Giant bile duct dilatation in newborn:A case report

BACKGROUND Giant congenital biliary dilation(CBD)is a rare condition observed in clinical practice.Infants born with this condition often experience a poor overall health status,and the disease progresses rapidly,leading to severe biliary obstruction,infections,pressure exerted by the enlarged CBD on abdominal organs,disturbances in the internal environment,and multiple organ dysfunction.The treatment of giant CBD using laparoscopy is challenging due to the high degree of variation in the shape of the bile duct and other organs,making it difficult to separate the bile duct wall from adjacent tissues or to control bleeding.CASE SUMMARY Herein,we present the details of an 11-d-old male newborn who was diagnosed with giant CBD.The patient was admitted to the neonatal surgery department of our hospital due to a history of common bile duct cyst that was detected more than 3 mo ago,and also because the patient had been experiencing yellowish skin for the past 9 d.The abnormal echo in the fetal abdomen was first noticed by the patient’s mother during a routine ultrasound examination at a local hospital,when the patient was at 24 wk+6 d of pregnancy.This finding raised concerns about the possibility of congenital biliary dilatation(22 mm×21 mm).Subsequent ultrasound examinations at different hospitals consistently confirmed the presence of a congenital biliary dilatation.No specific treatment was administered for biliary dilatation during this period.A computed tomography scan conducted during the hospitalization revealed a large cystic mass in the right upper quadrant and pelvis,measuring approximately 9.2 cm×7.4 cm×11.3 cm.Based on the CONCLUSION The analysis reveals that prenatal imaging techniques,such as ultrasound and magnetic resonance imaging,play a crucial role in the early diagnosis,fetal prognosis,and treatment plan for giant CBD.Laparoscopic surgery for giant CBD presents certain challenges,including difficulties in separating the cyst wall,anastomosis,and hemostasis,as well as severe biliary system infection and ulceration.Consequently,there is a high likelihood of converting to laparotomy.The choice between surgical methods like hepaticojejunostomy(HJ)or hepaticoduodenostomy has not been standardized yet.However,we have achieved favorable outcomes using HJ.Preoperative management of inflammation,biliary drainage,liver function protection,and supportive treatment are particularly vital in improving children’s prognosis.After discharge,it is essential to conduct timely reexamination and close follow-up to identify potential complications.

Recommendations for perinatal and neonatal surgical management during the COVID-19 pandemic

Coronavirus disease 2019(COVID-19)caused by severe acute respiratory syndrome coronavirus 2 has spread rapidly around the world and is a significant threat to global health.Patients in the Neonatal Surgery Department have rapidly progressing diseases and immature immunity,which makes them vulnerable to pulmonary infection and a relatively higher mortality.This means that these patients require multidisciplinary treatment including early diagnosis,timely transport,emergency surgery and intensive critical care.The COVID-19 pandemic poses a threat to carrying out these treatments.To provide support for the health protection requirements of the medical services in the Neonatal Surgery Department,we developed recommendations focusing on patient transport,surgery selection and protection requirements with the aim of improving treatment strategies for patients and preventing infection in medical staff during the current COVID-19 pandemic.

Single-incision pediatric endosurgery in newborns and infants

This study focuses on the successful application of single-incision pediatric endosurgery in the treatment of congenital anomalies and acquired diseases in neonates and infants. The purpose of this scientific review consists in highlighting the spectrum, indications, applicability, and effectiveness of single-port endosurgery in children during the first 3 postnatal months.

Primary repair of esophageal atresia gross type C via thoracoscopic magnetic compression anastomosis:A case report

BACKGROUND Esophageal atresia(EA)is a life-threatening congenital malformation in newborns,and the traditional repair approaches pose technical challenges and are extremely invasive.Therefore,surgeons have been actively investigating new minimally invasive techniques to address this issue.Magnetic compression anastomosis has been reported in several studies for its potential in repairing EA.In this paper,the primary repair of EA with magnetic compression anastomosis under thoracoscopy was reported.CASE SUMMARY A full-term male weighing 3500 g was diagnosed with EA gross type C.The magnetic devices used in this procedure consisted of two magnetic rings and several catheters.Tracheoesophageal fistula ligation and two purse strings were performed.The magnetic compression anastomosis was then completed thoracoscopically.After the primary repair,no additional operation was conducted.A patent anastomosis was observed on the 15th day postoperatively,and the magnets were removed on the 23rd day.No leakage existed when the transoral feeding started.CONCLUSION Thoracoscopic magnetic compression anastomosis may be a promising minimally invasive approach for repairing EA.

NLRP3 activation in macrophages promotes acute intestinal injury in neonatal necrotizing enterocolitis

Background Macrophages are involved in various immune inflammatory disease conditions.This study aimed to investigate the role and mechanism of macrophages in regulating acute intestinal injury in neonatal necrotizing enterocolitis(NEC).Methods CD68,nucleotide-binding oligomerization domain,leucine-rich repeat,and pyrin domain-containing 3(NLRP3),cysteine aspartate-specific protease-1(caspase-1),and interleukin-1β(IL-1β)in paraffin sections of intestinal tissues from NEC and control patients were detected with immunohistochemistry,immunofluorescence,and western blot.Hypertonic pet milk,hypoxia and cold stimulation were used to establish a mouse(wild type and Nlrp3^(-/-))model of NEC.The mouse macrophage(RAW 264.7)and rat intestinal epithelial cell-6 lines were also cultured followed by various treatments.Macrophages,intestinal epithelial cell injuries,and IL-1β release were determined.Results Compared to the gut“healthy”patients,the intestinal lamina propria of NEC patients had high macrophage infiltration and high NLRP3,caspase-1,and IL-1β levels.Furthermore,in vivo,the survival rate of Nlrp3^(-/-)NEC mice was dramatically improved,the proportion of intestinal macrophages was reduced,and intestinal injury was decreased compared to those of wild-type NEC mice.NLRP3,caspase-1,and IL-1β derived from macrophages or supernatant from cocultures of macrophages and intestinal epithelial cells also caused intestinal epithelial cell injuries.Conclusions Macrophage activation may be essential for NEC development.NLRP3/caspase-1/IL-1β cellular signals derived from macrophages may be the underlying mechanism of NEC development,and all these may be therapeutic targets for developing treatments for NEC.

Liver transplantation for polycystic liver with massive hepatomegaly: A case report

A previous study has shown that liver or combined liver-kidney transplantation can be a valuable surgical technique for the treatment of polycystic liver disease. Herein, we present the case of a 35-year-old woman with polycystic liver disease, who underwent orthotopic liver transplantation (OLT) on November 11, 2008. The whole-size graft was taken from a deceased donor (a 51-year-old man who died of a heart attack). Resection in a patient with massive hepatomegaly is very difficult. Thus, after intercepting the portal hepatic vein, left hepatectomy was performed, then the vena cava was intercepted, the second and third porta hepatic isolated, and fi nally, right hepatectomy was performed. OLT was performed successfully. The recipient did well after transplantation. This case suggested that OLT is an effective therapeutic option for polycystic liver disease and left hepatectomy can be performed fi rst during OLT if the liver is over enlarged.

Autoimmune liver disease-related autoantibodies in patients with biliary atresia

AIM To investigate the prevalence and clinical significance of autoimmune liver disease(ALD)-related autoantibodies in patients with biliary atresia(BA).METHODS Sera of 124 BA patients and 140 age-matched non-BA controls were assayed for detection of the following autoantibodies: ALD profile and specific anti-nuclear antibodies(ANAs), by line-blot assay; ANA and antineutrophil cytoplasmic antibody(ANCA), by indirect immunofluorescence assay; specific ANCAs and antiM2-3 E, by enzyme linked immunosorbent assay. Associations of these autoantibodies with the clinical features of BA(i.e., cytomegalovirus infection, degree of liver fibrosis, and short-term prognosis of Kasai procedure) were evaluated by Spearman's correlation coefficient.RESULTS The overall positive rate of serum autoantibodies in preoperative BA patients was 56.5%. ALD profile assay showed that the positive reaction to primary biliary cholangitis-related autoantibodies in BA patients was higher than that to autoimmune hepatitis-related autoantibodies. Among these autoantibodies, anti-BPO was detected more frequently in the BA patients than in the controls(14.8% vs 2.2%, P < 0.05). Accordingly, 32(25.8%) of the 124 BA patients also showed a high positive reaction for anti-M2-3 E. By comparison, the controls had a remarkably lower frequency of anti-M2-3 E(P < 0.05), with 6/92(8.6%) of patients with other liver diseases and 2/48(4.2%) of healthy controls. The prevalence of ANA in BA patients was 11.3%, which was higher than that in disease controls(3.3%, P < 0.05), but the reactivity to specific ANAs was only 8.2%. The prevalence of ANCAs(ANCA or specific ANCAs) in BA patients was also remarkably higher than that in the healthy controls(37.9% vs 6.3%, P < 0.05), but showed no difference from that in patients with other cholestasis. ANCA positivity was closely associated with the occurrence of postoperative cholangitis(r = 0.61, P < 0.05), whereas none of the autoantibodies showed a correlation to cytomegalovirus infection or the stages of liver fibrosis.CONCLUSION High prevalence of autoantibodies in the BA developmental process strongly reveals the autoimmunemediated pathogenesis. Serological ANCA positivity may be a useful predictive biomarker of postoperative cholangitis.

Risk Factors for Strangulated Ovarian Hernia in Female Infants:the Role of Ovarian Volume

The risk factors associated with strangulated ovarian hernia (SOH)in female patients (<1 year old)were identified.A retrospective analysis was conducted regarding the data from 2006 to 2017.The patients were divided into 2groups:SOH group (n=9)and non-SOH group (n=23). Patient demographics,clinical signs,preoperative examinations and intraoperative findings were compared between the two groups,and risk factors for SOH were tested using a binary logistic regression model.To explore whether greater ovary was more likely to be twisted,leading to SOH, all the patients were divided into ovary volume <5cm^3 and ≥5cm^3 groups and the association between ovarian volume and ovary torsion was assessed.Among a total of 32 female patients (<1year old)with incarcerated ovarian herniation,9 patients developed SOH.The single variate analysis revealed that times of manual reduction,ovarian volume,ovary with or without multiple cysts,ovary torsion or not and angle of ovary torsion were found to be significant factors associated with SOH.The multivariate analysis showed ovarian volume was evidenced as an independent risk factor for SOH.Furthermore,the incidence of ovary torsion was significantly higher in ovarian volume ≥5cm^3 group than in ovarian volume <5cm^3 group,indicating that larger ovary was more likely to result in ovary torsion,leading to SOH.Our study demonstrated that the odds of SOH increased with increasing ovarian volume in female patients (<1 year old)because the relatively greater ovary at this age was more likely to be incarcerated and twisted,leading to SOH.

Postoperative intussusception in infants and children:a report of seven cases

Postoperative intussusception is an uncommon but serious condition in infants and children. Here, we report seven cases of postoperative intussusception in infants and children who were seen at our institution over the last 13 y. The patients showed increased nasogastfic drainage, vomiting, lack of stool, and/or growing abdominal dis- tension 2 to 9 d following abdominal surgery. Manual reduction was successful in five cases. In two cases, necro- sis was found and intestinal resection and anastomosis were carded out, No recurrence was observed at six months of follow-up. Postoperative intussusception should be suspected in pediatric surgical patients who showed signs of intestinal obstruction in the early postoperative period.

Treatment of hepatic venous stenosis by transfemoral venous balloon dilation following living donor liver transplantation:a case report

Hepatic venous stenosis may be a cause of graft failure in living donor liver transplantation （LDLT）. Balloon dilation and metallic frame approaches have been used successfully to treat hepatic venous stenosis. Here, we report the effect of transfemoral venous balloon dilation for treating a child with hepatic venous stenosis after LDLT .

Survey on surgical treatment of neonatal necrotizing enterocolitis in China 2022

Objective The aim of this study was to identify the state of surgical treatment of neonatal necrotizing enterocolitis(NEC)in China.Methods A total of 246 delegates(88.0%senior surgeons)completed a survey sent by the Neonatal Surgery Group of the Pediatric Surgery Branch of the Chinese Medical Association in 2022.Five centers were eliminated due to lack of experience.Results Generally,38.2% of surgeons work in centers where more than 20 cases of surgical NEC are treated per year.A total of 81.3% of surgeons reported the use of ultrasonography;the most used biomarkers were white blood cell count(95.9%),C-reactive protein(93.8%),and procalcitonin(76.3%).Most surgeons(80.9%)used a combination of two(67.2%)antibiotics or single(29.5%)antibiotic for a treatment period of 7-14 days,and most used antibiotics were carbapenems(73.9%),penicillin and cephalosporins(56.0%).Patients are issued the fasting order for 5-7 days by nearly half surgeons(49.8%)for conservative treatment.70.1% of surgeons deemed that the most difficult decision was to evaluate the optimal timing of surgery.Most surgeons(76.3%)performed diagnostic aspiration of peritoneal fluid.Laparoscopy was performed for the diagnosis and/or treatment of NEC by 40.2% of surgeons.A total of 53.5% of surgeons reported being able to identify localized intestinal necrosis preoperatively.Surgeons relied the most on pneumoperitoneum(94.2%)and failure of conservative treatment(88.8%)to evaluate the surgical indications.At laparotomy,surgical treatments vary according to NEC severity.Infants are fasted for 5–7 days by 55.2% of surgeons postoperatively.Most surgeons(91.7%)followed up with patients with NEC after discharge for up to 5 years(53.8%).Conclusions The most difficult aspect of surgical NEC is evaluating the timing of surgery,and surgeons in the children’s specialized hospitals are experienced.The treatment of NEC totalis is controversial,and the indications for laparoscopy need to be further clarified.More multicenter prospective studies are needed to develop surgical guidelines in the future.

出生时的体重和McGoon指数对先天性膈疝新生儿患者死亡率的预测作用

Background: Despite improvements in clinical management, mortality of congenital diaphragmatic hernia (CDH) remains high. Early prediction of mortality risk helps in comparing strategies and/or performances of different centers. Birth weight (BW), Apgar Score at 5 minutes, and modified McGoon Index (MGI) calculated by the ratio between the diameters of pulmonary arteries and the descending aorta have been used to determine mortality of CDH. Aim: The purpose of this study is to evaluate the relationship between early detectable variables and survival in newborns with CDH intubated at birth, managed with “gentle”ventilation and delayed surgery. Methods: All medical records of patients affected by highrisk CDH and treated with a standardized protocol at Bambino GesúChildren’s Hospital, Rome, Italy, between January 2002 and September 2004 were reviewed. Prenatal diagnosis, gestational age, BW, sex, side of hernia, and MGI were recorded on admission. The relationship with mortality of each variable was evaluated by univariate analysis. Subsequently, a predictive model of mortality was developed using a logistic regression: the explanatory variables, BW, and MGI were dichotomized in high (HBW and HMGI) and low (LBW and LMGI) according to the best cutoff found with receiver-operating characteristic curves. Results: Thirty-four newborns with CDH, treated with a standardized protocol, were studied. The main characteristics of the 34 patients were BW, 2886 g (1500-3620 g); gestational age, 37.7 weeks (32-42 weeks); male/female, 22/12; right/left, 8/26; prenatal diagnosis, 29; MGI, 1.31 (0.9-1.85). Only BW and MGI were significantly (P < .05) associated with mortality at the univariate analysis. The best cutoff values were 2755 g for BW (sensitivity, 70%; specificity, 74%) and 1.25 for MGI (sensitivity, 73%; specificity, 78%). Using these limits, BW and MGI resulted independently associated with mortality in the multivariate analysis. Using the 4 possible combinations, the LBW associated with the LMGI presented the highest prediction of mortality (80%). Conclusions: Birth weight and MGI, variously combined,were predictive of mortality. Because they are not influenced by subsequent modalities of care, they can be considered as valid early severity scores in CDH and used for comparing strategies and/or performances of different centers.

Sirolimus treatment for neonate with blue rubber bleb nevus syndrome:A case report

BACKGROUND Blue rubber bleb naevus syndrome(BRBNS)is a rare disease that usually presents with multiple venous malformations in the skin and gastrointestinal tract.Lesions located in the gastrointestinal tract always result in chronic gastrointestinal bleeding and severe anemia.The successful management of BRBNS with sirolimus had been reported in many institutions,due to its impact on signaling pathways of angiogenesis.However,the experience in treatment of neonates with BRBNS was limited.CASE SUMMARY A 38-day-old premature female infant born with multiple skin lesions,presented to our center complaining of severe anemia and hematochezia.Laboratory examination demonstrated that hemoglobin was 5.3 g/dL and contrast-enhanced abdominal computed tomography showed multiple low-density space-occupying lesions in the right lobe of the liver.She was diagnosed as having BRBNS based on typical clinical and examination findings.The patient was treated by transfusions twice and hemostatic drugs but symptoms of anemia were difficult to alleviate.A review of BRBNS case reports found that patients had been successfully treated with sirolimus.Then the patient was treated with sirolimus at an average dose of 0.95 mg/m2/d with a target drug level of 10-15 ng/mL.During 28 mo of treatment,the lesion was reduced,hemoglobin returned to normal,and there were no adverse drug reactions.CONCLUSION This case highlights the dosing regimen and plasma concentration in neonates,for the current common empiric dose is high.

Perioperative nursing of a newborn with Beckwith-Wiedemann syndrome

Objective:To explore the perioperative nursing of a newborn with Beckwith-Wiedemann syndrome.Methods:We observed the blood glucose of the child and prevent infection of omphalocele before transpor tation and before the operation;after the operation,we performed airway nursing,blood glucose monitoring,urination observation,and tumor marker monitoring;finally,at the time of discharge from the hospital,we provided health education.Results:After a series of perioperative nursing measures,the child was discharged smoothly from hospital 34 d after operation.Conclusions:Beckwith-Wiedemann syndrome is a rare congenital malformation.Timely and accurate observation and evaluation of the child during perioperative period and targeted nursing measures can effectively reduce or avoid the occurrence of postoperative complications.

术前气管支气管镜检查对于食管闭锁的新生儿是否有作用

Background/Purpose: Despite surgical refinements, perioperative use of tracheobronchoscopy (TBS) as part of surgical approach to esophageal atresia (EA) is still controversial. The purpose of this study was to evaluate the influence of preoperative TBS in newborns with EA in preventing complications and improving diagnosis and surgical treatment. Methods: In the period ranging from 1997 to 2003, 62 patients with EA underwent preoperative TBS. The procedure was carried out with flexible bronchoscope maintaining spontaneous breathing.When a wide carinal fistula was found, this was mechanically occluded by Fogarty catheter and cannulated with rigid bronchoscopy.Type of EA, surgical procedure variations caused by TBS, and associated anomalies not easily detectable were recorded. Results: Before TBS, the Gross classification of the 62 patients was as follows: type A, 9 patients; type B,none; type C, 51 patients. At TBS, however, 3 of 9 type A patients had an unsuspected proximal fistula (type B). These 3 patients, plus the 2 with H-type fistula, were repaired through a cervical approach. In 4 patients, previously undetected malformations of the respiratory tree (2 aberrant right upper bronchus and 2 hypoplastic bronchi) were found at TBS. Carinal fistulas in 14 type C patients were occluded by Fogarty catheter to improve ventilation during repair. No complications were observed.Overall, TBS was clinically useful in 28 (45.2%) of 62 patients, including 15 (24.2%) of 62 infants in whom it was crucial in modifying the surgical approach. Conclusion:Tracheobronchoscopy is a useful and safe procedure and should be recommended in tertiary centers for babies with EA before surgical repair.

先天性肠道畸形、新生儿短肠综合征及其产前(新生儿期)咨询

Background:Short bowel syndrome (SBS) is a severe malabsorption caused by bowel loss. Congenital intestinal anomalies (CIA) detectable by prenatal ultrasound as jejunoileal atresia,meconium peritonitis,complicated meconium ileus,and fetal volvulus can be responsible for SBS. Aims:This study aims to investigate either frequency of SBS or the morbidity in CIA population during the first admission. Material and methods:Records of CIA treated from 1997 to 2003 were reviewed. The prenatal ultrasound findings were correlated with SBS. Student’s t and χ 2 tests were performed to analyze epidemiological data,growth at discharge,sepsis,liver disease,catheter-related complications,motor developmental delay,and hospital stay in CIA with and without SBS. Results:Forty-four CIA:SBS developed in 43% ,ranging from 83% in volvulus to 0% in complicated meconium ileus. Thirty-six prenatal diagnoses:a strong correlation with SBS was observed in isolated dilated bowel (58% ). In SBS neonates,birth weight,gestational age,and growth at discharge were statistically lower,whereas sepsis,motor delay,and hospital stay were statistically higher. Conclusions:Many neonates with CIA detectable by prenatal ultrasound develop SBS. Short bowel syndrome presents a significant higher morbidity. The counseling should stress the frequent association between CIA and SBS as well as the significant morbidity in SBS.

Clinical characteristics and prognosis of 69 cases of neonatal appendicitis

Importance:Neonatal appendicitis(NA)is a rare and potentially fatal neonatal disease.However,misdiagnosis is common owing to atypical clinical manifestations and non-specific laboratory tests.Objective:The aim of this study was to summarize the clinical characteristics,treatments,and prognoses of infants with NA.Methods:This retrospective analysis included 69 patients diagnosed with NA admitted to Beijing Children’s Hospital between 1980 and 2019.The patients were divided into surgical and non-surgical groups based on whether surgery was performed.Their clinical characteristics were analyzed using the chi-square test,t-test,or the Mann-Whitney U test.Results:The study included 47 males and 22 females with NA.The primary symptoms were abdominal distension(n=36,52.2%),fever(n=19,27.5%),refusal to feed or decreased feeding(n=16,23.2%),and vomiting(n=15,21.7%).Sixty-five patients underwent abdominal ultrasound examinations;43 had definite appendiceal abnormalities,10 had right lower abdominal adhesive masses,and 14 had neonatal enterocolitis manifestations.Twenty-nine and 40 patients were in the surgical and non-surgical groups,respectively.No statistically significant differences were observed between the groups regarding sex,age at onset,birth weight,admission weight,or hospitalization time.However,parenteral nutrition was prolonged in the surgical group(P=0.001).Additionally,two patients(2.9%)died.Interpretation:NA is a rare neonatal disease with atypical clinical manifestations.Abdominal ultrasonography may aid in the diagnosis.Similarly,appropriate treatment can improve the prognosis.

Chinese expert consensus statement on the diagnosis and treatment of Hirschsprung disease

Hirschsprung disease(HSCR)is a congenital anomaly of the intestine caused by the developmental absence of the enteric nervous system,which results in variable lengths of intestinal dysfunction and requires surgical intervention.^([1])Due to the complex etiology,multiple surgical procedures and postoperative complications,the diagnosis and treatment strategies of HSCR have always been the focus of pediatric surgeons around the world.Seventy pediatric surgical experts with rich clinical experience from almost all national and provincial children’s medical centers in China constituted the Chinese Research Group of Hirschsprung disease(CRGHSCR).

Clinical characteristics of postoperative necrotizing enterocolitis in patients with congenital jejunoileal atresia and its risk factors

Objective To review postoperative necrotizing enterocolitis(NEC)in patients with jejunoileal atresia(JIA)and to explore the potential risk factors related to the concurrence ofNEC.Methods Patients diagnosed with JIA who received surgical treatment from January 2016 to June 2021 were enrolled.Demographics,viral infection of the fetus,transfusion within 48 hours before NEC,sepsis before JIA repair,pathological and anatomical classification of JIA,combined malformation,occurrence time of NEC after the operation,treatment,and prognosis of patients were analyzed.Patients were divided into NEC group and non-NEC group,and all patients were followed up for 3-6 months to observe for complications.Results A total of 180 patients with JIA were included,of whom 12 were diagnosed with NEC after surgery and 1 patient with NEC died during follow-up.The average age,birth weight,gestational age,proportion of premature infants,proportion of preoperative infections,and pathological classification of JIA did not significantly differ between the two groups.The probability of patients with proximal jejunal atresia(PJA)in the NEC group(58.3%)was higher than that in the non-NEC group(22.6%)(p=0.011),and patients with PJA had longer parenteral nutrition time than patients without PJA(26.64±9.21 days vs 15.11±6.58 days,p<0.001).Conclusion PJA was more likely to be associated with concurrent NEC after surgery,which is a highly NEC-related risk factor inherent in JIA.

Application and prospects of robotic surgery in children: a scoping review

As an innovative minimally invasive surgical technology, robot-assisted surgery (RAS) has greatly improved the accuracy and safety of surgery through the advantages of three-dimensional magnification, tremor filtering, precision and flexibility, and has been carried out by an increasing number of surgeries. In recent years, robots have been gradually applied to children, bringing new ideas and challenges to pediatric surgeons. This review will describe the advantages and limitations of robotic surgery in children, summarize its application in pediatric surgery, and provide an outlook. It is believed that clinicians should actively carry out RAS under the premise of rigorously ensuring surgical indications and strive to improve the efficacy of surgical treatment for children.