Pediatric surgery during the COVID-19 pandemic

The coronavirus disease 2019(COVID-19)pandemic has had a major impact on pediatric surgery.The infection is often asymptomatic and atypical in children,while overlapping presentations with other infectious diseases generate additional diagnostic challenges.The high probability of missed pediatric cases and the invasive nature of surgery generate great concern for widespread transmission in this setting.Current guidelines suggest that triage of cases should be made on a case-by-case basis by a multidisciplinary team of experts.Decisionmaking can be assisted by classifying cases as elective,urgent,or an emergency according to the risks of delaying their surgical management.A workflow diagram should ideally guide the management of all cases from admission to discharge.When surgery is necessary,all staff should use appropriate personal protective equipment,and high-risk practices,such as aerosol-generating tools or procedures,should be avoided if possible.Furthermore,carefully designed organizational protocols should be established to minimize transmission while ensuring the uninterrupted operation of pediatric surgery units.For example,surgical teams can be divided into small weekly rotating groups,and healthcare workers should be continuously monitored for COVID-19 symptoms.Additionally,team protocols in the operating room can optimize communication and improve adherence to personal protective equipment use.Isolated operating rooms,pediatric intensive care units,and surgical wards should be specifically designed for suspected or confirmed COVID-19 cases.Finally,transportation of patients should be minimal and follow designated short routes.All these measures can help mitigate the effects of the COVID-19 pandemic on pediatric surgery units.

Global dissemination of minimally invasive living donor hepatectomy: What are the barriers?

Minimally invasive donor hepatectomy(MIDH)is a relatively novel procedure that can potentially increase donor safety and contribute to faster rehabilitation of donors.After an initial period in which donor safety was not effectively validated,MIDH currently seems to provide improved results,provided that it is conducted by experienced surgeons.Appropriate selection criteria are crucial to achieve better outcomes in terms of complications,blood loss,operative time,and hospital stay.Beyond a pure laparoscopic technique,various approaches have been recommended such as hand-assisted,laparoscopic-assisted,and robotic donation.The latter has shown equal outcomes compared to open and laparoscopic approaches.A steep learning curve seems to exist in MIDH,mainly due to the fragility of the liver parenchyma and the experience needed for adequate control of bleeding.This review investigated the challenges and the opportunities of MIDH and the barriers to its global dissemination.Surgeons need expertise in liver transplantation,hepatobiliary surgery,and minimally invasive techniques to perform MIDH.Barriers can be categorized into surgeon-related,institutionalrelated,and accessibility.More robust data and the creation of international registries are needed for further evaluation of the technique and the acceptance from more centers worldwide.

Adrenal ganglioneuroma:What you need to know

Adrenal ganglioneuromas(GNs) constitute rare,differentiated tumors which originate from neural crest cells. GNs are usually hormonally silent and tend to be discovered incidentally on imaging tests. Adrenalectomy is the gold standard for the treatment of primary adrenal GNs. Nevertheless,preoperative differential diagnosis of GNs remains extremely challenging,and thus histopathological examination is required in order to confirm the diagnosis of GN. Overall,prognosis after surgical resection seems to be excellent,without any recurrences or need for adjuvant therapy.

Pediatric transplantation during the COVID-19 pandemic

Children infected by severe acute respiratory syndrome coronavirus 2(SARSCoV-2)seem to have a better prognosis than adults.Nevertheless,pediatric solid organ transplantation(SOT)has been significantly affected by the unprecedented coronavirus disease 2019(COVID-19)pandemic during the pre-,peri-,and posttransplant period.Undoubtedly,immunosuppression constitutes a real challenge for transplant clinicians as increased immunosuppression may prolong disease recovery,while its decrease can contribute to more severe symptoms.To date,most pediatric SOT recipients infected by SARS-CoV-2 experience mild disease with only scarce reports of life-threatening complications.As a consequence,after an initial drop during the early phase of the pandemic,pediatric SOTs are now performed with the same frequency as during the pre-pandemic period.This review summarizes the currently available evidence regarding pediatric SOT during the COVID-19 pandemic.

Management of biliary atresia:To transplant or not to transplant

Kasai procedure(KP)and liver transplantation(LT)represent the only therapeutic options for patients with biliary atresia(BA),the most common indication for LT in the pediatric population.However,KP represents by no means a radical option but rather a bridging one,as nearly all patients will finally require a liver graft.More and more experts in the field of transplant surgery propose that maybe it is time for a paradigm change in BA treatment and abandon KP as transplantation seems inevitable.Inadequacy of organs yet makes this option currently not feasible,so it seems useful to find ways to maximize the efficacy of KP.In previous decades,multiple studies tried to identify these factors which opt for better results,but in general,outcomes of KP have not improved to the level that was anticipated.This review provides the framework of conditions which favor native liver survival after KP and the ones which optimize a positive LT outcome.Strategies of transition of care at the right time are also presented,as transplantation plays a key role in the surgical treatment of BA.Future studies and further organization in the transplant field will allow for greater organ availability and better outcomes to be achieved for BA patients.

Acute esophageal necrosis: A systematic review and pooled analysis

BACKGROUND Acute esophageal necrosis(AEN)is a rare entity with multifactorial etiology,usually presenting with signs of upper gastrointestinal bleeding.AIM To systematically review all available data on demographics,clinical features,outcomes and management of this medical condition.METHODS A systematic literature search was performed with respect to the PRISMA statement(end-of-search date:October 24,2018).Data on the study design,interventions,participants and outcomes were extracted by two independent reviewers.RESULTS Seventy-nine studies were included in this review.Overall,114 patients with AEN were identified,of whom 83 were males and 31 females.Mean patient age was 62.1±16.1.The most common presenting symptoms were melena,hematemesis or other manifestations of gastric bleeding(85%).The lower esophagus was most commonly involved(92.9%).The most widely implemented treatment modality was conservative treatment(75.4%),while surgical or endoscopic intervention was required in 24.6%of the cases.Mean overall followup was 66.2±101.8 d.Overall 29.9%of patients died either during the initial hospital stay or during the follow-up period.Gastrointestinal symptoms on presentation[Odds ratio 3.50(1.09-11.30),P=0.03]and need for surgical or endoscopic treatment[surgical:Odds ratio 1.25(1.03-1.51),P=0.02;endoscopic:Odds ratio 1.4(1.17-1.66),P<0.01]were associated with increased odds of complications.A sub-analysis separating early versus late cases(after 2006)revealed a significantly increased frequency of surgical or endoscopic intervention(9.7%vs 30.1%respectively,P=0.04)CONCLUSION AEN is a rare condition with controversial pathogenesis and unclear optimal management.Although the frequency of surgical and endoscopic intervention has increased in recent years,outcomes have remained the same.Therefore,further research work is needed to better understand how to best treat this potentially lethal disease.

Preventing pediatric cardiothoracic trauma:Role of policy and legislation

Data from the last 50 years suggest that pediatric pa-tients typically suffer cardiothoracic injuries following blunt traumatic force(70%) in the setting of either motor vehicle crashes(53.5%) or vehicle-pedestrian accidents(18.2%). Penetrating trauma accounts for 30% of pediatric cardiothoracic injuries, half of which are gunshot wounds. Graduated driver licensing progr-ams, gun-control legislation, off-road vehicle regulation, initiatives such as "Prevent the Bleed", as well as prof-essional society recommendations are key in preventing pediatric cardiothoracic injuries.

Immunotherapy for advanced hepatocellular carcinoma:From clinical trials to real-world data and future advances

Hepatocellular carcinoma(HCC)is a leading cause of cancer-associated mortality worldwide.HCC is an inflammation-associated immunogenic cancer that frequently arises in chronically inflamed livers.Advanced HCC is managed with systemic therapies;the tyrosine kinase inhibitor(TKI)sorafenib has been used in 1st-line setting since 2007.Immunotherapies have emerged as promising treatments across solid tumors including HCC for which immune checkpoint inhibitors(ICIs)are licensed in 1st-and 2nd-line treatment setting.The treatment field of advanced HCC is continuously evolving.Several clinical trials are investigating novel ICI candidates as well as new ICI regimens in combination with other therapeutic modalities including systemic agents,such as other ICIs,TKIs,and anti-angiogenics.Novel immunotherapies including adoptive cell transfer,vaccine-based approaches,and virotherapy are also being brought to the fore.Yet,despite advances,several challenges persist.Lack of real-world data on the use of immunotherapy for advanced HCC in patients outside of clinical trials constitutes a main limitation hindering the breadth of application and generalizability of data to this larger and more diverse patient cohort.Consequently,issues encountered in real-world practice include patient ineligibly for immunotherapy because of contraindications,comorbidities,or poor performance status;lack of response,efficacy,and safety data;and cost-effectiveness.Further real-world data from high-quality large prospective cohort studies of immunotherapy in patients with advanced HCC is mandated to aid evidence-based clinical decision-making.This review provides a critical and comprehensive overview of clinical trials and real-world data of immunotherapy for HCC,with a focus on ICIs,as well as novel immunotherapy strategies underway.

Platelet rich plasma effectiveness in bowel anastomoses:A systematic review

BACKGROUND Anastomotic leak constitutes a major problem in abdominal surgery.Technical insufficiency,topical or systemic factors contribute to disrupted healing of the performed bowel anastomosis and result in anastomosis leakage,with detrimental effects on patient postoperative outcomes.Despite the investigation of several factors and the invention of protective materials,the ideal agent to prevent anastomotic leaks is yet to be determined.AIM To study the effect of platelet rich plasma(PRP)on the healing of bowel anastomoses.METHODS A systematic literature search was performed in PubMed,EMBASE,and Scopus databases to identify studies investigating the effect of PRP application on bowel anastomosis.RESULTS Eighteen studies were eligible with a total population of 712 animals including rats(14 studies),rabbits(2 studies)and pigs(2 studies).No postoperative complications were reported following PRP application.Fourteen out of 18 studies reported a statistically significant higher anastomosis bursting pressure in PRP groups compared to control either in healthy animals or animal models with underlying condition or intervention,such as intraperitoneal chemotherapy or peritonitis.Similar results were reported by ten studies in terms of tissue hydroxyproline levels.One study reported significant increase in collagen deposition in PRP groups.PRP application resulted in significantly decreased inflammatory cell infiltration in the presence of peritonitis or intraperitoneal chemotherapy(6 studies).CONCLUSION The application of PRP is associated with improved bowel anastomosis outcomes,especially in animal models having an underlying condition affecting the normal healing process.PRP application seems to augment the normal healing process under these circumstances.However,further studies are needed to investigate the potential role of PRP on bowel anastomosis healing,especially in clinical settings.

Liver transplantation for hepatoblastoma

Liver transplantation is the only potentially curative option for unresectable hepatoblastoma.The introduction of platinum-based chemotherapy drastically improved the survival outcomes of patients with hepatoblastoma.However,the use of neoadjuvant chemotherapy and the optimal number of cycles required in patients listed for liver transplantation,as well as the potential use of adjuvant chemotherapy,remain unclear.Additionally,the shortage of donor liver grafts,along with the lack of clear consensus on the management of metastatic hepatoblastoma,makes the decision on whether to proceed to liver transplantation even more complex and challenging.Technological advances may optimize intraoperative imaging of both the primary tumor and metastatic sites,thus facilitating complete resection.Such improvements,along with the wider use of social media platforms to increase public awareness,could potentially pave the way for more optimal implementation of liver transplantation for the treatment of patients with unresectable hepatoblastoma.