The Nuss procedure is a minimally invasive method for the correction of pectus excavatum, with several centers reporting its successful application. Complications related to the Nuss procedure are not uncommon and life-threatening complications have been reported. This study focuses on the incidence and management of complications in a series of 167 children and adults with funnel chest corrected by Nuss procedure. Guidelines and strategies to avoid the most common and typical complications are proposed. All patients with funnel chest, operated between April 2000 and 2006 were evaluated prospectively. Our surgical approach involved the submuscular insertion of the pectus bar under right-sided thoracoscopic control. The bar was secured in most cases with one stabilizer on the right side on the underlying rib to prevent bar displacement. Postoperative pain was primarily managed by epidural catheters. All data in the patient report forms was prospectively entered in a database. All complications were documented and classified into major or minor complication. A major complication was noted, if an organ injury occurred or if a significant surgical intervention became necessary. A minor complication was documented, if either an endoscopy or an evacuation of fluid or gas from the thorax by puncture were necessary. One hundred and sixty seven patients (136 males and 31 females) with a mean age of 16.3 (range 5-40 years) were included in this study. Major complications occurred in seven patients (4.2%) and consisted of one intraoperative heart perforation, one piercing of the liver with the trocar, bar infections (n = 2) and significant bar displacement (n = 3). Minor complications were seen in 122 patients (73.1%) and consisted of breakage of wires used to secure the lateral stabilizer plate (n = 48), pleural effusions (n = 28), intraoperative rupture of the intercostal muscle (n = 15), pericardial tears without clinical significance (n = 7) and lung atelectasia (n = 4). Major complications related to the Nuss procedure were rare but preventable and could mainly be attributed to the learning curve. Most minor complications can be avoided by changing the technique, e.g. fixation of the bar and the stabilizer onto the underlying rib, use of PDS cords instead of metal wires to fix the bar and the stabilizer, entrance into and exit of the thorax medial to the rim of the pectus excavatum, etc. Some complications are related to the technique, such as minor pleural effusion or remaining gas in the thorax. Clear guidelines in regard to the technique are presented to prevent the majority of complications and thereby shorten the learning curve.

Introduction Because many aspects of the management of esophageal atresia (EA) are still controversial, we evaluated the practice patterns of this condition across Europe. Methods A survey was completed by 178 delegates (from 45 [27 European] countries; 88% senior respondents) at the EUPSA-BAPS 2012. Results Approximately 66% of respondents work in centers where more than five EA repairs are performed per year. Preoperatively, 81% of respondents request an echocardiogram, and only 43% of respondents routinely perform preoperative bronchoscopy. Approximately 94% of respondents prefer an open approach, which is extrapleural in 71% of respondents. There were no differences in use of thoracoscopy between Europeans (10%) and non-Europeans (11%, p ¼ nonsignificant). Approximately 60% of respondents measure the gap intraoperatively. A transanastomotic tube (90%)

We conclude that the Nuss procedure was beneficial in adult patients. Dislocation of the pectus bar can be prevented by submuscular placement. The use of corticosteroids may be helpful in case of repeated, uncontaminated pleural effusions. Patient satisfaction and the acceptable number and kind of complications are encouraging.

Pull-through (PT) is performed at diagnosis by 33% or delayed by 67% (4 months or > 5 kg). Awaiting definitive surgery, 77% perform rectal irrigations, 22% rectal dilatation/stimulations, and 33% perform a stoma. The preferred type of PT is the Soave approach (65%), performed with transanal technique by 70% respondents. If symptoms persist after PT, most opt for conservative approach (enemas/laxatives = 76%; botulinum toxin = 27%), 30% would redo the PT. Total colonic aganglionosis: PT is performed in neonates (4%), at 1 to 6 months (29%), 6 to 12 months (37%) or older (30%). If required, a stoma is sited in the ileum (31%), according to intraoperative biopsies (54%), macroscopic impression (13%), and radiology (2%). Duhamel PT is performed by 52%, Soave by 31%, and Swenson by 17%. Overall, 31% would perform a J-pouch. Most aspects of HD management lack consensus with wide variations in obtaining a diagnosis. Transanal Soave PT is the most common technique in standard segment HD. Guidelines should be developed to avoid such variability in management and to facilitate research studies.

Aim The aim of this study is to define patterns in the management of necrotizing enterocolitis (NEC). Methods A total of 80 delegates (81% senior surgeons) from 29 (20 European) countries completed a survey at the European Pediatric Surgeons' Association 2013 annual meeting. Results Overall, 59% surgeons work in centers where > 10 cases of NEC are treated per year. Diagnosis: 76% surgeons request both anteroposterior and lateral abdominal Xrays, which are performed at regular intervals by 66%; 50% surgeons also request Doppler ultrasonography; most frequently used biochemical markers are platelets (99% of surgeons), C-reactive protein (90%), and white cell count (83%). Laparoscopy is performed for diagnosis and/or treatment of NEC by only 8% surgeons. Overall, 43% surgeons reported being able to diagnose focal intestinal perforation preoperatively. Medical NEC: medical NEC is managed by surgical and neonatal teams together in most centers (84%). Most surgeons (67%) use a combination of two (51%) or three (48%) antibiotics for more than 7 days, and keep patients nil by mouth for 7 (41%) or 10 (49%) days. Surgical NEC: In extremely low-birth-weight infants (< 1,000 g) with intestinal