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Purpose: Jejunoileal atresia (JIA) is a rare disease. We aimed to determine the overall incidence of this malformation and associated malformations in a national cohort. Furthermore, we compared the treatment results of this cohort with the current literature.
Methods: Data from the major health insurance company, which covers ∼30% of the German population, were analyzed. All patients with ICD-10-Code Q41.1-9 (atresia of jejunum, ileum, other parts and not designated parts of the small bowel) who underwent any surgical procedure for small bowel were analyzed in a 10-year period between 2007 and 2016.
Results: A total of 435 patients were included in the study. The incidence was 2.1 per 10,000 live births. The male:female ratio was 1:2. Sixty-four percent were premature, 21% had associated cardiac anomalies, 16% had abdominal wall defects, 7% had urogenital malformations, and 7% had cystic fibrosis. Sixty percent of all patients with jejunoileal atresia, 57% of patients with accompanying abdominal wall defects and 72% of patients with associated cystic fibrosis required ostomy as the initial procedure. In 25% of all patients, only one intestinal operation was coded. In 39% of patients, two operations were coded. Twelve percent of all patients required feeding gastrostomy or jejunostomy. Sixteen percent of all patients presented with liver-related complications, i.e., cholestasis or liver insufficiency. Six patients underwent an intestinal lengthening procedure (2 Bianchi, 4 STEP). In five patients, initial lengthening was performed within 1 year after the first intestinal operation. Mortality until 1 year after initial surgery was 5%. Of those who died, 88% were premature, 34% had cardiac anomalies and 16% had abdominal wall defects. None had cystic fibrosis. Patients with ostomy significantly more often needed operative central venous line or operative feeding tube. Short bowel was coded significantly more often in these patients.
Conclusion: Patients with JIA present with low mortality. The rate of ostomies is higher than in literature. To give clinical recommendations for the initial surgical approach, further clinical research is needed.
Congenital diaphragmatic hernia (CDH) is a major congenital malformation with high mortality. Outcome data on larger unselected patient groups in Germany are unavailable as there is no registry for CDH. Therefore, routine data from the largest German health insurance fund were analyzed for the years 2009–2013. Main outcome measures were incidence, survival and length of hospital stay. Follow-up was 12 months. 285 patients were included. The incidence of CDH was 2.73 per 10,000 live births. Overall mortality was 30.2%. A total of 72.1% of the fatalities occurred before surgery. Highest mortality (64%) was noted in patients who were admitted to specialized care later as the first day of life. Patients receiving surgical repair had a better prognosis (mortality: 10.8%). A total of 67 patients (23.5%) were treated with ECMO with a mortality of 41.8%. The median cumulative hospital stay among one-year survivors was 40 days and differed between ECMO- and non-ECMO-treated patients (91 vs. 32.5 days, p < 0.001). This is the largest German cohort study of CDH patients with a one-year follow-up. The ECMO subgroup showed a higher mortality. Another important finding is that delayed treatment in specialized care increases mortality. Prospective clinical registries are needed to elucidate the treatment outcomes in detail.
Inguinal hernia repair (IHR) is a common procedure in childhood. Laparoscopic IHR has been evolving for the last three decades. Although clear advantages have been shown, adaptation in Germany has been slow. We aim to study the current status of pediatric laparoscopic IHR. A survey was sent to all 89 pediatric surgical departments in Germany on current practices and preferences of open versus laparoscopic IHR. Two nationwide databases of administrative claims data from 2019 were analyzed and correlated with responses from the survey. A total of 56% of the pediatric surgical departments supplied data through the quality reports. The recall of our survey was 58% of all pediatric surgery departments. According to the pooled data, laparoscopic IHR was performed in 8.2% of all inpatients treated. Laparoscopic IHR was considered a training procedure in 48% of the departments. Five different laparoscopic techniques were described (most commonly percutaneous closure of the hernia under laparoscopic vision). The choice between open and laparoscopic IHR was mainly determined by the child’s age. Currently, only a minority of German children undergo inguinal hernia repair by laparoscopy. More training opportunities in the form of hands-on and video workshops may lead to more widespread employment of the laparoscopic technique.
Im 20. Jahrhundert entwickelte sich die Kinderchirurgie aus der Allgemeinchirurgie als eigenständiges Fachgebiet, da zunehmend klar wurde, dass Kinder einer anderen Behandlung bedürfen als Erwachsene und andere Rahmenbedingungen benötigen. Während sich die Erwachsenenchirurgie danach in immer mehr Subdisziplinen aufteilte, ist die Kinderchirurgie ein generalistisches chirurgisches Fach geblieben.
Die vorliegende Arbeit analysiert die Entwicklung der Kinderchirurgie in Deutschland im Hinblick auf medizinische und nicht-medizinische Aspekte und die aktuelle Versorgungssituation, letzteres mit einem Vergleich der Ergebnisqualität ausgewählter angeborener Fehlbildungen im internationalen Vergleich.
Für die Analyse wurden Methoden der Versorgungsforschung angewandt. Die beinhaltete insbesondere die Nutzung von öffentlichen Statistiken und Sekundärdaten, die Statistiken der Deutschen Gesellschaft für Kinderchirurgie sowie die Befragung von ausgewählten Gruppen. Die Analyse bezog sich im Detail auf die Anzahl der Einrichtungen, die akademische und nicht akademische Ausrichtung der Leistungserbringer, die regionale Verteilung, die Personalentwicklung, die Verteilung von Patientinnen und Patienten zwischen den Fachgebieten und innerhalb der Kinderchirurgie und die Netzwerkbildung. Weiterhin wurde die Ergebnisqualität ausgewählter angeborener Fehlbildungen im internationalen Kontext analysiert.
Die Kinderchirurgie ist in Deutschland die Hauptdisziplin für die chirurgische Behandlung von Kindern und Jugendlichen geworden. Sie hat eine weitgehende Flächendeckung erreicht. Die Entwicklung wurde dabei von politischen Entscheidungen beeinflusst, was am Beispiel der Stagnation der Niederlassungen und der Zunahme der kinderchirurgischen Einrichtungen nach Änderung der Perinatal-Versorgung gezeigt werden konnte. Das Spektrum der Kinderchirurgie umfasst die allgemeine Kinderchirurgie, die Neugeborenenchirurgie, Kinderurologie, Kindertraumatologie, Thoraxchirurgie, Teile der Kinderneurochirurgie, plastische Kinderchirurgie, operative Kinderonkologie und die Verbrennungsmedizin. Sie geht damit weit über die Versorgung von angeborenen Fehlbildungen hinaus, wenngleich diese im Zentrum der politischen Diskussionen stehen. Die Arbeitsbedingungen in der Kinderchirurgie haben sich in den letzten Jahren konstant geändert. Die Zahl der Kliniken hat kontinuierlich zugenommen, genauso wie die Zahl der Fachärztinnen und Fachärzte. Der Anteil an Frauen und an Teilzeitbeschäftigten stieg ebenfalls. Die Zahl der ausgeschriebenen Stellen nahm in den Jahren 2021 und 2022 deutlich zu. Die Patientenzahl in den Abteilungen nahm insbesondere seit 2017 ab.
Für die Analyse der Ergebnisqualität wurden die Krankheitsbilder Ösophagusatresie, Dünndarmatresie, Colonatresie, Bauchwanddefekte und Zwerchfellhernien gewählt. Für Kinder mit Ösophagusatresie und Bauchwanddefekten konnte aufgrund der spezifischen Prozeduren die dezentrale Versorgung für Deutschland aufgezeigt werden. Der Vergleich der Ergebnisqualität der Versorgung von angeborenen Fehlbildungen zeigte keine schlechteres Mortalität bei den operierten Kindern mit Ösophagusatresie, den Kindern mit Bauchwanddefekten, Zwerchfellhernie und Darmatresien. Die Verweildauer entsprach bei der Ösophagusatresie, den Bauchwanddefekten und Zwerchfellhernie dem internationalen Vergleich, bei den Darmatresien war sie länger. Weiterhin gab es eine vermehrte Anlage von Stomata bei den Darmatresien.
Die Auswertung der Perinatalzentren Level 1 und 2 ergab eine konstant große Anzahl von Zentren ohne Kinderchirurgie am eigenen Standort. Im Bereich der seltenen Erkrankungen zeigte die Zuordnung der Kliniken zu den verschiedenen Zentren keine durchgehende Systematik. Das Gütesiegel „Ausgezeichnet für Kinder“ hatten 26 kinderchirurgische Kliniken, das Gütesiegel „Das schwerbrandverletzte Kind“ erhielten 16 Zentren für schwerbrandverletzte Kinder, 4 Erwachsenenzentren, die auch Kinder behandelten und 6 spezialisierte Kliniken für brandverletzte Kinder.
Zusammenfassend zeigt die Arbeit die erreichte Flächendeckung der Kinderchirurgie, die teilweise durch politische Entscheidungen geprägt ist. Das Spektrum ist weiterhin generalistisch geblieben, auch wenn nicht jede Abteilung alle Anteile des Spektrums abdeckt. Die Versorgung von angeborenen Fehlbildungen erfolgt grundsätzlich dezentral.
We report a case of a 2-day-old neonate with bilious vomiting and abdominal distension. A small bowel obstruction with ileal perforation due to a misplaced clamping of the umbilical cord was apparent before laparotomy. This complication was a sequala after clamping the cord too close to the abdominal wall in a case where there was a hernia into the cord with intestinal content. A herniation of abdominal contents due to an omphalocele minor or a hernia must be taken into consideration during the inspection of the umbilical cord before clamping.
Purpose: Neonatal surgery for abdominal wall defects is not performed in a centralized manner in Germany. The aim of this study was to investigate whether treatment for abdominal wall defects in Germany is equally effective compared to international results despite the decentralized care.
Methods: All newborn patients who were clients of the major statutory health insurance company in Germany between 2009 and 2013 and who had a diagnosis of gastroschisis or omphalocele were included. Mortality during the first year of life was analysed.
Results: The 316 patients with gastroschisis were classified as simple (82%) or complex (18%) cases. The main associated anomalies in the 197 patients with omphalocele were trisomy 18/21 (8%), cardiac anomalies (32%) and anomalies of the urinary tract (10%). Overall mortality was 4% for gastroschisis and 16% for omphalocele. Significant factors for non-survival were birth weight below 1500 g for both groups, complex gastroschisis, volvulus and anomalies of the blood supply to the intestine in gastroschisis, and female gender, trisomy 18/21 and lung hypoplasia in omphalocele.
Conclusions: Despite the fact that paediatric surgical care is organized in a decentralized manner in Germany, the mortality rates for gastroschisis and omphalocele are equal to those reported in international data.
Purpose: The COVID-19 pandemic has led to an unprecedented expansion of telemedicine services worldwide. This study aimed to explore the practice of telemedicine in Pediatric Surgery in Germany, the impact of the pandemic on its development and parents’ and surgeons’ experiences with telemedicine.
Methods: The study is a cross-sectional analysis using three surveys between 6/2020 and 10/2020: (1) all Pediatric Surgery departments of Germany reported whether they provide telemedicine services. (2) Members of the German Society of Pediatric Surgery and (3) families who participated in an outpatient visit by telephone or video with the Department of Pediatric Surgery and Pediatric Urology of the University Hospital Frankfurt completed an anonymous survey on their experience with telemedicine.
Results: 21% of the Pediatric Surgery departments in Germany provided telemedicine, of which 57% started due to the pandemic. The lack of physical examination and face-to-face contact seem to be the major limitations to surgeons and parents. 48% of the parents answered that telemedicine is equal to or better than traditional appointments, while 33% thought that telemedicine is worse.
Conclusions: This study shows that families and doctors alike have had positive experiences with telemedicine and most will continue to use this format after the pandemic.