BACKGROUND:Few studies have focused on the respiratory management after slide tracheoplasty. This study aimed to evaluate the effect of high-flow nasal cannula (HFNC) compared with conventional therapy in preventing reintubation after slide tracheoplasty. METHODS:This was a retrospective study conducted at a single center, the Department of Pediatric Surgery. The medical records of 68 patients who had undergone slide tracheoplasty for congenital tracheal stenosis (CTS) before the age of 2 years from February 2012 to September 2021 were included. Patients were divided into group C (conventional therapy) or H (HFNC therapy), based on whether conventional oxygen therapy and positive pressure ventilation or HFNC was used after withdrawal from the ventilator, respectively. RESULTS:There were no significant differences in the postoperative reintubation rate and ventilator dependency between groups C and H. There were no HFNC complications. CONCLUSIONS:The use of postoperative HFNC is not inferior to noninvasive ventilation in terms of therapeutic efficacy. HFNC can be used without complications for a limited time after extubation.

We aimed to compare survival rates in a 4-day-old mouse model of cecal slurry (CS)-induced bacterial peritonitis managed by laparotomy (LAP) or percutaneous peritoneal lavage (PPL). Four-day-old pups received intraperitoneal injections of CS to induce severe (3.0 g/gBW) or mild (1.0 g/gBW) peritonitis. Two hours later, pups underwent either LAP or PPL. Seven-day survival rates, perioperative body temperature (BT) changes, and postoperative ascites and plasma cytokine levels were assessed. In the severe peritonitis group, the 7-day survival rate tended to be higher in pups who underwent PPL than in those who underwent LAP (36.4% vs. 9.1%, p = 0.069). In the mild peritonitis group, survival rates were similar between treatments (83.3% vs. 72.7%, p = 0.53). The median perioperative BT change was significantly smaller in pups who underwent PPL for both the severe (-1.2℃ vs. -2.6℃, p < 0.01) and mild (-0.2℃ vs. -2.9℃, p < 0.01) peritonitis groups. Postoperative tumor necrosis factor levels were significantly lower in the PPL group compared with the LAP group under mild peritonitis (202 pg/ml vs. 443 pg/ml, p = 0.034). We established a novel 4-day-old PPL mouse model and identified PPL as a potential minimally invasive alternative that might help prevent perioperative hypothermia in the fatal peritonitis.

Biliary atresia (BA) has potential immune-mediated pathogenesis involving CD4 + Th1 and Th17 cells. We therefore examined antigen-presenting cells to elucidate their etiopathogenetic mechanisms. This study cohort included 17 patients with BA and 15 controls (8 normal controls [NCs] and 7 clinical inflammation controls [CICs]). We focused on CD86+ macrophages, which are antigen-presenting cells. We performed double immunohistochemistry for CD86/CD68, with double-positive and CD68-single-positive cells representing M1 and non-M1 macrophages, respectively. Macrophage subsets were morphometrically analyzed in the hepatic lobule (HL), portal area (PA), and interface (IF) and investigated in relation to clinical data. In the BA group, M1 macrophages in all regions and non-M1 macrophages in the IF and PA were significantly increased compared to those in the NC group. Notably, M1 macrophages often clustered in the IF, and non-M1 macrophages in the PA showed a small spindle-shaped morphology. Non-M1 macrophages in the IF showed a significant positive correlation with alanine aminotransferase, direct bilirubin, and fibrotic area. M1 macrophages were detected as the major population in the HL and IF in BA, whereas non-M1 macrophages in the PA were correlated with hepatic fibrosis. CD86+ and CD86− macrophages immunologically distinguish HL with IF from PA in BA.

Purpose Superabsorbent polymers (SAPs) are widely used materials that pose a risk of pediatric intestinal obstruction following accidental ingestion. However, in vivo gastrointestinal dynamics of SAPs remain unclear. Methods We developed a murine model to determine the temporal changes in SAP localization and size following ingestion. The results were compared with the in vitro behavior of SAPs. Additionally, the effects of the co-administration of water on SAP behavior in vivo were also assessed. Results In vitro , SAPs rapidly expanded within 1 h, and the extent of expansion was strongly influenced by pH and the composition of the solution. In vivo , SAPs enlarged more gradually, reaching maximum size in the cecum approximately 4 h after ingestion and subsequently shrinking during colonic passage until excretion, thereby reducing the risk of intestinal obstruction. Co-administration of water accelerated SAP expansion, delayed gastrointestinal transit, and increased particle size, particularly in the small intestine and cecum, suggesting that dietary and fluid management should be carefully considered in patients with accidental SAP ingestion. Conclusions SAP gradually expanded from the stomach to the small intestine and shrank during expulsion through the colon. The simultaneous administration of water accelerated SAP expansion and delayed gastrointestinal transit.

OBJECTIVE:The pediatric subglottic airway is susceptible to various pathological conditions, both congenital and acquired. Accurate imaging of subglottic mucosal lesions is essential for appropriate treatments, but existing methods such as bronchoscopy or computed tomography (CT) often lack resolution or objectivity. Optical coherence tomography (OCT) has been used, but the correlation between OCT-based imaging and histopathological findings has not been evaluated. Optical frequency domain imaging (OFDI), a clinical-grade variant of OCT, offers higher resolution and faster acquisition. We aimed to evaluate whether OFDI can safely and clearly visualize subglottic mucosal structures and examine how well the imaging findings correspond to histological features in an animal model. METHODS:Twelve rabbits weighing approximately 3 kg were used. Under anesthesia, brush scrubbing was performed to induce mucosal lesions in the subglottic space. The resected larynx was pathologically examined. The primary efficacy endpoints were circumferential visualization of the subglottic space and concordance with pathology in differentiating between the cartilage, mucosa, and lesions. The primary safety endpoints were the absence of mucosal injury and catheter dislodgement during OFDI. RESULTS:Clear images of the subglottic space were obtained, and OFDI clearly distinguished the cartilage from the mucosa and lesions. The interobserver reliability of the OCT assessment was 0.87, and the agreement between OCT and the histological assessment was 0.94. No mucosal hemorrhage or catheterization-induced dehiscence was observed. CONCLUSIONS:Our findings suggest that OFDI can be used safely and has a diagnostic performance comparable to that of histological assessment of mucosal lesions in the subglottic space.

This study aimed to evaluate the ability of the hinotori™ system to mitigate technical and ergonomic challenges in pediatric laparoscopy by comparing usability, suturing precision, and stress responses with that of conventional laparoscopy in a simulated infant abdomen. Ten pediatric surgeons with limited robotic experience performed peg transfer and suturing in a 1,400-mL box model simulating a 6-month-old abdomen, using robotic-assisted (Robo) and laparoscopic (Lap) approaches in a crossover design. Performance was assessed using the Fundamentals of Laparoscopic Surgery (FLS) score and the A-Lap Mini platform, which evaluates suturing accuracy across five domains. Physiological stress (heart rate and salivary amylase levels) and subjective fatigue (Chalder Fatigue Scale and visual analog scale) were recorded. Peg-transfer FLS scores were comparable between Robo and Lap (497.5 vs 531), with progressive improvement across Robo trials. Robotic suturing demonstrated greater air-leak resistance, smaller wound openings, and fewer internal collisions. Stress and fatigue indices did not differ significantly, although trends favored Robo. Pediatric surgeons with minimal robotic experience achieved higher suturing precision using hinotori™, suggesting intuitive usability and potential safety-related benefits in training. Owing to the small sample size, absence of resident-level validation, and lack of formal performance–stress correlation, confirmation in larger cohorts is warranted.

This study investigated the anti-inflammatory effect of clodronate, a vesicular nucleotide transporter (VNUT) inhibitor, on intestinal-failure-associated liver disease (IFALD) in a rat model of short bowel syndrome (SBS). The rats underwent jugular vein catheterization for continuous total parenteral nutrition (TPN) and 90

We investigate the histopathology of the portal vein branches and lymphatic vessels to elucidate the mechanism of atrophy of the left lateral segment (LLS) of the liver in biliary atresia (BA). LLS and right anterior segment (RAS) liver biopsy samples obtained during Kasai portoenterostomy (KPE) from ten consecutive patients with BA underwent histopathological investigation of the portal vein and lymphatic vessels using double chromogenic immunostaining for CD31/D2-40 and the hepatitis-like findings (HLF) score. Each parameter and clinical data were compared between prognostic groups. HLF scores in the LLS were always higher than those in the RAS. There was no difference in portal vein and lymphatic vascular morphology, whereas the number of lymphatic vessels was correlated with the fibrotic area of all specimen areas. Left-to-right ratio of the number of lymphatic vessels was correlated with the age at KPE (r = 0.784, p = 0.007) and the pre-KPE CRP value (r = 0.723, p = 0.018). Lymphangiogenesis on the LLS compared to the RAS was significantly correlated with the degree of fibrosis and the age at KPE. Further investigation is warranted to clarify the causes of LLS atrophy and lymphangiogenesis relevant to immune dysregulation.

Introduction Peroral endoscopic myotomy (POEM) is a minimally invasive endoscopic procedure for achalasia; its indication has expanded from adults to children. We aimed to evaluate the postoperative efficacy and antireflex status of POEM in young children with achalasia aged 12 years or younger. Patients and Methods Pediatric patients with achalasia aged 18 years or younger who underwent POEM in our hospital between 2016 and 2021 were included and divided into two age groups: group A (<= 12 years) and group B (13-18 years). The success rate (Eckardt score <= 3), endoscopic reflux findings, and antiacid use at 1 year postoperatively were compared between the groups. Results Ten patients (four boys and six girls; Chicago classification type I: five, type II: four, and unclassified: one) were included. Mean age and preoperative Eckardt scores in groups A (n = 4) and B (n = 6) were 9.2 +/- 3.0 versus 15.6 +/- 0.6 years (p = 0.001) and 5.5 +/- 3.9 versus 7.2 +/- 3.7 (p = 0.509), respectively, and mean operative time and myotomy length were 51.3 +/- 16.6 versus 52.5 +/- 13.2minutes (p = 0.898) and 10.8 +/- 4.6 versus 9.8 +/- 3.2 cm (p = 0.720), respectively. The 1- year success rate was 100% in both groups. Mild esophagitis (Los Angeles classification B) was endoscopically found in one patient in each group (16.7 vs. 25.0%, p = 0.714), and antiacid use was required in three patients (group A, two; group B, one; 50.0 vs. 16.7%, p = 0.500). Conclusion The success rate of POEM within 1 year in young children with achalasia aged 12 years or younger was equal to that in adolescent patients. However, young children tended to require antiacids 1 year postoperatively; therefore, long-term follow-up is necessary.

Serum leucine-rich alpha-2 glycoprotein (LRG) has been utilized for adult inflammatory bowel disease (IBD); however, its efficacy in pediatric IBD remains unknown. The aim of this study was to compare the diagnostic accuracy of serum LRG for pediatric IBD with that of current inflammatory markers, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). This retrospective case-control study included pediatric patients, aged <16 years, who underwent colonoscopy and/or esophagogastroduodenoscopy between April 2017 and March 2022. All eligible patients were divided into two groups: patients with IBD, diagnosed with ulcerative colitis and Crohn's disease, and non-IBD controls. The optimal cut-off value of serum LRG for IBD diagnosis was determined from receiver operating characteristic analysis, and diagnostic accuracy of serum LRG was compared to serum ESR and CRP. A total of 53 patients (24 with IBD and 29 non-IBD controls) met the inclusion criteria. The cut-off value of serum LRG for IBD diagnosis was determined to be 19.5 μg/ml. At this cut-off value, serum LRG had a positive predictive value (PPV) of 0.80 and negative predictive value (NPV) of 0.88. In contrast, PPV and NPV were 0.78 and 0.70 for serum ESR and 0.82 and 0.72 for serum CRP, respectively. Serum LRG can be a potential diagnostic marker for pediatric IBD, with higher diagnostic accuracy than that of the conventional serum markers ESR and CRP.

Duchenne muscular dystrophy (DMD) is a progressive neuromuscular disease that commonly requires gastrostomy due to dysphagia. This study aimed to investigate the proportion of patients with DMD requiring gastrostomy and to assess the timing and outcomes of gastrostomy in patients with DMD to optimize perioperative care and improve long-term management. We conducted a retrospective cohort study by reviewing the medical records of patients with DMD treated between March 1991 and November 2023 at Kobe University Hospital. To identify risk factors for gastrostomy, Fisher's two-tailed test and logistic analysis were used to compare the gastrostomy (group G) and comparison group without gastrostomy (group C) groups. We identified patients >18 years with DMD. We excluded those without medical records from the last decade and those on nasogastric tube feeding. Among the 135 eligible patients, five (median age, 23 years) underwent percutaneous endoscopic gastrostomy (PEG; uptake rate, 3.7 %), and their data were analyzed for perioperative outcomes. Complications included ventilatory disturbances, aspiration pneumonia, and hemorrhagic shock. Two patients experienced significant postoperative complications, underscoring the high-risk nature of PEG in this population. Participants' postoperative weight changes varied significantly. The presence or absence of ventilatory management, cardiomyopathy treatment, scoliosis, and steroid treatment were examined as risk factors between groups G and C, but no significant differences were observed. This study highlights low gastrostomy usage among patients with DMD, with varying outcomes. Meticulous planning and early consideration of gastrostomy are crucial to enhance the quality of life and nutritional outcomes in these patients.

The hinotori™ Surgical Robot System (hinotori™, Medicaroid, Kobe, Japan) is increasingly being utilized primarily in urology and adult surgery; however, data on its application in pediatric surgery are lacking. This preclinical study aimed to evaluate the limitations of this system for accurate suturing in small cavities designed for pediatric and neonatal applications. Two trained operators performed simple ligature sutures (easy task [ET]) and hepaticojejunostomy sutures (difficult task [DT]) within five differently sized boxes, ranging from 5123 to 125 mL. The suture time, number of internal and external instrument/instrument collisions, instrument/box collisions, and suture accuracy were evaluated. The suture accuracy was assessed using the A-Lap Mini endoscopic surgery skill assessment system. As a result, an increase in the number of collisions and extended suturing times were observed in boxes with volumes smaller than 215 mL. Despite these variations, there were no significant differences between the boxes, and all tasks were precisely performed in all boxes (p = 0.10 for the ET and p = 1.00 for the DT). These findings demonstrate the capability of the hinotori™ system to perform precise suturing techniques within tightly confined simulated neonatal cavities as small as 125 mL. To advance the integration of pediatric robotic surgery utilizing the hinotori™ system, additional trials comparing it with conventional laparoscopic and thoracoscopic techniques using pediatric and animal models are necessary to assess its clinical safety and applicability.

Purpose This study assessed the efficacy of a high-impact, short-term workshop in honing the laparoscopic hepaticojejunostomy technical skills and self-confidence of novice pediatric surgeons, focusing on vertical needle driving and knot tying. Methods Lectures, hands-on sessions, pre- and post-workshop evaluations, and training using porcine models were conducted to refine basic and advanced skills. The “hepaticojejunostomy simulator” was used for comparative analysis of precision in pre- and post-workshop vertical needle driving and knot tying. Participants self-evaluated their skills and confidence on a 5-point scale. Results After the workshop, eight inexperienced pediatric surgeons demonstrated a significant improvement in hepaticojejunostomy suturing task completion rates and needle-driving precision at the jejunum and hepatic duct. However, the A-Lap Mini Endoscopic Surgery Skill Assessment System indicated no significant improvements in most assessed parameters, except for the full-layer closure score ( p = 0.03). However, a significant increase in participants' confidence levels in performing laparoscopic hepaticojejunostomy was observed. Conclusion The workshop augmented technical proficiency and confidence in young pediatric surgeons. The combination of lectures, practical exposure, and model training is an effective educational strategy in pediatric surgical instruction.

Pediatrics InternationalVolume 65, Issue 1 e15569 CLINICAL NOTE Laparoscopic Necrosectomy for walled-off necrosis following necrotizing pancreatitis Yasuyuki Kameoka, Yasuyuki Kameoka Division of Pediatric Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, JapanSearch for more papers by this authorYuichi Okata, Corresponding Author Yuichi Okata [email protected] orcid.org/0000-0002-8966-5812 Division of Pediatric Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan Correspondence Yuichi Okata, Division of Pediatric Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan. Email: [email protected]Search for more papers by this authorHirochika Toyama, Hirochika Toyama Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, JapanSearch for more papers by this authorShohei Yoshimura, Shohei Yoshimura orcid.org/0000-0001-8549-8941 Division of Pediatric Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, JapanSearch for more papers by this authorSuguru Uemura, Suguru Uemura Department of Hematology and Oncology, Hyogo Prefectural Kobe Children's Hospital, Kobe, JapanSearch for more papers by this authorTadashi Hatakeyama, Tadashi Hatakeyama Department of Pediatric Surgery, Hyogo Prefectural Kobe Children's Hospital, Kobe, JapanSearch for more papers by this authorYuko Bitoh, Yuko Bitoh orcid.org/0000-0002-0691-866X Division of Pediatric Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, JapanSearch for more papers by this author Yasuyuki Kameoka, Yasuyuki Kameoka Division of Pediatric Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, JapanSearch for more papers by this authorYuichi Okata, Corresponding Author Yuichi Okata [email protected] orcid.org/0000-0002-8966-5812 Division of Pediatric Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan Correspondence Yuichi Okata, Division of Pediatric Surgery, Department of Surgery, Kobe University Graduate School of Medicine, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan. Email: [email protected]Search for more papers by this authorHirochika Toyama, Hirochika Toyama Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, JapanSearch for more papers by this authorShohei Yoshimura, Shohei Yoshimura orcid.org/0000-0001-8549-8941 Division of Pediatric Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, JapanSearch for more papers by this authorSuguru Uemura, Suguru Uemura Department of Hematology and Oncology, Hyogo Prefectural Kobe Children's Hospital, Kobe, JapanSearch for more papers by this authorTadashi Hatakeyama, Tadashi Hatakeyama Department of Pediatric Surgery, Hyogo Prefectural Kobe Children's Hospital, Kobe, JapanSearch for more papers by this authorYuko Bitoh, Yuko Bitoh orcid.org/0000-0002-0691-866X Division of Pediatric Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, JapanSearch for more papers by this author First published: 10 July 2023 https://doi.org/10.1111/ped.15569Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL No abstract is available for this article. CONFLICT OF INTEREST STATEMENT The authors declare no conflict of interest. REFERENCES 1Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG, et al. Classification of acute pancreatitis-2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013; 62: 102– 11. 2Van Santvoort HC, Besselink MG, Bakker OJ, et al. A step-up approach or open necrosectomy for necrotizing pancreatitis. N Engl J Med. 2010; 362: 1491– 502. 3Top PC, Tissing WJE, Kuiper JW, Pieters R, van Eijck CH. L-asparaginase-induced severe necrotizing pancreatitis successfully treated with percutaneous drainage. Pediatr Blood Cancer. 2005; 44(1): 95– 7. 4Nabi Z, Talukdar R, Lakhtakia S, Reddy DN. Outcomes of endoscopic drainage in children with pancreatic fluid collections: a systematic review and meta-analysis. Pediatr Gastroenterol Hepatol Nutr. 2022; 25: 251– 62. 5Gardner TB, Coelho-Prabhu N, Gordon SR, Gelrud A, Maple JT, Papachristou GI, et al. Direct endoscopic necrosectomy for the treatment of walled-off pancreatic necrosis: results from a multicenter U.S. series. Gastrointest Endosc. 2011; 73: 718– 26. Volume65, Issue1January/December 2023e15569 ReferencesRelatedInformation

Background: Cloacal exstrophy (CE) is a rare congenital disease that requires multiple surgeries for complex gastrointestinal and genitourinary anomalies. Long-term complications are not uncommon; however, they are poorly reported. Pyosalpinx is sometimes encountered during CE management in adolescents and young adults. Case: A 28-year-old woman with a history of CE presented with fever, lower abdominal pain, and vomiting and was diagnosed with left pyosalpinx. Computed tomography-guided drainage and intravenous antibiotic administration were successful; however, she had 2 readmissions for recurrent pyosalpinx 1 week after discharge and again 4 months later. She was administered Dienogest, a synthetic progestin, to prevent recurrent pyosalpinx and had no recurrence for 8 months. Summary and Conclusion: Dienogest is a conservative treatment choice for preventing the recurrence of pyosalpinx for patients with CE.

Congenital tracheal stenosis (CTS) has been reported to occur in 50–65

Background: Peritoneal lavage (PL) during laparotomy is a treatment option for preterm bacterial peritonitis; however, its efficacy remains controversial. We investigated the effects of PL temperature during laparotomy on survival in a cecal slurry (CS)-induced preterm peritonitis mouse model. Methods: Four-day-old pups that were intraperitoneally administered 1.8 mg/g CS solution underwent laparotomy through a 5-mm transverse incision 2 h after CS injection (sham group). An additional PL was established during laparotomy with 500 mu l of 25CC, 35CC, and 45CC sterile saline, respectively (PL25, PL35, and PL45 groups). Postoperative 7-day survival, body temperature, and plasma and ascites cytokine concentrations were evaluated for each group. Results: Postoperative 7-day survival rates in the sham, PL25, PL35, and PL45 groups were 52.9%, 56.3%, 33.3%, and 18.2% (p = 0.097), respectively. Median BT changes between before and after surgery were- 1.85CC,- 2.30CC, - 3.40CC, and- 1.80CC for each group (p = 0.0065). The median ascites MCP-1 and IL-6 concentrations (pg/ml) at postoperative 2 h were 32,432, 16,244, 6279, and 5100 (p = 0.049) and 22,346, 11,537, 5519, and 4535 (p = 0.076), and plasma MCP-1 and IL-6 concentrations (pg/ml) were 68,687, 16,327, 9277, and 1868 (p = 0.084) and 112,290, 14,415, 11,403, and 4113 (p = 0.123) for each group, respectively. Conclusion: Postoperative 7-day survivals were slightly improved by PL with 25CC sterile saline, however decreased by increasing PL temperatures to 35CC and 45CC in a CS-induced preterm peritonitis mouse model. As PL temperature was increased, both plasma and ascites MCP-1 and IL-6 concentrations tended to be suppressed, suggesting to decrease postoperative survivals.