulmonary sequestration with cystic components, consistent with a hybrid lesion. Postoperative recovery was uneventful. Methods: A systematic literature review was conducted according to PRISMA guidelines across PubMed, Scopus and Embase databases, including only histologically confirmed intrapericardial ELPS. Results: Ten cases were identified. Including the present case, eleven cases have been reported. Prenatal detection occurred in 54% of cases. Fetal demise occurred in two cases due to cardiac tamponade. Aberrant arterial supply originated from the pulmonary arteries in 54% of patients and venous drainage into the right atrium or superior vena cava in 45%. Surgery via sternotomy was performed in all cases with excellent outcomes. Conclusions: Intrapericardial ELPS is an exceptionally rare but surgically curable entity. Early recognition and complete resection are essential to prevent life-threatening complications. This systematic review highlights a consistent vascular pattern supporting its classification as a unique embryologic variant within the CPAM-sequestration spectrum.

OBJECTIVE:Patient satisfaction (PS) is an important healthcare outcome and should be an integral part of quality improvement agendas. Between 2019 and 2021, the Italian Society of Pediatric Gastroenterology, Hepatology and Nutrition, Endoscopy Interest Group conducted a nationwide quality assessment survey, EndoPed. One of the study's aims was to identify areas for improvement based on the results of a PS questionnaire. METHODS:The smartphone app-based, prospective survey involved 24 Italian pediatric endoscopy centers. Procedure details and quality standards were recorded. The modified Group Health Association of America-9 (GHAA-9m) satisfaction questionnaire consisted of 7 Likert-scale questions that explored waiting times, communication, and staff evaluation. Two additional closed questions investigated the will to confirm the endoscopist and the facility. Dissatisfaction was defined with the arbitrary cut-off of < 7/10. RESULTS:Questionnaire results were available for 1974 (55%) procedures. The questionnaire's internal consistency was good (Cronbach's α 0.86). Overall satisfaction was high. Shorter operator experience (odds ratio [OR] 4 [95% confidence interval [CI] 1.6 to -10.3]; p < 0.003), prolonged waiting time (OR 2.7 [95%CI 1.6-4.5]; p < 0.000), prolonged procedure duration (OR 2.9 [95% CI 1.8-4.7]; p < 0.000) and conscious sedation (OR 5 [95% CI 3-6.2]; p < 0.000) were confirmed in a multivariate model to be associated to lower satisfaction rates. CONCLUSIONS:Through a standardized methodology, the PS questionnaire is a valuable tool for clinical quality assessment. PS highlight improvement fields different from those identified by quality standards and items, adding elements for an exhaustive quality evaluation. Interventions derived from PS analysis could help to improve pediatric endoscopy.

Aortopexy is the most common surgical intervention for pediatric tracheomalacia (TM). The thoracoscopic approach, despite being reported by a few authors, remains controversial due to the different reported techniques and outcomes.We report a retrospective review of our preliminary experience with thoracoscopic aortopexy from 2023 to date. Patients' demographic data and symptoms were collected: age and weight at surgery, comorbidities, presence of brief resolved unexplained event (BRUE), dyspnea, chest infections, and barking cough. The study describes our surgical technique and its evolution. We analyzed the clinical outcome and endoscopic improvement, success and complication rate, operative time, and length of stay. We then compared our findings with the results of open and thoracoscopic aortopexy reported in the current literature.A total of 12 thoracoscopic aortopexies were performed on 10 patients (including two redo). The mean age and weight at operation were 3.2 years (range: 4 months-6 years) and 13.6 kg (range: 3.5-23), respectively. Two patients presented with BRUE, one with dyspnea, in the other cases the indications were recurrent pneumonia (more than six per year or three in 6 months). All patients underwent preoperative flexible bronchoscopy for the diagnosis of TM. The average estimated tracheal collapse was 86% (range: 70-95%). One intraoperative bleeding caused a conversion to open surgery, but no other complications occurred. All patients were extubated on the same day. Two cases required a redo due to suture tearing, and one of them required an additional posterior tracheopexy for persistent symptoms. The remaining patients had significant improvement on follow-up: success rate is 75%. Both patients requiring redo underwent aortopexy without pledgeted sutures or innominate artery (IA) suspension: these steps are associated with a success rate of 88.9% (p = 0.0182). Our refined technique now includes total thymectomy, pericardiotomy, pledgeted horizontal mattress sutures on the aorta, and the IA after full mobilization of the innominate vein.Thoracoscopic aortopexy appears to be a feasible and effective option for pediatric TM, particularly when replicating open surgical principles. Further research is needed to optimize the technique and improve the clinical results.

The purpose of this paper was to define the specturm of management for Parapneumonial Pleural Effusion/Pleural Empyema (PE/PPE) in children in Italy. We conducted an online survey, distributed by the SIVI committee to 54 Italian pediatric surgery centers. A total of 23/54 (43%) Italian pediatric surgery centers responded. All responders (100%) required an anteroposterior chest radiograph (CXR) as the first imaging approach to suspect PPE, and chest Ultrasound (US) was routinely used in 96% of centers. A preoperative CT scan was routinely performed in 70% of centers. An etiological diagnosis was obtained in more than 80% of patients in 13% of centers, between 40% and 80% of cases in 61% of centers and in less than 40% of patients in 26% of centers. Empirical antimicrobial therapy with 2 antibiotics is the most commonly used therapeutic scheme (78% of centers) and targeted antibiotic therapy was used in 82% of enrolled centers. The majority of centers (57%) approached advanced stage pleural empyema with pleural drain placement and fibrinolysis (PDF); 26% of centers preferred to execute upfront Video-Assisted Thoracoscopic Debridement (VATD), and in 13% of centers, both fibrinolysis and VATD were used. In all cases (100%), urokinase was the fibrinolytic agent of choice. Broncho-Pleural Fistula (BPF) was treated conservatively with prolonged Pleural Drainage (PD) and antibiotics in 82% of centers, while the remaining 18% proposed early surgical treatment. 82% of centers proposed prolonged antimicrobial therapy for the treatment of Lung Abscess (LA), while 18% of centers preferred to execute upfront ultrasound-guided or thoracoscopic positioning of a pig-tail drain. As expected, we observed a lack of homogeneity in the treatment between the different centers: most of these have a preference for fibrinolysis over the use of primary VATD, with urokinase being the only fibrinolytic agent used in all centers. It would be desirable to involve as many centers as possible for the drafting of shared national guidelines in the treatment of PPE in children in Italy.

Focal nodular hyperplasia (FNH)-like lesions of the liver are rare in the pediatric population and are seldom reported as congenital lesions. The differential diagnosis between these lesions and pure-fetal hepatoblastoma (HBL) is challenging. We present a case of a congenital FNH-like hepatic lesion, managed with a right hepatectomy due to suspected fetal HBL. Additionally, a review of all published cases of congenital FNH-like lesions of the liver was carried out.MRI

Background: Bronchopulmonary sequestration (BPS) is a portion of dysplastic pulmonary tissue not communicating with the tracheobronchial tree. Its vascularization is provided by abnormal arteries originating from the systemic circulation. Previous papers report different venous drainage (VD) between intralobar (ILS) and extralobar sequestration (ELS), respectively, into the pulmonary or the systemic veins. The aim of our study is to investigate the VD as independent predictor of the type of PS. Methods: We retrospectively reviewed 41 pediatric patients who underwent surgery for BPS between 2016 and 2023 in two centers. Patients treated prenatally and without pre-operative CT were excluded. BPS were classified either intra or extra lobar. Pre-operative radiological BPS classification prediction was assessed based on intra-operative thoracoscopic findings. Lesion VD and sharp margins (SM) on pre-operative CT were assessed as predicting factors. Results: A total of 36 patients were included: 24 ILS and 12 ELS. All patients underwent thoracoscopic resection without major complications. VD is significantly different between ILS and ELS: 96% of ILS drain into the pulmonary system while 83% of ELS drain into a systemic vein (p < 0.00001). On pre-operative CT, the absence of SM predicts for an ILS in 100% of cases. SM has a PPV for ELS of 85.7%. The combination of SM and systemic VD has a PPV for ELS of 91.7%. Conclusions: In our series, the absence of SM alone is suggestive for an ILS in 100% of cases, while the combination of SM and systemic VD is more accurate in predicting ELS. This may help improving surgical planning and family consultation.

Introduction: Aortopexy is the most common surgical option for the treatment of severe tracheomalacia (TM) in children. Despite being described over 75 years ago, several aspects of the procedure remain controversial. Materials and Methods: A systematic review of aortopexy was conducted following the PRISMA guidelines. All original articles describing at least one case of aortopexy performed in children for the treatment of TM were included. Patients’ characteristics, surgical indications, approaches and details were collected. Outcomes were reviewed, and potential factors associated with procedural success were investigated. Results: Of 243 papers, 17 were included in this review, encompassing a total of 473 patients who underwent aortopexy. Of these, 65.3% were male, with a mean age at surgery of 12.2 months (5 days–18 years). Primary TM accounted for 7.9% of cases, while 92.1% were secondary to other anomalies, including esophageal atresia (54.1%), aberrant innominate artery (16.1%) and vascular rings (8.3%). There is a general consensus on the surgical indication for TM with severe symptoms, although the definition of severity is not well established. Overall success was 84%, but 40.8% of patients experienced some persistent symptoms. Sternotomy and thoracotomy were the most successful approaches (92.6% and 84.2%, respectively). Thoracoscopy had a similar success rate to sternotomy when pericardiotomy, thymectomy and pledgeted suture were performed (86.4% vs. 92.6% p = 0.41). Conclusions: Aortopexy is associated with good outcomes, but no evidence-based guidelines are currently available. Success appears to be associated with specific surgical steps rather than the surgical approach. Prospective studies are desirable for establishing precise guidelines.

BACKGROUND AND AIMS:Foreign body ingestion (FBI) in children is a critical health concern. This study aimed to describe the epidemiology of FBI in children in Italy. METHODS:We retrospectively enrolled children <18 years admitted for FBI from January 2015 to December 2020. Data were collected across 21 hospitals with dedicated pediatric endoscopy services and normalized by the population of the corresponding municipalities. RESULTS:A total of 5,771 FBI cases were analyzed. FBI incidents showed consistent time trends across age groups, with most events occurring at home and being witnessed (94.7 %). Children <6 years accounted for 74.3 % of cases. Comorbidities were present in 5.3 % of cases, primarily neurologic/psychiatric disorders in older children (6-17 years). Blunt objects accounted for 65.5 % of ingestions. Young males commonly ingested button batteries, while females showed higher rates of ingesting hair products and jewelry. Most children were discharged (60 %) or observed briefly (75 % of total admissions), with endoscopic removal performed in 24 % of cases. CONCLUSIONS:Rates of FBI have remained stable over the years, including during the COVID-19 pandemic. FBI predominantly occurs in domestic settings among healthy young children, particularly those ≤5 years old. These findings emphasize the need for preventive measures to reduce the impact of FBI among children.

Transfer critically ill newborn to the operating theater is a very difficult challenge for nurses, anesthesiologists, neonatologists and surgeons. Most of these patients are mechanically ventilated and cardiocirculatory supported. The biggest challenge for premature infants that need to leave the incubator, while outside the Neonatal Intensive Care Unit (NICU), is maintaining temperature homeostasis. A male preterm newborn, born at 28 gestational week with a birth weight of 700 g underwent a major surgical procedure due to a type C esophageal atresia. This case report is focused on two points: the multidisciplinary approach and the preparation of the patient and settings. Favorable logistic and expertise of the staff can make a difference in this process. An hybrid OT combines the advantages of both the bedside surgery and the OT setting.

Introduction Over the years, congenital lung malformations (CLM) management remains a controversial topic in pediatric thoracic surgery. The Italian Society of Pediatric Surgery performed a national survey to study the current management variability among centers, trying to define national guidelines and a standardized approach of children with congenital lung malformations. Methods Following a National Society approval, an electronic survey including 35 items on post-natal management was designed, focusing on surgical, anesthesiology, radiology and pneumology aspects. The survey was conducted contacting all pediatric surgical units performing thoracic surgery. Results 39 pediatric surgery units (97.5%) participated in the study. 13 centers (33.3%) were classified as high-volume (Group A), while 26 centers (66.7%) were low volume (Group B). Variances in diagnostic imaging protocols were observed, with Group A performing fewer CT scans compared to Group B ( p = 0.012). Surgical indications favored operative approaches for asymptomatic CLM and pulmonary sequestrations in both groups, while a wait-and-see approach was common for congenital lobar emphysema. Surgical timing for asymptomatic CLM differed significantly, with most high-volume centers operating on patients younger than 12 months ( p = 0.02). Thoracoscopy was the preferred approach for asymptomatic CLM in most of centers, while postoperative long-term follow-up was not performed in most of the centers. Conclusion Thoracoscopic approach seems uniform in asymptomatic CLM patients and variable in symptomatic children. Lack of uniformity in surgical timing and preoperative imaging assessment has been identified as key areas to establish a common national pattern of care for CLM.

PurposeProne cross-table lateral x-ray (CTLxR) and colostogram aid surgical planning for anorectal malformations (ARMs) without perineal fistulas. We suggest objective imaging tools to classify ARMs.MethodsThree observers prospectively evaluated CTLxR and colostograms of male ARM patients (2012-2022) without perineal fistulas. The level of the rectal pouch was estimated with pubococcygeal (PC) and ischiatic (I) lines. On CTLxR, we described the "pigeon sign", defined as the rectal pouch ending with a beak-like image, suspicious for a rectourinary fistula. ARM was defined as rectobulbar when the rectal pouch was below the I line, rectoprostatic when between PC and I lines, and rectovesical when above the PC line. Concordance was assessed with Fleiss' kappa. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the "pigeon sign" were calculated.ResultsThirteen patients were included in this study. The interobserver agreement on CTLxR was 69.2% (k = 0.54) on pouch ending, 84.6% (k = 0.69) on the "pigeon sign", and 76.9% (k = 0.69) on diagnosis; concordance between observers and intraoperative diagnosis was 66.6% (k = 0.56). The "pigeon sign" had 75% sensitivity, 100% specificity, 100% PPV, and 50% NPV. The interobserver agreement on colostograms was 84.6% (k = 0.77) on pouch ending and 89.7% (k = 0.86) on diagnosis; concordance between observers and intraoperative diagnosis was 92.3% (k = 0.90).ConclusionPC and I lines and the "pigeon sign" are useful tools in examining CTLxR and colostograms. Adequate CTLxR interpretation may modify surgical strategy.

Congenital pulmonary airway malformation (CPAM) is a rare congenital lung lesion that usually remains asymptomatic during the fetal and neonatal period. However, it can occasionally cause prenatal cardiocirculatory failure and fetal hydrops, requiring a thoraco-amniotic shunt (TAS) placement. In other cases, it can also cause symptoms at birth (such as respiratory distress) and may require urgent surgical intervention. Thoracoscopic lobectomy for neonates is rarely reported. Here, we report a case of right macrocystic CPAM causing fetal hydrops at 27 weeks of gestation. The fetus was treated with a TAS placement that successfully resolved the hydrops. At 39 weeks of gestation, a male neonate was born (weight 2,850 g). The TAS spontaneously displaced during delivery, causing an open pneumothorax (PNX), initially treated with a drainage. His condition gradually worsened, requiring ventilatory support. Computed tomography (CT) scan showed different giant cysts in the context of the right lower lobe, left mediastinal shift, and compression of the rest of the lung. An urgent surgical management was required. A thoracoscopic right lower lobectomy was performed at 10 days of life (weight 2,840 g). The postoperative course was uneventful; the child remained totally asymptomatic and showed a good recovery. To the best of our knowledge, this is the first reported case of open iatrogenic PNX following TAS positioning and the second of neonatal thoracoscopic lobectomy in a newborn weighting less than 3 kg. The purpose of this report is to indicate that minimally invasive surgery is feasible, safe, and effective for the resection of CPAM, even in small newborns.

Background: The management of asymptomatic congenital lung malformations (CLM) is debated, and pulmonary function of patients with CLM is seldom discussed. Short-term respiratory outcome in patients operated for CLM was assessed in order to better define surgical impact.Methods: A retrospective study on patients operated for CLM between 2012 and 2021 was performed. Respiratory function was assessed with tidal breath analysis (TBA) in spontaneous sleep within 2 years of life. Patients with comorbidities affecting pulmonary function were excluded. Three variables were studied: tPTEF/tE (time to peak tidal expiratory flow/total expiratory time), tV (tidal volume), RR (respiratory rate).Results were assessed as z-score (normal +/- 1.64) and expressed as median (range). Pre- and post-operative results were compared, as well as post-operative results of disease and surgery type subgroups. Results: Thirty-nine patients were included. Median pre- and post-operative tPTEF/tE were normal (pre: -0.32 (-2.12; +1.56); post: -0.18 (-1.62; +2.43)). Patients with extralobar sequestration had preoperative high median RR, which improved after sequestrectomy (pre: +1.99 (-2.49; +7.43); post -0.22 (-3.01; +1.18)). All groups had reduced pre-operative median tV, which restored after surgery (pre: -2.15 (-9.75; +0.91); post: -0.35 (-6.65; +3.14)). Patients undergoing lobectomy and patients with intralobar sequestration showed greater improvement. Median post-operative TBA results were normal for all sub-groups except for reduced tV in patients operated with thoracotomy (-2.27 (-6.12; +5.26)).Conclusions: Patients with clinically asymptomatic CLM can have pathologic pulmonary function tests, which improve after surgery. These results add to the elements in favor of an interventional approach. Level of evidence: III, Treatment study.

BACKGROUND:Congenital Pulmonary Malformations (CPMs) are rare benign lesions potentially causing infective complications and/or malignant transformation, requiring surgery even when asymptomatic. CPMs are rare in adulthood but potentially detected at any age. There is not a consensus on the correct extent of resection in both adults and paediatrics. This retrospective multicentric study aims to identify the appropriate surgical resection to prevent the recurrence of the related respiratory symptoms.METHODS:Between 2010 and 2020, a total of 96 patients (adults and pediatrics) underwent surgery for CPMs in 4 centers. A 2:1 propensity score matching (considering sex and lesion side) was performed, identifying 2 groups: 50 patients underwent lobectomy (group A) and 25 sub-lobar resections (group B). Clinical and histopathological characteristics, early and late complications, and symptom recurrence were retrospectively analyzed and compared between the two groups by univariate and multivariate analysis.RESULTS:Patients who underwent lobectomy had a statistically significant lower rate of recurrence (4% vs. 24% of group B, p = 0.014) and a lower rate of intraoperative complications (p = 0.014). Logistic regression identified sub-lobar resection (p = 0.040), intra- and post-operative complications (p = 0.105 and 0.022),and associated developed neoplasm (p = 0.062) as possible risk factors for symptom recurrence after surgery.CONCLUSIONS:Pulmonary lobectomy seems to be the most effective surgical treatment for CPMs, guaranteeing the stable remission of symptoms and a lower rate of intra- and postoperative complications. To our knowledge, this is one of the largest studies comparing lobectomy and sub-lobar resections in patients affected by CPMs, considering the low incidence worldwide.

Follow-up of children born with esophageal atresia (EA) is mandatory due to high incidence of comorbidities. We evaluated endoscopic findings at follow-up of EA patients performed at our Centre according to ESPGHAN-NASPGHAN 2016 guidelines. A retrospective observational study was performed using data from January 2016 to January 2021. We included EA patients (age range: 1–18 years) who were offered a program of endoscopic and histological high gastrointestinal (GI) tract examinations as per ESPGHAN-NASPGHAN 2016 guidelines. Clinical, surgical, auxological, endoscopic, and histological data were reviewed; variables as polyhydramnios, EA type, surgical type, enteral feeding introduction age, growth data, and symptoms were correlated to endoscopic and histological findings. The population included 75 patients (47 males), with mean age of 5 ± 4 years. In 40/75 (53.3%) patients, we recorded oral feeding problems, and upper gastrointestinal or respiratory symptoms suspicious of gastroesophageal reflux. Eosinophilic esophagitis (EoE) incidence was 9/75 (12%), significantly higher than in general population (p < 0.0001), and 10/75 (13.3%) presented non-specific duodenal mucosal lesions. EoE represents a frequent comorbidity of EA, as previously known. EA is also burdened by high, never-described incidence of non-specific duodenal mucosal lesions. Embedding high GI tract biopsies in EA endoscopic follow-up should be mandatory from pediatric age.

Extracorporeal membrane oxygenation (ECMO) is a lifesaving support for respiratory and cardiovascular failure. However, ECMO induces a systemic inflammatory response syndrome that can lead to various complications, including endothelial dysfunction in the cerebral circulation. We aimed to investigate whether ECMO-associated endothelial dysfunction also affected coronary circulation. Ten-day-old piglets were randomized to undergo either 8 h of veno-arterial ECMO (n = 5) or no treatment (Control, n = 5). Hearts were harvested and coronary arteries were dissected and mounted as 3 mm rings in organ baths for isometric force measurement. Following precontraction with the thromboxane prostanoid (TP) receptor agonist U46619, concentration–response curves to the endothelium-dependent vasodilator bradykinin (BK) and the nitric oxide (NO) donor (endothelium-independent vasodilator) sodium nitroprusside (SNP) were performed. Relaxation to BK was studied in the absence or presence of the NO synthase inhibitor Nω-nitro-L-arginine methyl ester HCl (L-NAME). U46619-induced contraction and SNP-induced relaxation were similar in control and ECMO coronary arteries. However, BK-induced relaxation was significantly impaired in the ECMO group (30.4 ± 2.2% vs. 59.2 ± 2.1%; p < 0.0001). When L-NAME was present, no differences in BK-mediated relaxation were observed between the control and ECMO groups. Taken together, our data suggest that ECMO exposure impairs endothelium-derived NO-mediated coronary relaxation. However, there is a NO-independent component in BK-induced relaxation that remains unaffected by ECMO. In addition, the smooth muscle cell response to exogenous NO is not altered by ECMO exposure.

Recurrence is one of the most common surgical complications in Congenital Diaphragmatic Hernia (CDH). It could remain clinically silent for a long time or present as an acute complication week, months, or even years after the primary surgery. Several risk factors have been identified so far. An extended diaphragmatic defect represents one of the leading independent risk factors, together with indirect signs of large defect such as the liver position related to the diaphragm and the use of the prosthetic patch and with the use of a minimally invasive surgical (MIS) approach. However, the exact contribution of each factor and the overall risk of recurrence during the life span still need to be fully understood. This mini-review aims to give an overview of the current knowledge regarding CDH recurrence, focusing on predisposing factors, clinical presentation, management and follow-up of high-risk patients, and future perspectives.

Fresh frozen plasma (FFP) is largely misused in the neonatal setting. The aim of the study is to evaluate the impact of a Thromboelastography (TEG)-based Quality Improvement (QI) project on perioperative FFP use and neonatal outcomes. Retrospective pre-post implementation study in a level-III NICU including all neonates undergoing major non-cardiac surgery before (01–12/2017) and after (01–12/2019) the intervention. In 2018, the intervention included the following: (1) Training on TEG, (2) Implementation of TEG, and (3) Algorithm for TEG-directed FFP administration in surgical neonates. We compared pre- vs post-intervention patient characteristics, hemostasis, and clinical management. Linear and logistic regression models were used to evaluate the impact of the project on main outcomes. We analyzed 139 neonates (pre-intervention: 72/post-intervention: 67) with a mean (± SD) gestational age (GA) 34.9 (± 5) weeks and birthweight 2265 (± 980) grams which were exposed to 184 surgical procedures (pre-intervention: 91/post-intervention: 93). Baseline characteristics were similar between periods. In 2019, prothrombin time (PT) was longer (14.3 vs 13.2 s; p < 0.05) and fibrinogen was lower (229 vs 265 mg/dl; p < 0.05), if compared to 2017. In 2019, the intraoperative exposure to FFP decreased (31% vs 60%, p < 0.001), while the pre-operative FFP use did not change. The reduction of intraoperative FFP did not impact on mortality and morbidity. Intraoperative FFP use was lower in the post-intervention even after controlling for GA, American Society of Anesthesiologists score, PT, and fibrinogen (Odds ratio: 0.167; 95% CI: 0.070, 0.371).    Conclusion: The TEG-based QI project for the management of FFP during neonatal surgery reduced intraoperative FFP exposure.