Comparison of a CO2 (Carbon Dioxide) Laser and Tissue Glue with Conventional Surgical Techniques in Circumcision

Introduction:  CO2 (Carbon Dioxide) laser application in circumcision, for cutting and coagulation, has been reported to have excellent results. Also, tissue glue has been reported to have advantages over sutures for approximation of wound edges. Most previous studies focused on comparisons between CO2 laser and scalpel, or between tissue glue and sutures. This study prospectively compared the results and complications CO2 laser and tissue glue, with standard surgical techniques in circumcision.Methods: Thirty boys were prospectively divided into two groups. Group 1 (n = 17) underwent circumcision by scalpel with approximation of the wound edges using chromic catgut sutures. Group 2 (n = 13) underwent circumcision with CO2 laser and approximation of the wound edges using tissue glue. Patient age, indications for surgery, operative time, wound swelling, bleeding, wound infection, local irritation, pain score, and cosmetic appearance were recorded.Results:  Group 1 had a significantly longer operative time (P= 0.011), higher rate of local irritation (P= 0.016), and poorer cosmetic appearance (P< 0.001) than group 2. Bleeding only occurred in one patient in group 1. There were no significant differences in pain score, wound infection rate, or cost of surgery between the two groups.Conclusions:  CO2 laser and tissue glue have advantages over standard surgical techniques in circumcision, with a significantly shorter operative time, lower rate of local irritation, and better cosmetic appearance. The cost of surgery is similar between the two groups

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Predictors of Surgical Complications and Survival in Pediatric Wilms’ Tumor: A 20-Year Retrospective Study from Two Thai Centers

(1) Background: Wilms’ tumor (WT) is the most common pediatric renal malignancy. Although survival outcomes have improved with multimodal therapy, the optimal sequence of surgery and chemotherapy remains debated, particularly in resource-limited settings. This study evaluates the effect of treatment strategy on surgical complications and survival, utilizing two decades of data from Thai tertiary centers. (2) Methods: A retrospective cohort study was conducted on 83 children who underwent radical nephrectomy for WT between 2002 and 2022 at two university hospitals in Thailand. Patients were grouped by treatment protocol: primary nephrectomy (n = 59) or neoadjuvant chemotherapy (n = 24). Clinical, pathological, operative, and follow-up data were analyzed to identify predictors of surgical complications and survival. (3) Results: Short-term postoperative complications occurred in 16.9% of cases, more frequently in males and in patients with hypoalbuminemia, anemia, or large tumors. Estimated blood loss greater than 5 mL/kg, serum albumin less than 3.5 g/dL, and hemoglobin lower than 10 g/dL were independent predictors of complications. The five-year overall survival (OS) and progression-free survival (PFS) rates were 82.4% and 68.1%, respectively. Patients with unfavorable histology or short-term complications experienced significantly poorer OS. Neoadjuvant chemotherapy was associated with increased nutritional compromise and a trend toward higher complication rates, although it was not directly linked to inferior OS. (4) Conclusions: In pediatric WT, the perioperative nutritional and hematologic statuses significantly influence surgical outcomes. While neoadjuvant chemotherapy may assist in tumor downsizing, it might also compromise surgical fitness. Customized preoperative risk assessment and nutritional support can enhance outcomes, particularly in low- and middle-income countries

Extrahepatic Portal Vein Obstruction in Children: Etiology, Treatment and Long-Term Outcome

Objective: Extrahepatic portal vein obstruction (EHPVO) is a common cause of portal hypertension in children. Informative data about this disease in Thai children is still limited. The objective was to study etiology, clinical presentation, investigation, treatment, result and long-term outcome. Methods: The medical records of patients aged less than 15 years with diagnosis of EHPVO at Siriraj Hospital from 1993 to 2013 were retrospectively analyzed. Results: There were 22 children (13 males and 9 females) with median age at diagnosis 5.1 years. The etiology was idiopathic in more than 50%. The patients had umbilical vein catheterization at least 27.2%. The presenting symptoms were splenomegaly 54.5% and upper gastrointestinal bleeding 45.5%. Doppler ultrasonography showed positive results in 52.6%. Initial endoscopic finding showed esophageal varices (EV) grade I 27.3%, grade II 36.3%, grade III 31.8%, and gastric varices (GV) 4.6%. The indications for endoscopic interventions were pri- mary prophylaxis 30%, secondary prophylaxis 40% and stopping GI bleeding 30%. The interventions included endoscopic sclerotherapy (EST) in 6 cases, esophageal variceal ligation (EVL) in 6 cases, both in 7 cases and glue injection in 1 case. Rebleeding occurred in 50% of secondary prophylaxis and bleeding groups, but none in the primary prophylaxis group. Patients were followed up for a median of 5.3 years. For long term follow-up, massive splenomegaly and hypersplenism were the major concerns. Surgical treatment included splenectomy (3 cases) and distal splenorenal shunt (1 case). None of the patients died from complications. Conclusion: The etiology of EHPVO is unknown in the majority of patients. SCT and EVL had success to control and prevent variceal bleeding and eradicate varices. There is an unsettled issue about management of EHPVO after controlling acute bleeding. Currently, Meso-Rex bypass and distal splenorenal shunt are proposed to be the recommended treatment for suitable cases with reported success in both eradicating varices and controlling hypersplenism, albeit preserving the spleen