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Review. Gastrointestinal Surgery in Neonates: Practice, Facts, and Trends

Open Journal of Pediatrics 2019年第2期9卷 154-182页

作者： ralf-bodo trobs Department of Pediatric Surgery Ruhr University of BochumHerneGermany Helios-Klinikum Duisburg Sankt Johannes HospitalDuisburgGermany

The author presents an overview of the current trends in acute neonatal gastrointestinal surgery. Necrotizing enterocolitis and focal intestinal perforation are disorders of different etiology, appearance, and prognosis. In neonates with focal perforation, a good prognosis can be expected. Primary anastomosis is a valid option for primary surgery. Meconium ileus is based on obstruction of the terminal ileum. Medical treatment is the primary therapeutic option, although surgery may be required. In contrast, meconium plug syndrome is based on stool plugging in the left colon, and surgery is not appropriate. Hirschsprung’s disease is confirmed on the basis of representative biopsy of the rectum just above the dentate line. There is a trend toward a single-step pull-through operation without protective stoma. Open hernia repair in small neonates can be performed via a mini-incision and without opening the external inguinal ring. Laparoscopic hernia repair has some advantages, especially in girls. In infants with pyloric stenosis, laparoscopic pyloromyotomy is a first line option for treatment. There is a general trend toward single-stage procedures and laparoscopic reconstructive surgery for gastrointestinal malformations. With the exception of tracheoesophageal fistula and low bowel obstruction, the vast majority of upper gastrointestinal malformations can be identified using prenatal ultrasound examination. One-stage repair with excellent results is even possible in neonates below 1000 g. Surgery of duodenal or small bowel atresia can be performed following the postnatal adaptation period. For some forms of anorectal malformation, the need for a protective stoma has been questioned in the last decade. Posterior sagittal anorectoplasty remains the standard procedure for the majority of cases. Midgut or segmental volvulus affects different groups of infants. If a neonate is suspected of having any type of volvulus, urgent surgery is required. Intestinal duplication carr

关键词： Neonatal Surgery Acute Abdomen Gastrointestinal Atresia Necrotizing Enterocolitis Bowel Obstruction

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Duodenal Atresia-Tandler’s “Epithelial Plug Stage” Revisited

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Open Journal of Pediatrics 2019年第1期9卷 103-110页

作者： ralf-bodo trobs Department of Pediatric Surgery St.Marie’s HospitalSaint Elisabeth GroupRuhr University of BochumWittenGermany

Background: Duodenal atresia is the most common type of intestinal atresia. Pathogenesis of duodenal atresia can be explained by an embryological theory that involves persistent physiologic epithelial occlusion (“epithelial plug”), first published in 1900. Tandler’s developmental arrest theory has been accepted by the majority of recognized modern textbooks to date. The aim of the presented study is to re-evaluate the relevance of Tandler’s observations. Method: Tandler’s paper was reviewed retrospectively and discussed from the point of view of subsequent research. Results and Discussion: Local epithelial proliferation, vacuolization failure and mesenchyme ingrowth may continuously serve as a partly convincing but incomplete embryologic model to explain membranous duodenal atresia. Tandler’s theory has some weak points regarding the epithelial-mesenchymal interaction, the predisposition of the post-ampullary region, the association of duodenal atresia with other malformations and trisomy 21, and familial occurrence. Shrinkage artifacts, misinterpretation of a three-dimensional problem investigated with a two-dimensional tool (light microscope), animal studies, and the lack of apoptosis call the real existence of a solid stage in early duodenal embryology into question. Conclusion: More sophisticated morphologic, genetic and molecular-biological investigations revealed new insights regarding endoderm to mesoderm signaling as an important key to the pathogenesis of duodenal atresia.

关键词： Duodenal Atresia Embryology Epithelial Plug Tandler’s Theory

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Endoscopic Detection and Surgical Repair of Congenital Tracheo-Esophageal-Fistula(TEF)±Esophageal Atresia(EA)

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Open Journal of Pediatrics 2014年第4期4卷 283-290页

作者： ralf-bodo trobs Werner Finke Department of Pediatric Surgery Marienhospital HerneSt.Elisabeth GroupRuhr-University of BochumHerneGermany Department of Anesthesiology and Surgical Intensive Care Marienhospital HerneSt.Elisabeth GroupRuhr-University of BochumHerneGermany

Purpose: This study was performed to evaluate the management of tracheoesophageal fistula (TEF) ± esophageal atresia (EA) under the guidance of preoperative tracheo-bronchoscopy (TrSc). Methods: Between 2007 and July 2014, a total of 26 consecutive newborns who underwent rigid TrSc for suspected TEF were identified. All associated charts and operation reports were retrospectively analyzed. Results: Distal TEF with EA (Gross C) predominated (n = 18). Furthermore, we managed 2 infants with proximal and distal TEF (Gross D) and 4 infants with isolated TEF (Gross E). In our hands, TrSc was feasible in infants with a birth weight above 1300 g. Twenty-five fistulas were identified by endoscopy in 23 patients. In one infant with a birth weight below 1000 g, an attempt to perform TrSc was interrupted, and urgent TEF closure was required. Fistula site at the carina was associated with a high rate of esophageal anastomosis under tension. During surgery, proximal TEF and isolated TEF were safely approached via right cervicotomy (n =5). Conclusion: This study supports the routine use of rigid TrSc at the time of surgery. Rigid TrSc allowed the surgical team to identify the number and location of TEFs, and the incidence of side effects was low.

关键词： Tracheoesophageal Fistula Esophageal Atresia Tracheo-Bronchoscopy Airway Management Cervical Approach

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“Inverse Type” Apple-Peel Syndrome Is Associated with Type III Colonic Atresia in a Neonate with Gastroschisis—A “New” Subtype of Colonic Atresia

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Open Journal of Pediatrics 2015年第4期5卷 348-352页

作者： ralf-bodo trobs Micha Bahr ralf Schulze Matthias Neid Wolfgang Pielemeier Claudia Roll Department of Pediatric Surgery St.Mary’s HospitalSt.Elisabeth GroupRuhr-University of BochumHerneGermany Department of Obstetrics and Gynecology St.Vincenz’HospitalDattelnGermany Institute of Pathology Ruhr-University of BochumGeorgius-Agricola-FoundationBG-Clinics BergmannsheilBochumGermany Center of Perinatology Department of Neonatology and Pediatric Intensive CareVest Children’s HospitalUniversity of Witten-HerdeckeDattelnGermany

The colon is an unusual site of intestinal atresia. Colonic atresia is subdivided into three phenotypes. Type III is the most common phenotype, where the proximal and distal blind sacs are not connected. Here, we report on the presence of colonic atresia with an “inverse apple-peel” appearance in a neonate with gastroschisis. The lack of mesenteric fixation of the entire small intestine, including the proximal colon, and the twisting around the vascular axis of the superior mesenteric artery led to intrauterine volvulus and hemorrhagic infarction of the ileocolic bowel at 34 weeks of gestation. According to the current nomenclature for small bowel atresia, we introduce type IIIB into the current colonic atresia classification. The occurrence of type IIIB has been mentioned in the literature, but no single cases have been reported until now. Patients with this type of atresia are predisposed to the loss of the ileocecal region.

关键词： Apple-Peel Syndrome Colonic Atresia Volvulus Gastroschisis

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Pathophysiology of Hypertrophic Pyloric Stenosis Revisited: The Use of Isotonic Fluid for Preoperative Infusion Therapy Is Supported

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Open Journal of Pediatrics 2014年第3期4卷 208-215页

作者： ralf-bodo Troebs Klinik für Kinderchirurgie Marien Hospital Herne Ruhr University of Bochum Bochum Germany

Background: The aim of this study was to elucidate the preoperative clinical and biochemical profile of infants with IHPS to optimize infusion therapy. Patients and Method: We retrospectively analyzed data from 56 infants who were operated for IHPS. Our study includes growth and laboratory data prior to the initiation of therapy. Results: Median duration of propulsive vomiting was 4 d;the median age was 37 d (18 - 108), and the median body weight was 3840 g (2760 -5900). Metabolic alkalosis (MAlk) with a pH of 7.45 ± 0.06 and an stHCO3- of 28.7 ± 4.5 mmol/l was found. In a subgroup of the infants, negative base excess (BE) was observed. The sodium concentration was normal or reduced (mean/median of 137 mmol/l). There was a strong negative correlation between stHCO3- and K+. The carbon dioxide partial pressure tended to increase (5.72 ± 0.84 kPa). Calculations of osmolality revealed a normal osmolarity. Hypoglycemia did not occur. The creatinine clearance according to the Schwartz formula remained at a normal level (85.3 ± 24.3 ml/min/1.73 m2). Discussion: The presented case series is characterized by a short duration of preoperative vomiting. MAlk can be classified as a chloride deficiency syndrome. It is accompanied by normo- or hyponatremic dehydration with normal osmolality. Partial respiratory compensation occurred. A normal creatinine clearance indicated good glomerular renal function. Conclusion: The presented study supports the use of an isotonic infusion fluid with a low glucose concentration for preoperative infusion therapy.

关键词： Infantile Pyloric Stenosis Metabolic Alkalosis Dehydration Osmolality Glucose Lactate Creatinine Clearance Infusion Therapy

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Early Morbidity and Perioperative Course of Neonates with Esophageal Atresia and Tracheoesophageal Fistula in a Tertiary Pediatric Surgical Center

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Open Journal of Pediatrics 2016年第3期6卷 191-202页

作者： ralf-bodo Troebs Jan Wald Department of Pediatric Surgery St. Mary’s Hospital Herne St. Elisabeth Group Ruhr-University of Bochum Herne Germany Department of Diagnostic and Interventional Radiology St. Mary’s Hospital Herne St. Elisabeth Group Ruhr-University of Bochum Herne Germany

Background: The management of infants (infs.) with esophageal atresia and tracheoesophageal fistula (EA ± TEF) is demanding and complex. The aim of this study was to evaluate early morbidity, the timing of surgery, and the results of surgery. Patients and Method: We collected data of 30 consecutive infs. treated for EA ± TEF between 2006 and 2014. Results: The median gestational age was 38 weeks (12 preterm), and the median Birth Weight (BW) was 2660 g (4 infs. had a BW 1500 g). The median Apgar score at 10 minutes was 10 (range 7 - 10). The median umbilical artery pH (UapH) was 7.30. According to the Spitz classification, 19 infs. were group 1, 9 infs. were group 2, and 2 infs. were group 3. Surgical repair was performed in 29 cases (25 EA;4 isolated TEF). Once the infs. arrived at the pediatric surgery department, surgery was postponed overnight in 11 cases. The duration of postoperative (p.o.) mechanical ventilation was significantly shorter for operations performed on day 2 after delivery. Twenty-four infs. (83%) underwent surgery within 2 days after delivery, and 5 infs. had later surgery. Chest drains (p.o.) for pneumothorax were inserted in 6 infs. (21%), and gastrostomy was performed in 6 cases (21%). No re-thoracotomy was required. The median length of hospital stay was 17.5 days (6 to 120). The incidence of p.o. mortality was 1 in 29 (3%). Discussion: The majority of the infs. presented growth retardation (indicated by low birth weight) and a stable immediate postnatal course. The data from this study support the concept of early but not emergent surgery for the majority of infs. with EA ± TEF. However, a remarkable rate of perioperative morbidity must be taken into account. Conclusion: Surgery for EA ± TEF can be performed safely during the first postnatal days with exception of very unstable preterm infants.

关键词： Esophageal Atresia Tracheoesophageal Fistula Short-Term Outcome Morbidity Urgency Ventilation Lengths of Stay

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Do Immaturity, Dehydratation or Alkalosis Predispose to Intraoperative Complications at Pyloromyotomy?

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Open Journal of Pediatrics 2016年第3期6卷 203-212页

作者： ralf-bodo Tröbs Lars Burghardt Micha Bahr Matthias Nissen Department of Pediatric Surgery Clinic Marien Hospital Herne St. Elisabeth Gruppe Ruhr-Universit?t Bochum Herne Germany

Background: Hypertrophic pyloric stenosis is the most important cause for propulsive non-bilious vomiting in infants of the first trimester. Extramucous splitting of the hypertrophic pyloric muscle is the surgical gold standard for treatment. Serious major complications of pyloromyotomy (PM) are mucosal perforation and incomplete muscle splitting. The aim of the presented study is to find out if intraoperative complications are predisposed by biometric or biochemical factors. Furthermore, we looked for the influence of the board certification of the primary surgeon. Patients and Methods: 162 infants with IHPS were operated during a six-year period (n = 150 laparoscopic operations). We had 8 major complications (4.9%): iatrogenic mucosal perforation occurred in 6 cases, and incomplete PM in 2 infants. Preoperative demographic data and data resulting from the blood acid-base- and ion-analysis were compared with data of a previously published reference group from our institution (Tr?bs RB. Open J Pediatr, 2014;4: 208-215). Results: The duration of vomiting, the grade of dehydration and the severity of blood alkalosis did not differ between both groups. Furthermore, we found no influence of the gestational age and birth weight on the occurrence of intraoperative complications. It seems that early postnatal age (p = 0.07) and low body weight at surgery (p = 0.055) may contribute to surgical problems. Board certification as a paediatric surgeon did not influence the rate of intraoperative complications. Conclusions: Laboratory data did not show any predisposition to intraoperative complications. It is assumed that small infants with early occurring symptoms carry an elevated risk for intraoperative events. Our data support the hypothesis that the rate of intraoperative complications at PM is mainly influenced by skills and experience of the surgeon.

关键词： Hypertrophic Pyloric Stenosis Pyloromyotomy Complication Perforation Alkalosis Surgical Training

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Pyloric Stenosis and Nonbilious Vomiting in Infants: Negative Base Excess and Hypercapnia—Two Opposing Points of One Scale a Comparative Case Series

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Open Journal of Pediatrics 2023年第1期13卷 104-112页

作者： ralf-bodo Tröbs Tomasz Baranski Andreas Lipphaus Matthias Nissen Department of Pediatric Surgery St. John’s Hospital Helios Kliniken GmbH Duisburg Germany Biomechanics Research Group Chair of Product Development Faculty of Mechanical Engineering Ruhr University Bochum Bochum Germany Department of Pediatric Surgery Ruhr-University of Bochum St. Marie’s Hospital Witten Sankt Elisabeth Gruppe Witten Germany

Background: Blood pH and bicarbonate estimations are basal acid-base laboratory tests that are performed in infants with infantile hypertrophic pyloric stenosis (IHPS). This study aimed to define the clinical value of pCO2 and BE in infants suspected to have IHPS. Methods: We collected data from 80 “surgical” infants younger than 100 days with prolonged nonbilious vomiting who were suspected to have IHPS. In 65 infants, pyloric stenosis was confirmed, and 15 infants had nonsurgical conditions. Capillary blood was tested for standard acid-base parameters and lactate. The two groups were compared. Results: Eighty-eight percent of the IHPS infants had elevated standard bicarbonate levels (st bicarb) > 25 mmol/l, and 60% had BE > 3.5 mmol/l;12% of the infants showed hypercapnia (pCO2 ≥ 50 mmHg) associated with markedly increased standard bicarbonate and BE. Infants with nonsurgical vomiting were older at admission (p = 0.002), had a longer duration of vomiting (p 2 (p = 0.021), lower st bicarb (p < 0.001) and lower BE (p = 0.001). In addition, nonsurgical infants showed a trend to anemia (p = 0.002). Conclusions: In infants with IHPS/nonbilious vomiting, acid-base analysis (ABA) is equivocal or inconclusive. These findings may be misleading and could result in a false clinical decision. Nonsurgical vomiting is associated with a lower degree of alkalosis, normocapnia to slight hypercapnia and a base deficit. However, even infants with IHPS may present with a negative BE. In infants with IHPS and severe alkalosis, hypercapnia carries a risk for respiratory depression. Monitoring the infant’s respiration allows for the early detection of respiratory deterioration.

关键词： Pyloric Stenosis Nonbilious Vomiting Hypoventilation Base Excess Hypercapnia

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Pyloric Stenosis and Nonbilious Vomiting in Infants: Negative Base Excess and Hypercapnia —Two Opposing Points of One Scale a Comparative Case Series

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Open Journal of Pediatrics（儿科学期刊） 2023年第1期

作者： ralf-bodo Tröbs Tomasz Baranski Andreas Lipphaus Matthias Nissen

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