Publications by authors named "Lucas M Wessel"

22 Publications

  • Page 1 of 1

Small Bowel Obstruction After Neonatal Repair of Congenital Diaphragmatic Hernia-Incidence and Risk-Factors Identified in a Large Longitudinal Cohort-Study.

Front Pediatr 2022 17;10:846630. Epub 2022 May 17.

Department of Pediatric Surgery, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany.

Objective: In patients with a congenital diaphragmatic hernia (CDH), postoperative small bowel obstruction (SBO) is a life-threatening event. Literature reports an incidence of SBO of 20% and an association with patch repair and ECMO treatment. Adhesions develop due to peritoneal damage and underly various biochemical and cellular processes. This longitudinal cohort study is aimed at identifying the incidence of SBO and the risk factors of surgical, pre-, and postoperative treatment.

Methods: We evaluated all consecutive CDH survivors born between January 2009 and December 2017 participating in our prospective long-term follow-up program with a standardized protocol.

Results: A total of 337 patients were included, with a median follow-up of 4 years. SBO with various underlying causes was observed in 38 patients (11.3%) and significantly more often after open surgery (OS). The majority of SBOs required surgical intervention (92%). Adhesive SBO (ASBO) was detected as the leading cause in 17 of 28 patients, in whom surgical reports were available. Duration of chest tube insertion [odds ratio (OR) 1.22; 95% CI 1.01-1.46, = 0.04] was identified as an independent predictor for ASBO in multivariate analysis. Beyond the cut-off value of 16 days, the incidence of serous effusion and chylothorax was higher in patients with ASBO (ASBO/non-SBO: 2/10 vs. 3/139 serous effusion, = 0.04; 2/10 vs. 13/139 chylothorax, = 0.27). Type of diaphragmatic reconstruction, abdominal wall closure, or ECMO treatment showed no significant association with ASBO. A protective effect of one or more re-operations has been detected (RR 0.16; 95% CI 0.02-1.17; = 0.049).

Conclusion: Thoracoscopic CDH repair significantly lowers the risk of SBO; however, not every patient is suitable for this approach. GoreTex®-patches do not seem to affect the development of ASBO, while median laparotomy might be more favorable than a subcostal incision. Neonates produce more proinflammatory cytokines and have a reduced anti-inflammatory capacity, which may contribute to the higher incidence of ASBO in patients with a longer duration of chest tube insertion, serous effusion, chylothorax, and to the protective effect of re-operations. In the future, novel therapeutic strategies based on a better understanding of the biochemical and cellular processes involved in the pathophysiology of adhesion formation might contribute to a reduction of peritoneal adhesions and their associated morbidity and mortality.
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http://dx.doi.org/10.3389/fped.2022.846630DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9152166PMC
May 2022

Application of bacterial nanocellulose-based wound dressings in the management of thermal injuries: Experience in 92 children.

Burns 2022 May 13;48(3):608-614. Epub 2021 Jul 13.

Medical Faculty Mannheim, Heidelberg University, University Medical Center Mannheim, Department of Pediatric Surgery, Theodor-Kutzer-Ufer 1-3, D-68167, Mannheim, Germany.

Background: Management of pediatric thermal injuries involves a high standard of care in a multidisciplinary setting. To avoid physical and psychological sequelae, wound dressings should minimize hospitalization time and anesthesia while maximizing patient comfort.

Patients And Methods: 190 children with thermal injuries of the torso, arms and legs were treated with polyurethane foam dressings or bacterial nanocellulose sheets. Data were analyzed retrospectively regarding hospitalization, procedures with general anesthesia, scar formation, rate of infection and need for skin grafting.

Results: The groups did not differ significantly concerning age, gender distribution or percentage of injured total body surface area. Statistical analysis showed that length of hospitalized care and procedures undergoing anesthesia were significantly reduced in the nanocellulose group (each p < 0.0001). There was no significant difference in rate of complications, wound healing and rate of skin grafting between the two subgroups.

Discussion: Acting as a temporary epidermal substitute, bacterial nanocellulose enables undisturbed reepithelialization without further wound dressing changes. In children, no additional topical antimicrobial agents are indicated for unimpaired wound healing.

Conclusions: Bacterial nanocellulose is superior to polyurethane foam regarding length of hospitalization and number of interventions under anesthesia. It offers a safe, cost-effective treatment option and provides excellent comfort in pediatric patients.
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http://dx.doi.org/10.1016/j.burns.2021.07.002DOI Listing
May 2022

ERNICA Consensus Conference on the Management of Patients with Esophageal Atresia and Tracheoesophageal Fistula: Follow-up and Framework.

Eur J Pediatr Surg 2020 Dec 27;30(6):475-482. Epub 2019 Nov 27.

Department of Pediatric Surgery, Hannover Medical School, Hannover, Germany.

Introduction:  Improvements in care of patients with esophageal atresia (EA) and tracheoesophageal fistula (TEF) have shifted the focus from mortality to morbidity and quality-of-life. Long-term follow-up is essential, but evidence is limited and standardized protocols are scarce. Nineteen representatives of the European Reference Network for Rare Inherited Congenital Anomalies (ERNICA) from nine European countries conducted a consensus conference on the surgical management of EA/TEF.

Materials And Methods:  The conference was prepared by item generation (including items of surgical relevance from the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN)-The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) guidelines on follow-up after EA repair), item prioritization, formulation of a final list containing the domains Follow-up and Framework, and literature review. Anonymous voting was conducted via an internet-based system. Consensus was defined as ≥75% of those voting with scores of 6 to 9.

Results:  Twenty-five items were generated in the domain Follow-up of which 17 (68%) matched with corresponding ESPGHAN-NASPGHAN statements. Complete consensus (100%) was achieved on seven items (28%), such as the necessity of an interdisciplinary follow-up program. Consensus ≥75% was achieved on 18 items (72%), such as potential indications for fundoplication. There was an 82% concordance with the ESPGHAN-NASPGHAN recommendations. Four items were generated in the domain Framework, and complete consensus was achieved on all these items.

Conclusion:  Participants of the first ERNICA conference reached significant consensus on the follow-up of patients with EA/TEF who undergo primary anastomosis. Fundamental statements regarding centralization, multidisciplinary approach, and involvement of patient organizations were formulated. These consensus statements will provide the cornerstone for uniform treatment protocols and resultant optimized patient care.
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http://dx.doi.org/10.1055/s-0039-3400284DOI Listing
December 2020

Is there a standard treatment for displaced pediatric diametaphyseal forearm fractures?: A STROBE-compliant retrospective study.

Medicine (Baltimore) 2019 Jul;98(28):e16353

Department of Pediatric Surgery, Medical Faculty Mannheim (UMM), Heidelberg University.

To review our institutional results and assess different surgical and non-surgical techniques for the treatment of displaced diametaphyseal forearm fractures in children and adolescents.Thirty-four children (25M, 9F) with a total of 36 diametaphyseal forearm fractures who underwent treatment under general anesthesia between July 2010 and February 2016 were recruited to this retrospective study. From October 2016 until March 2018 patients and/or parents were contacted by telephone and interviewed using a modified Pediatric Outcomes Data Collection Instrument (PODCI).Median age at the time of injury was 9.1 years (range, 1.9-14.6 years). Initial treatment included manipulation under anesthesia (MUA) and application of plaster of Paris (POP) (n = 9), elastic stable intramedullary nailing (ESIN) (n = 10), percutaneous insertion of at least one Kirschner wire (K-wire) (n = 16), and application of external fixation (n = 1). Eleven children (32%) experienced a total of 22 complications. Seven complications were considered as major, including delayed union (n = 1) and extensor pollicis longus (EPL) tendon injury (n = 1) following ESIN, as well as loss of reduction (n = 2) and refractures (n = 3) after MUA/POP. The median follow-up time was 28.8 months (range, 5.3-85.8 months). In 32 out of 34 cases (94%) patients and/or parents were contacted by telephone and a PODCI score was obtained. Patients who experienced complications in the course of treatment had a significantly lower score compared with those whose fracture healed without any sequelae (P = .001). There was a trend towards an unfavorable outcome following ESIN compared with K-wire fixation (P = .063), but not compared with POP (P = .553). No statistical significance was observed between children who were treated initially with a POP and those who had K-wire fixation (P = .216).There is no standard treatment for displaced pediatric diametaphyseal forearm fractures. Management with MUA/POP only is associated with an increased refracture rate. Based on our experience K-wire fixation including intramedullar positioning of at least one pin seems to be favorable compared with ESIN.
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http://dx.doi.org/10.1097/MD.0000000000016353DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6641800PMC
July 2019

ERNICA Consensus Conference on the Management of Patients with Esophageal Atresia and Tracheoesophageal Fistula: Diagnostics, Preoperative, Operative, and Postoperative Management.

Eur J Pediatr Surg 2020 Aug 2;30(4):326-336. Epub 2019 Jul 2.

Department of Pediatric Surgery, Hannover Medical School, Hannover, Lower Saxony, Germany.

Introduction:  Many aspects of the management of esophageal atresia (EA) and tracheoesophageal fistula (TEF) are controversial and the evidence for decision making is limited. Members of the European Reference Network for Rare Inherited Congenital Anomalies (ERNICA) conducted a consensus conference on the surgical management of EA/TEF based on expert opinions referring to the latest literature.

Materials And Methods:  Nineteen ERNICA representatives from nine European countries participated in the conference. The conference was prepared by item generation, item prioritization by online survey, formulation of a final list containing the domains diagnostics, preoperative, operative, and postoperative management, and literature review. The 2-day conference was held in Berlin in October 2018. Anonymous voting was conducted via an internet-based system. Consensus was defined when 75% of the votes scored 6 to 9.

Results:  Fifty-two items were generated with 116 relevant articles of which five studies (4.3%) were assigned as level-1evidence. Complete consensus (100%) was achieved on 20 items (38%), such as TEF closure by transfixing suture, esophageal anastomosis by interrupted sutures, and initiation of feeding 24 hours postoperatively. Consensus ≥75% was achieved on 37 items (71%), such as routine insertion of transanastomotic tube or maximum duration of thoracoscopy of 3 hours. Thirteen items (25%) were controversial (range of scores, 1-9). Eight of these (62%) did not reach consensus.

Conclusion:  Participants of the conference reached significant consensus on the management of patients with EA/TEF. The consensus may facilitate standardization and development of generally accepted guidelines. The conference methodology may serve as a blueprint for further conferences on the management of congenital malformations in pediatric surgery.
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http://dx.doi.org/10.1055/s-0039-1693116DOI Listing
August 2020

Experience with Stent Placement for Benign Pancreaticobiliary Disorders in Children.

J Laparoendosc Adv Surg Tech A 2019 Jun 13;29(6):839-844. Epub 2019 Apr 13.

1 Department of Pediatric Surgery, Medical Faculty Mannheim, Heidelberg University, University Medical Center, Mannheim, Germany.

There is a lack of experience with stenting for benign pancreaticobiliary disorders in children. Fifteen children (9 male and 6 female) with a median age of 7.1 years (range 0.7-14.2 years) who underwent treatment with a plastic stent for a benign disorder of the pancreaticobiliary system between May 2003 and September 2017 were recruited to this retrospective study. Biliary and/or pancreatic plastic stents were inserted into 5 patients with congenital, 4 with post-traumatic, and 6 with idiopathic pathologies. Median duration of individual stent placement was 111 days (range 14-1569 days). Eleven children (73%) were treated with one stent only. In 4 cases, up to 22 stents were successively placed over time. There were no complications during stent insertion or stent removal. Seven patients (47%) experienced adverse effects during stenting, including choledocholithiasis, pancreaticolithiasis, cholangitis, acute pancreatitis, stent obstruction, and stent fracture. At follow-up, in 11 cases (73%), the underlying condition was resolved. In 4 children, all of whom suffered from congenital pancreaticobiliary disorders, stent therapy was considered as a temporary treatment before definite surgery. Patients with congenital anomalies of the pancreaticobiliary tree often require surgery for definitive management. However, temporary stent placement can be accomplished safely and successfully and this serves as a bridge to temporize their obstructive process while awaiting surgical intervention. Children with post-traumatic or idiopathic disorders can frequently be managed definitively by stenting alone and many of these require only one single stent insertion.
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http://dx.doi.org/10.1089/lap.2018.0663DOI Listing
June 2019

The Surgical Treatment of Toxic Megacolon in Hirschsprung Disease.

Pediatr Emerg Care 2016 Nov;32(11):785-788

From the Departments of *Pediatric Surgery and †Pediatrics, University of Mannheim, Medical Faculty of Heidelberg, Mannheim, Germany.

Objectives: Enterocolitis remains the most significant cause of morbidity and mortality in Hirschsprung disease (HD). It could progress into toxic megacolon (TM)-acute dilatation of the colon as accompanying toxic complication of Hirschsprung enterocolitis. It is a devastating complication, especially in infants with so far undiagnosed HD.

Methods: A retrospective analysis of medical records of 4 infants with TM was performed. The diagnosis TM was determined on the basis of clinical information (abdominal pain or tenderness, abdominal distension, diarrhea, bloody diarrhea, and constipation), plain x-rays of the abdomen (segmental or total colonic dilation), and the presence of such criteria (fever, high heart rate, increased white blood cell count, C reactive protein, anemia, dehydration, electrolyte disturbances, hypotension). Surgical management and outcome was evaluated by retrospective chart review.

Results: The median duration of symptoms characteristic for TM was 3 days. Toxic megacolon was seen as the first manifestation of previously unknown HD in 3 patients; in 1 newborn, the contrast radiograph was suggestive of HD. In all patients, conservative treatment was failed. Three patients were treated with surgical decompression and ileostomy only. In all these cases, severe complications occurred, consequently 2 of them died. In 1 patient, a resection of the transverse dilated colon additionally was performed. This patient had no complications in postoperative period and survived.

Conclusions: Because of the high mortality in patients with TM that were treated medically or with colonic decompression, a resection of massively distended part of the colon should be performed.
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http://dx.doi.org/10.1097/PEC.0000000000000444DOI Listing
November 2016

The effect of intermittent intraabdominal pressure elevations and low cardiac output on the femoral to carotid arterial blood pressure difference in piglets.

Surg Endosc 2016 11 16;30(11):5052-5058. Epub 2016 Mar 16.

Department of Pediatric Surgery, Medical Faculty Mannheim (UMM), University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.

Background: Our previous work in a laparoscopic setting in piglets revealed that the systolic femoral artery pressure was approximately 5 % higher than its carotid counterpart, whereas the mean and diastolic values showed no significant difference. This remained idem when the intraabdominal pressure (IAP) was gradually increased. In this study, we aimed to investigate the effect of (1) intermittent IAP elevations and (2) a low cardiac output (CO) on the blood pressure (BP) difference cranially (carotid artery) and caudally (femoral artery) of a capnoperitoneum (ΔP = P -P ).

Methods: A total of twenty-two piglets (mean body weight 11.0 kg; range 8.9-13.3 kg) were studied. Of these, 14 underwent intermittent IAP elevations at 8 and 16 mmHg, and ΔP was measured. In another 8 piglets, a model of reduced CO was created by introducing an air embolism (2 ml/kg over 30 s) in the inferior caval vein (VCI) at 12 mmHg IAP to further assess the influence of this variable on ΔP.

Results: Systolic ΔP remained at a mean of 5.6 mmHg and was not significantly affected by insufflation or exsufflation up to an IAP of 16 mmHg. Diastolic and mean values showed no differences between P and P . P remained higher than its carotid counterpart as long as the cardiac index (CI) was above 1.5 l/min/m, but fell significantly below P at a low CI. There was no CO-dependent effect on diastolic and mean ΔP. Repeated IAP elevations do not significantly influence ΔP.

Conclusions: Intermittent IAP elevations do not significantly influence ΔP. Despite of a CO-dependent inversion of systolic ΔP, mean BP measurements at the leg during laparoscopy remain representative even at low CO values.
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http://dx.doi.org/10.1007/s00464-016-4853-6DOI Listing
November 2016

Use of covered self-expandable stents for benign colorectal disorders in children.

J Pediatr Surg 2017 Jan 4;52(1):184-187. Epub 2016 Mar 4.

Medical Faculty Mannheim, Heidelberg University, University Medical Center Mannheim, Department of Pediatric Surgery, Theodor-Kutzer-Ufer 1-3, D-68167, Mannheim, Germany.

Purpose: There is a lack of experience with covered self-expandable stents for benign colorectal disorders in children.

Methods: Five children (4M, 1F) with a median age of 5years (range, 6months-9years) who underwent treatment with covered self-expandable plastic (SEPSs) or self-expandable metal stents (SEMSs) for a benign colorectal condition between April 2005 and November 2013 were recruited to this retrospective study. Etiologies included: anastomotic stricture with (n=1) or without (n=3) simultaneous enterocutaneous fistula, as well as an anastomotic leak associated with enterocutaneous fistula (n=1). All children suffered from either Hirschsprung's disease (n=3) or total colonic aganglionosis (Zuelzer-Wilson syndrome) (n=2).

Results: Median duration of individual stent placement was 23days (range, 1-87days). In all cases up to five different stents were placed over time. At follow-up two patients were successfully treated without further intervention. In another patient the anastomotic stricture resolved fully, but a coexisting enterocutaneous fistula persisted. Overall, three patients did not improve completely following stenting and required definite surgery. Stent-related problems were noted in all cases. There was one perforation of the colon at stent insertion. Further complications consisted of stent dislocation (n=4), obstruction (n=1), formation of granulation tissue (n=1), ulceration (n=1) and discomfort (n=3).

Conclusions: Covered self-expandable stents enrich the armamentarium of interventions for benign colorectal disorders in children including anastomotic strictures and intestinal leaks. A stent can be applied either as an emergency procedure (bridge to surgery) or as an adjuvant treatment further to endoscopy and dilatation. Postinterventional problems are frequent but there is a potential for temporary or definite improvement following stent insertion.
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http://dx.doi.org/10.1016/j.jpedsurg.2016.01.020DOI Listing
January 2017

A comparison of intervention and conservative treatment for angulated fractures of the distal forearm in children (AFIC): study protocol for a randomized controlled trial.

Trials 2015 Sep 30;16:437. Epub 2015 Sep 30.

Clinic for Pediatric Surgery, University Hospital Mannheim, Faculty of Heidelberg, Mannheim, Germany.

Background: Angulated fractures of the distal forearm are very frequent lesions in childhood. Currently, there are no standard guidelines on whether these children should be treated conservatively with a cast; with reduction and a cast; or with reduction, pinning and a cast under anesthesia. Minor prospective and retrospective studies have shown that the distal physis of the forearm possesses high remodeling capacity leading to reliable correction of malalignment. The aim of this trial is to answer the question about whether operative and conservative treatment show equivocal results.

Methods/design: This is a prospective, multinational, multicenter, randomized, observer-blinded, actively controlled, parallel group trial, with 24 months of observation. The primary objective of this trial is to assess whether or not the long-term functional outcome in remodeling patients is inferior to patients receiving closed reduction and K-wire pinning. The trial should include 742 patients with acute fracture. The patients will be included in 30 medical centers in Germany, Switzerland and Austria. All patients 5 to 11 years of age presenting at the emergency department with an angulated distal fracture of the forearm will be randomized online after informed consent. The primary endpoint is the Cooney Score after 24 months. The secondary endpoint is the grade of radiological displacement at 12/24 months.

Discussion: Therapy of angulated fractures is a matter of intensive debate. Primary manipulation and pinning under general anesthesia is recommended in order to avoid malalignment. No major study has proven the advantage of manipulation and pinning over immobilization alone. Should remodeling appear to be a safe alternative, manipulation under general anesthesia, K-wire pinning and removal of pins could be avoided, thus sparing significant costs.

Trial Registration: DRKS00004874 , 30 October 2013.
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http://dx.doi.org/10.1186/s13063-015-0912-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4590691PMC
September 2015

The Surgical Correction of Congenital Deformities: The Treatment of Diaphragmatic Hernia, Esophageal Atresia and Small Bowel Atresia.

Dtsch Arztebl Int 2015 May;112(20):357-64

Department of Pediatric Surgery, University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Department of Pediatric Surgery and Pediatric Urology, University Children's Hospital Tübingen, Department of Pediatric Surgery and Pediatric Urology, University Hospital Frankfurt, Campus Niederrad,Frankfurt am Main.

Background: More than half of all congenital deformities can be detected in utero. The initial surgical correction is of paramount importance for the achievement of good long-term results with low surgical morbidity and mortality.

Methods: Selective literature review and expert opinion.

Results: Congenital deformities are rare, and no controlled trials have been performed to determine their optimal treatment. In this article, we present the prenatal assessment, treatment, and long-term results of selected types of congenital deformity. Congenital diaphragmatic hernia (CDH) affects one in 3500 live-born infants, while esophageal atresia affects one in 3000 and small-bowel atresia one in 5000 to 10,000. If a congenital deformity is detected and its prognosis can be reliably inferred from a prenatal assessment, the child should be delivered at a specialized center (level 1 perinatal center). The associated survival rates are 60-80% after treatment for CDH and well over 90% after treatment for esophageal or small-bowel atresia. Despite improvements in surgical correction over the years, complications and comorbidities still affect 20-40% of the treated children. These are not limited to surgical complications in the narrow sense, such as recurrence, postoperative adhesions and obstruction, stenoses, strictures, and recurrent fistulae, but also include pulmonary problems (chronic lung disease, obstructive and restrictive pulmonary dysfunction), gastrointestinal problems (dysphagia, gastro-esophageal reflux, impaired intestinal motility), and failure to thrive. Moreover, the affected children can develop emotional and behavioral disturbances. Minimally invasive surgery in experienced hands yields results as good as those of conventional surgery, as long as proper selection criteria are observed.

Conclusion: Congenital deformities should be treated in recognized centers with highly experienced interdisciplinary teams. As no randomized trials of surgery for congenital deformities are available, longitudinal studies and registries will be very important in the future.
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http://dx.doi.org/10.3238/arztebl.2015.0357DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4558645PMC
May 2015

Single-staged surgical approach in congenital diaphragmatic hernia associated with esophageal atresia.

J Pediatr Surg 2015 Aug 28;50(8):1418-24. Epub 2015 Apr 28.

Department of Pediatric Surgery, University of Mannheim, Medical Faculty of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim. Electronic address:

Background: The coexistence of congenital diaphragmatic hernia (CDH) with esophageal atresia (EA) has only been reported occasionally in literature. Series of patients from a single institution with comparison of different postnatal therapeutic approaches have not been reported. We describe our management in this unique cohort of patients and discuss the procedures that can lead to successful outcomes in this association of congenital anomalies.

Methods: The surgical approaches and outcome of six neonates with CDH associated with EA and distal tracheo-esophageal fistula (TEF) are discussed.

Results: Five newborns were treated surgically, while one patient with trisomy 18 only received palliative treatment. In four patients TEF was ligated during laparotomy for CDH repair. Secondary surgery was performed for correction of EA via thoracotomy after 4-6 weeks (primary anastomosis in two patients, Foker's-technique in one patient, one patient deceased prior to secondary surgery). All three surviving patients required fundoplication due to severe gastro-esophageal reflux during the first year of life. Two patients also required dilatation for anastomotic stricture. In one preterm infant correction of both malformations was accomplished during one surgical intervention. The herniated organs were eventrated and temporarily placed into a silastic bag to allow a mediastinal shift to the left. Thus a continuous ventilation of the right lung with minimal compression and sufficient oxygenation was possible during esophageal repair via a right-sided thoracotomy and extrapleural approach. No further surgery was required so far.

Conclusions: Definitive surgical correction in newborns with CDH and EA was so far accomplished with multiple surgical interventions. Ligation of TEF via an abdominal approach with repair of CDH followed by delayed repair of EA is prone to stenosis and gastro-esophageal reflux due to loss of esophageal length. With a new combination of established surgical methods a single-staged correction of both malformations is possible. This new approach might help to preserve sufficient length of esophagus to accomplish primary anastomosis without tension and therefore avoid long-term morbidity and repetitive surgeries.
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http://dx.doi.org/10.1016/j.jpedsurg.2015.04.015DOI Listing
August 2015

Use of fully covered self-expandable metal stents for benign esophageal disorders in children.

J Laparoendosc Adv Surg Tech A 2015 Apr 13;25(4):335-41. Epub 2015 Mar 13.

1 Department of Pediatric Surgery, Medical Faculty Mannheim, Heidelberg University , University Medical Center Mannheim, Mannheim, Germany .

Purpose: There is a lack of experience with fully covered self-expandable metal stents (SEMSs) for benign esophageal disorders in children.

Patients And Methods: Eleven children (six boys, five girls) with a median age of 30.5 months (range, 1 month-11 years) who underwent treatment with SEMSs for a benign esophageal condition between February 2006 and January 2014 were recruited to this retrospective study. Etiologies included esophageal atresia with postoperative stricture (n=4), recurrent fistula (n=1), and/or anastomotic leak (n=1), as well as iatrogenic perforation of the esophagus following endoscopy (n=4) or laparoscopic fundoplication (n=1). As part of an interdisciplinary cooperation patients were jointly managed from the Department of Pediatric Surgery and Central Interdisciplinary Endoscopy at our institution.

Results: Median duration of individual stent placement was 29 days (range, 17-91 days). In 4 cases up to four different SEMSs were placed successively over time. There were no complications noted at stent insertion or removal. At follow-up, 6 patients (55%) were successfully treated without further intervention. Two children each (18%) underwent one single dilatation after stent removal and remained well afterward. Three patients (27%) did not improve following stenting and required definite surgery. Minor stent-related complications were noted in 5 cases (45%), including gastroesophageal reflux (n=2), silent stent migration (n=2), and pneumonia (n=1).

Conclusions: SEMSs for benign esophageal disorders in children can be used safely and effectively in selected cases, including esophageal anastomotic strictures, esophageal leaks following primary surgery, or perforations postdilatation. An SEMS can be applied either as an emergency procedure or as an adjuvant treatment further to endoscopy or previous surgery. Establishment of a standardized approach in the pediatric population is mandatory.
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http://dx.doi.org/10.1089/lap.2014.0203DOI Listing
April 2015

Comparison of long-term outcomes between open and laparoscopic Thal fundoplication in children.

J Pediatr Surg 2014 Jul 26;49(7):1069-74. Epub 2014 Feb 26.

Department of Pediatric Surgery, Mannheim Medical School (UMM), University of Heidelberg, Theodor-Kutzer-Ufer 1-3, D-68167 Mannheim, Germany.

Objectives: In recent years laparoscopic fundoplication is increasingly performed in pediatric surgery. The aim of this study was to compare the long-term outcomes between open and laparoscopic Thal fundoplication in children.

Methods: This retrospective study includes children who underwent a Thal fundoplication between 3/1997 and 7/2009. The minimum follow-up time to enter the study was 2 years; the overall median follow-up was 77 months (range, 29-176 months).

Results: A total of 101 patients were included, of which 47 underwent an open and 54 a laparoscopic Thal. Intraoperative problems, early postoperative complications, time to establish enteral feeds and length of stay did not differ among both groups. The mean duration of surgery was significantly less in the open group (OPG) (108.0 (± 7.72) versus 144.1 (± 6.36) minutes; p=0.001) and this was mainly attributed to patients with neurological problems. Severe dysphagia requiring endoscopy was observed in 10 patients, but this did not differ significantly between groups (n=2 in the OPG vs. n=8 in the laparoscopic group (LAPG); p=0.10). Overall 12 patients (11.9%) (6 in each group) required a redo-fundoplication after a median of 18.7 months (range, 6-36 months). In the whole study group, 80 patients (79.2%) were classified as having surgical results being excellent, good or satisfactory and this did not differ significantly between groups.

Conclusions: In the long-term open and laparoscopic Thal fundoplication have similarly good outcomes. The laparoscopic approach can be considered as an alternative, however there is not a clear superiority compared with the open counterpart.
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http://dx.doi.org/10.1016/j.jpedsurg.2014.02.077DOI Listing
July 2014

[Sprain of the ankle].

MMW Fortschr Med 2011 Nov;153(47):41-2

Klinik für Kinderchirurgie der Univ.-Medizin Mannheim.

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November 2011

Biomechanical analysis of a synthetic femoral spiral fracture model: Do end caps improve retrograde flexible intramedullary nail fixation?

J Orthop Surg Res 2011 Sep 18;6:46. Epub 2011 Sep 18.

Department of Paediatric Surgery, Medical Faculty of the University of Luebeck, Ratzeburger Allee 160, Luebeck, 23562, Germany.

Background: Elastic Stable intramedullary Nailing (ESIN) of dislocated diaphyseal femur fractures has become an accepted method for the treatment in children and adolescents with open physis. Studies focused on complications of this technique showed problems regarding stability, usually in complex fracture types such as spiral fractures and in older children weighing > 40 kg. Biomechanical in vitro testing was performed to evaluate the stability of simulated spiral femoral fractures after retrograde flexible titanium intramedullary nail fixation with and without End caps.

Methods: Eight synthetic adolescent-size femoral bone models (Sawbones® with a medullar canal of 10 mm and a spiral fracture of 100 mm length identically sawn by the manufacturer) were used for each group. Both groups underwent retrograde fixation with two 3.5 mm Titanium C-shaped nails inserted from medial and lateral entry portals. In the End Cap group the ends of the nails of the eight specimens were covered with End Caps (Synthes Company, Oberdorf, Switzerland) at the distal entry.

Results: Beside posterior-anterior stress (4.11 Nm/mm vs. 1.78 Nm/mm, p < 0.001), the use of End Caps demonstrated no higher stability in 4-point bending compared to the group without End Caps (anterior-posterior bending 0.27 Nm/mm vs. 0.77 Nm/mm, p < 0.001; medial-lateral bending 0.8 Nm/mm vs. 1.10 Nm/mm, p < 0.01; lateral-medial bending 0.53 Nm/mm vs. 0.86 Nm/mm, p < 0.001) as well as during internal rotation (0.11 Nm/° vs. 0.14 Nm/°, p < 0.05). During compression in 9°- position and external rotation there was no statistical significant difference (0.37 Nm/° vs. 0.32 Nm/°, p = 0.13 and 1.29 mm vs. 2.18 mm, p = 0.20, respectively) compared to the "classic" 2-C-shaped osteosynthesis without End Caps.

Conclusion: In this biomechanical study the use of End Caps did not improve the stability of the intramedullary flexible nail osteosynthesis.
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http://dx.doi.org/10.1186/1749-799X-6-46DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3191472PMC
September 2011

Preventive antireflux surgery in neonates with congenital diaphragmatic hernia: a single-blinded prospective study.

J Pediatr Surg 2011 Aug;46(8):1510-5

Department of Pediatric Surgery, Universitätsklinikum Mannheim, University of Heidelberg, Mannheim 68167, Germany.

Objective: Congenital diaphragmatic hernia (CDH) is known to be a predisposing factor in gastroesophageal reflux (GER) leading to pulmonary and nutritional problems. The aim of this prospective, randomized, patient-blinded study was to evaluate the benefit of antireflux surgery at the time of CDH repair.

Methods: From 2003 to 2009, 79 neonates with left-sided CDH were included. Forty-three had regular hernia closure. Thirty-six patients additionally had fundoplication at hernia repair. Follow-up was at 6, 12, and 24 months after birth with a standardized questionnaire and a thorax radiograph. Patients with clinical signs for GER were evaluated with upper gastrointestinal series and 24-hour pH-metry.

Results: Seventy-nine of 263 patients participated in this prospective trial. Survival rate was 88.61%. The GER symptoms were almost significantly more frequent in the group without concomitant fundoplication at the age of 6 months. At 24 months, the difference between both groups was not significant anymore. Development of body weight in the first 2 years of life was similar in both groups. No complications related to initial antireflux surgery were noted.

Conclusion: Patients profit from fundoplication at CDH repair only within the first year of life. At the present point of this study, simultaneous fundoplication at the time of primary CDH repair cannot be recommended as a standard procedure in all patients with left-sided CDH.
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http://dx.doi.org/10.1016/j.jpedsurg.2011.03.085DOI Listing
August 2011

Outcome of transanal endorectal vs. transabdominal pull-through in patients with Hirschsprung's disease.

Langenbecks Arch Surg 2011 Oct 22;396(7):1027-33. Epub 2011 Jun 22.

Department of Surgery, Division of Pediatric Surgery, University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany.

Introduction: Various outcomes have been reported in patients with Hirschsprung's disease (HD) following transanal endorectal (TERPT) or conventional transabdominal (ABD) pull-through procedures. This study examined postoperative complications and the long-term outcome of TERPT vs. ABD pull-through for HD.

Methods: Records were reviewed for 53 patients over 3 years of age in whom a pull-through procedure was performed for HD (TERPT, n = 24; ABD, n = 29) between 1992 and 2007 at the Departments of Pediatric Surgery, University of Heidelberg and University Hospital of Mannheim, and their families were interviewed and scored via a thorough 15-item, post-pull-through, long-term outcome questionnaire. Total scores ranged from 0 to 40: 0 to 10, excellent; 11 to 20, good; 21 to 30, fair; and 31 to 40, poor. Two-sided Fisher's exact test and analysis of variance were used to compare different variables in patients in the two groups with significance set at p < 0.05. Results are expressed as mean and standard deviation (SD).

Results: Overall scores were similar (TERPT, n = 16, 7.3 +/- 6.6 vs. ABD, n = 23, 4.6 +/- 3.5, p = 0.11) and showed mainly excellent or good long-term outcome for TERPT (93.8%) and ABD (99.7%) pull-through procedures. The incidence of incontinence in children older than 3 years was insignificantly lower in ABD group (TERPT 18.7% vs. ABD 4.3 %, p = 0.15). Regarding the soiling score, however, the soiling tended to be significantly more severe after TERPT than ABD. For the TERPT procedure, the appearance of postoperative constipation, enterocolitis, anastomotic dehiscence, and symptomatic anastomotic stricture was lower but this was not statistically significant. After TERPT, patients started to feed sooner (TERPT 2.8 days vs. ABD 4.4 days, p = 0.005) and operating time (TERPT 133.2 min vs. ABD 204 min, p < 0.001) and hospital stay (TERPT 9.8 days vs. ABD 17.7 days, p < 0.001) were significantly shorter.

Conclusion: We employ the TERPT procedure as the first choice in children with rectosigmoid HD.
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http://dx.doi.org/10.1007/s00423-011-0804-9DOI Listing
October 2011

Elastic Stable Intramedullary Nailing (ESIN), Orthoss® and Gravitational Platelet Separation--System (GPS®): an effective method of treatment for pathologic fractures of bone cysts in children.

BMC Musculoskelet Disord 2011 Feb 12;12:45. Epub 2011 Feb 12.

Department of Pediatric Surgery, University of Luebeck, Luebeck, Germany.

Background: The different treatment strategies for bone cysts in children are often associated with persistence and high recurrence rates of the lesions. The safety and clinical outcomes of a combined mechanical and biological treatment with elastic intramedullary nailing, artificial bone substitute and autologous platelet rich plasma are evaluated.

Methods: From 02/07 to 01/09 we offered all children with bone cysts the treatment combination of elastic intramedullary nailing (ESIN), artificial bone substitute (Orthoss®) and autologous platelet rich plasma, concentrated by the Gravitational Platelet Separation (GPS®)--System. All patients were reviewed radiologically for one year following the removal of the intramedullary nailing, which was possible because of cyst obliteration.

Results: A cohort of 12 children (4 girls, 8 boys) was recruited. The mean patient age was 11.4 years (range 7-15 years). The bone defects (ten humeral, two femoral) included eight juvenile and four aneurysmal bone cysts. Five patients suffered from persistent cysts following earlier unsuccessful treatment of humeral bone cyst after pathologic fracture; the other seven presented with acute pathologic fractures. No peri- or postoperative complications occurred. The radiographic findings showed a total resolution of the cysts in ten cases (Capanna Grade 1); in two cases a small residual cyst remained (Capanna Grade 2). The intramedullary nails were removed six to twelve months (mean 7.7) after the operation; in one case, a fourteen year old boy (Capanna Grade 2), required a further application of GPS® and Orthoss® to reach a total resolution of the cyst. At follow-up (20-41 months, mean 31.8 months) all patients showed very good functional results and had returned to sporting activity. No refracture occurred, no further procedure was necessary.

Conclusions: The combination of elastic intramedullary nailing, artificial bone substitute and autologous platelet rich plasma (GPS®) enhances the treatment of bone cysts in children, with no resulting complications.
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http://dx.doi.org/10.1186/1471-2474-12-45DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3046000PMC
February 2011

Intramedullary nailing for metacarpal 2-5 fractures.

J Pediatr Orthop B 2009 Nov;18(6):296-301

Department of Pediatric Surgery, Hospital of the University Luebeck, Ratzeburger Allee, Luebeck, Germany.

Twenty-eight patients with 31 closed fractures (27 acute fractures and four with malalignment after conservative treatment) of the metacarpal bones 2-5 were treated with only one elastic stable intramedullary nail and followed prospectively. Treatment protocol was without immobilization or physiotherapy. These patients were reviewed at a mean follow-up time of 15 months for ultrasound results as well as functional outcome concerning complications, pain, range of motion, and grip strength measured with a Vernier-Dynamometer. Satisfaction of the patients was investigated by Clients Satisfaction Questionnaire. Radiographs before nail removal, ultrasound, and clinical examination always showed complete union of the fracture without deviation of axis. All patients gained full range of motion without any limits in daily activity and sports. There was no loss of grip strength compared with the other hand. Patients' satisfaction was very high, especially because of almost no postoperative pain and lack of immobilization. This method can be offered as an effective and safe alternative in the treatment of closed displaced fractures of the 2-5 metacarpus without significant complications.
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http://dx.doi.org/10.1097/BPB.0b013e32832f5abbDOI Listing
November 2009

[Percutaneous closed pin fixation of supracondylar fractures of the distal humerus in children].

Oper Orthop Traumatol 2008 Oct-Nov;20(4-5):297-309

Klinik für Kinderchirurgie, UK S-H Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.

Objective: Prevention of long-term angular and extension deformity of the elbow and restoration of full range of motion.

Indications: Malalignment of > 20 degrees in the sagittal plane in children > 6 years. Rotatory displacement as well as displacement in the frontal plane.

Contraindications: Severe cardiorespiratory diseases.

Surgical Technique: In most cases, a closed reduction is possible. Fixation of the fracture with two percutaneous Kirschner wires from lateral and medial; the pins cross beyond the fracture line and penetrate the metaphyseal cortex.

Postoperative Management: Elbow cast in 90 degrees flexion; the cast has to be split. Removal of cast and pins after 3-4 weeks. Occasionally physiotherapy required.

Results: Between October 2005 and September 2006, 77 supracondylar fractures were treated. According to the classification of von Laer 31 were type I (no displacement), 14 type II, nine type III, and 23 type IV (wide displacement). 34 of them required operative treatment due to nine type III and 23 type IV displacements, as well as two cases with (unstable) type II. In all patients treated surgically, the elbow angle was successfully restored. At follow-up after 8-14 months, 32 had regained full range of motion. In two children, extension/flexion was 0-10-120 degrees and 0-10-140 degrees , respectively. Two deficits of the ulnar nerve due to the operation as well as one deficit of the median nerve and the radial nerve due to the initial trauma recovered completely. According to the Flynn Score 32 patients had an excellent outcome; one result was classified as good and one as satisfactory. On the Mayo Performance Score all patients reached 100 of 100 points.
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http://dx.doi.org/10.1007/s00064-008-1402-zDOI Listing
March 2009

Ligamentous rupture of the ACL associated with dislocated fracture of the proximal tibial physis in a 12-year-old boy.

BMC Musculoskelet Disord 2002 5;3. Epub 2002 Feb 5.

Department of Surgery, Vanderbilt University Medical Center, Nashville/TN, USA.

Background: Dislocated fracture of the proximal physeal plate of the tibia with or without metaphyseal fragment is rare in children. This unusual fracture classically excludes rupture of the anterior cruciate ligament due to the ligament's stability. A combination of both injuries has not been previously published in the literature.

Case Presentation: The authors report the case of a 12-year-old boy who presented with a dislocated fracture (Salter-Harris II) of the proximal tibia combined with ligamentous rupture of the anterior cruciate ligament after a sporting accident.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC78999PMC
http://dx.doi.org/10.1186/1471-2474-3-5DOI Listing
October 2003
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