Preface: Neonatal surgery
Article Outline
This issue of Seminars in Paediatric Surgery is dedicated to Neonatal Surgery. The surgical treatment of neonates has enjoyed rapid development during the last 50 years. Neonatal Surgery is an established branch of general surgery, which requires the expertise of dedicated paediatric surgeons.
There has been a steady improvement in the outcome of most neonatal diseases requiring surgery. For example at Great Ormond Street Hospital for Children, London the mortality rate for the most common congenital intestinal obstructions has declined from 50% in the ‘50s and ‘60s to 25% in the ‘60s and ‘70s to a current mortality of less than 5%. The reasons for this improvement can be ascribed to a better understanding of the physiology of surgical neonates, to the advances in fluid management, nutrition, mechanical ventilation and not least to refinements in surgical techniques. In this issue of the journal some important aspects of neonatal surgery are discussed.
The treatment of neonates with oesophageal has been one of the main challenges for paediatric surgeons. At Great Ormond Street Hospital for Children, London the overall survival of babies with oesophageal atresia and oesophageal atresia has significantly improved during the last 10 years. The current survival rate is 93%. Much of this improvement is due to the close collaboration between paediatric surgeons, neonatologists, intensivists, anaesthetists and nurses. In this issue Rothenberg (pages 2–7) presents his experience with the thoracoscopic repair of oesophageal atresia. This challenging minimally invasive approach has raised considerable interest among paediatric surgeons and may become more common in the future. Foker et al (pages 8–15) presents his experience with oesophageal lengthening, a technique that can avoid oesophageal replacement in long-gap oesophageal atresia. This remains a new technique and further studies will be required to prove its effects on long-term oesophageal function.
Many lung lesions are diagnosed antenatally by fetal ultrasound. Laberge et al (pages 16–33) present their approach to the management of asymptomatic lung malformations. The natural history of these anomalies as well as the diagnostic and therapeutic approach are debated.
Gastro-oesophageal reflux is common in newborn infants. Antireflux surgery is occasionally required in the neonatal period and during early infancy in the presence of severe GOR symptoms that persist despite medical treatment. Pacilli et al (pages 34–41) present a review of the literature on the results of fundoplication for gastro-oesophageal reflux in neonates and infants. It is apparent from this review that the best results are achieved in neonates with gastro-oesophageal reflux not associated with other anomalies. The real benefit of laparoscopic fundoplication in this age group needs to be demonstrated.
Biliary atresia remains a serious and potentially fatal disease of infants. Davenport (pages 42–48) discusses the recent advances in the understanding of the pathophysiology of the disease as well as in the diagnosis and treatment. The recent results obtained in the three designated centres for the treatment of the disease in England and Wales indicate that outcome can be improved by centralisation of treatment.1
Necrotizing enterocolitis is the commonest surgical emergency in the neonatal period affecting 0.5% of all live births and 3–5% of low-birth-weight live births. Although primarily a disease of the pre-term infants, 6–13% of the affected neonates are full-term. The ethilogy of the disease remains still unclear. Hackam et al (pages 49–56) present an extensive review of the pathogenesis of necrotizing enterocolitis with particular reference to enterocyte signalling and intestinal barrier dysfunction.
Surgical conditions of the neonate are often difficult because of their rarity. The megacystis microcolon hypoperistalsis syndrome is one of this rare and challenging conditions. Puri and Shinkai (pages 58–63) have reviewed the pathogenesis and the clinical findings of this complex anomaly.
The management of Hirschsprung’s disease has always been of great interest to paediatric surgeons. Advances in this field have been characterised by the introduction of the one-stage pull-through without stoma and by the introduction of minimally invasive procedures. In this issue of the journal Dasgupta et al (pages 64–71) report the experience with the use of the transanal pull-through.
Controversies exist on the best modality of treatment of neonates with congenital diaphragmatic hernia, an anomaly still presenting considerable mortality in neonates. A Cochrane review has investigated the role of extracorporeal membrane oxygenation (ECMO) in neonates with severe respiratory failure. ECMO offers short term benefits but the overall effect of employing ECMO in neonates with congenital diaphragmatic hernia is not clear.2 In this issue of the journal Harrington et al (pages 72–76) discuss the role of ECMO in the treatment of neonates with congenital diaphragmatic hernia. This review indicates that a large, multicentre randomized trial is needed to determine whether ECMO is really beneficial in neonates with diaphragmatic hernia.
Although several randomised controlled trials have been performed in adult patients to investigate the role of surgery in their management, very few trials have been performed in neonatal surgery.3 According to the epidemiologist A. Cochrane, the introduction of new therapeutic procedures should always be supported by randomised controlled trials demonstrating their superiority over existing treatment.4 I hope that future advances in neonatal surgery will be characterised by the introduction of collaborative multicentre randomised controlled trials.
References
- Seamless management of biliary atresia in England and Wales (1999–2002) . Lancet . 2004;363(363):1354–1357
- . Extracorporeal membrane oxygenation for severe respiratory failure in newborn infants (Cochrane Review) . In: The Cochrane Library (Issue 1) . Oxford: Update Software; 2003;
- . Evidence-based operations in paediatric surgery . Pediatr Surg Int . 1998;13:331–335
- . Archie Cochrane in his own words. Selections arranged from his 1972 introduction to “Effectiveness and Efficiency: Random Reflections on the Health Services” 1972 . Control Clin Trials . 1989;10:428–433
PII: S1055-8586(05)00016-8
doi:10.1053/j.sempedsurg.2005.02.001
© 2005 Elsevier Inc. All rights reserved.
