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A special issue of Children (ISSN 2227-9067). This special issue belongs to the section "Pediatric Surgery".

Deadline for manuscript submissions: closed (25 March 2022) | Viewed by 34766

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Special Issue Editor

Dr. Jurgen Schleef

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Guest Editor

Department of Pediatric Surgery and Urology, Institute of Maternal and Child Health - IRCCS "Burlo Garofolo", 34137 Trieste, Italy
Interests: endoscopic surgery; prenatal diagnostics and counselling; pulmonary malformation; short bowel; bacterial translocation
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

Dear Colleagues,

It is a great honor to serve as the Guest Editor for this Special Issue of Children, entitled “Abdominal Surgery in Pediatrics”.

Pediatric abdominal surgery is a vast field. The younger the child, the higher the incidence of connatal malformations as a reason for surgery. Nevertheless, malignant diseases of solid organs, a continuously rising number of inflammatory diseases in children and adolescents, represent an important issue. Finally, acute abdominal diseases such as appendicitis, intussusception, volvulus, and all kinds of herniation are important topics. The strategies in surgical therapy are continuously changing, and are under discussion. Minimally invasive approaches, interdisciplinary treatment strategies, robotics, endoscopic surgery, and new techniques are of great interest. Not all of these “new” strategies are validated and always better just because they are new and popular.

The goal of this Special Issue is to discuss any of these mentioned topics and to share experiences.

Surgeons and researchers are invited and should be stimulated to contribute their manuscripts. The contributions can be of different character: experimental papers, review articles, systemic reviews, proposals for new strategic approaches, and prospective/retrospective case studies. Please avoid single case reports.

I look forward to receiving your contributions.

Dr. Jurgen Schleef
Guest Editor

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Children is an international peer-reviewed open access monthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2400 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

acute abdominal disease
surgical technique
complications in abdominal surgery
interdisciplinary strategies
long-term follow up
inflammatory bowel disease
metabolic aspects of abdominal surgery

Published Papers (13 papers)

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Research

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8 pages, 472 KiB

Open AccessArticle

Early Bowel Lengthening Procedures: Bi-Institutional Experience and Review of the Literature

by Elisa Negri, Riccardo Coletta, Lynette Forsythe, Francesca Gigola, Maria Chiara Cianci and Antonino Morabito

Children 2022, 9(2), 221; https://0-doi-org.brum.beds.ac.uk/10.3390/children9020221 - 07 Feb 2022

Cited by 1 | Viewed by 1260

Abstract

Early bowel lengthening procedure (EBLP) has been defined as any bowel lengthening procedure performed before six months of age. The purpose of this paper is to compare our experience with literature on this subject to identify common indications. A bi-institutional retrospective analysis was performed. Diagnosis, type of surgery, age at procedure and outcomes were analysed. Eleven EBLP were performed in Manchester and Florence from 2006 to 2021. The median age at surgery was 126 days (102–180), pre-operative median short bowel (SB) length was 28 cm (17–49) with a post-operative median increase of 81%. Furthermore, a PubMed/Embase search was undertaken regarding bowel lengthening procedures performed in the last 40 years. Sixty-one EBLP were identified. The median age was 60 days (1–90). Serial transverse enteroplasty (STEP) was the most frequent procedure used, with a median increased bowel length of 57%. This study confirms that no clear consensus on indication or timing to perform early SB lengthening is reported. According to the gathered data, EBLP should be considered only in cases of actual necessity and performed in a qualified intestinal failure centre. Full article

(This article belongs to the Special Issue Abdominal Surgery in Pediatrics)

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7 pages, 584 KiB

Open AccessArticle

Minimizing Enterostomy Complication in Neonates, Lessons Learnt from Three European Tertiary Centres

by Riccardo Coletta, Andrea Zulli, Kathryn O’Shea, Elisa Mussi, Adrian Bianchi and Antonino Morabito

Children 2022, 9(2), 162; https://0-doi-org.brum.beds.ac.uk/10.3390/children9020162 - 27 Jan 2022

Cited by 2 | Viewed by 4846

Abstract

Introduction. Stoma formation in neonates is often a life-saving procedure across a variety of conditions but is still associated with significant morbidity. Tube stoma technique was originally described for short bowel patients, but in selected cases of neonates this approach could prevent the incidence of stoma-related complications. The aim of the study was to evaluate the safety and utility of tube stomas as an alternative to conventional enterostomy in the neonatal population. Material and Methods. A retrospective multicentre analysis of neonates undergoing emergency laparotomy and tube stoma formation between 2005 and 2017 was performed. Tube stoma complications were analysed. The investigation focused on stricture, skin lesion, enteric fistula and prolapse. Results. Thirty-seven neonates underwent tube stoma fashioning during the study period. Tube-stoma complications were limited to three patients (8.1%), with two children (5.4%) requiring additional stoma surgery during the first 30 days because of an enterocutaneous fistula, and one child (2.7%) for bowel stenosis. Conclusions. In select neonates, such as those with proximal enteric stomas, the tube stoma avoids some of the commonly encountered complications (prolapse, skin excoriation). Further prospective studies are needed to validate these findings in order for us to recommend this technique as superior. Full article

(This article belongs to the Special Issue Abdominal Surgery in Pediatrics)

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9 pages, 1992 KiB

Open AccessArticle

The Length of the Transition Zone in Patients with Rectosigmoid Hirschsprung Disease

by Christian Tomuschat, Stefan Mietzsch, Sebastian Dwertmann-Rico, Till Clauditz, Hansjoerg Schaefer and Konrad Reinshagen

Children 2022, 9(2), 152; https://0-doi-org.brum.beds.ac.uk/10.3390/children9020152 - 25 Jan 2022

Cited by 3 | Viewed by 2230

Abstract

Background: The transition zone (TZ) is defined by specific histological findings in patients with Hirschsprung Disease (HSCR). HSCR treatment includes surgical removal of the aganglionic zone (AZ). During the pull-through procedure, it is critical to resect the TZ. Given the TZ’s wide histological heterogeneity, we wanted to know how extensive the histological transition zone is. Methods: A retrospective study of patients who had pull-through surgery for rectosigmoid HSCR between January 2010 and December 2020 was carried out. Demographics, length of TZ and AZ, age and symptoms upon presentation, and complications after surgery were also obtained. Results: The inclusion criteria were met by 50 patients. The mean age of all patients was 10 months (0.1–107.5 months), with a mean age at pull-through of 16.3 months (3–112 months). Thirty-one out of fifty patients (62%) received primary laparoscopic endorectal pull-through surgery (LEPT). The average TZ length of all patients was 2.6 cm (0–10 cm), and the AZ length was 9.6 cm (1–30 cm). The length of the AZ and TZ were shown to have no correlation (r² = 0.237). Conclusions: The current study found that the mean length of the TZ in individuals with rectosigmoid HSCR is less than 5 cm in most cases and has no correlation with the length of the AZ. Full article

(This article belongs to the Special Issue Abdominal Surgery in Pediatrics)

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9 pages, 208 KiB

Open AccessArticle

Colectomy Followed by J-Pouch Reconstruction to Correct Total Colonic Aganglionosis

by Konrad Reinshagen, Gunter Burmester, Johanna Hagens, Thomas Franz Krebs and Christian Tomuschat

Children 2022, 9(1), 101; https://0-doi-org.brum.beds.ac.uk/10.3390/children9010101 - 12 Jan 2022

Cited by 1 | Viewed by 1934

Abstract

Background: Patients suffering from complete colonic aganglionosis (TCA) require the best surgical care possible. Only a few studies reported J-Pouch repair as the primary reconstructive surgery in TCA patients. This study adds to the current literature a thorough clinical and functional outcomes group. Methods: Between 2011 and 2021, medical records of Hirschsprung disease (HD) patients who underwent J-Pouch reconstruction during infancy (n = 12) were reviewed. In close follow-up, bowel function and satisfaction with operation results were evaluated. The median age at the time of J-Pouch reconstruction was 16 months, and covering ileostomies were closed four months later. There were no postoperative problems. After the final repair, Pouch-related problems (PRP) occurred in 27% of the children and were treated conservatively. There was no histological evidence of pouchitis in any of the individuals. The median 24-h stooling frequency was 4–5 at the latest follow-up 51 months following enterostomy closure. Conclusions: The current study’s findings support the existing literature and advocate for J-pouch repair in TCA patients. However, more research will be needed to determine the best time to undergo pouch surgery and ileostomy closure in TCA patients. Full article

(This article belongs to the Special Issue Abdominal Surgery in Pediatrics)

10 pages, 257 KiB

Open AccessArticle

Meckel’s Diverticulum in Children: A Monocentric Experience and Mini-Review of Literature

by Matthias Nissen, Volker Sander, Phillip Rogge, Mohamad Alrefai and Ralf-Bodo Tröbs

Children 2022, 9(1), 35; https://0-doi-org.brum.beds.ac.uk/10.3390/children9010035 - 01 Jan 2022

Cited by 1 | Viewed by 1676

Abstract

Vitelline duct anomalies (VDA, including Meckel’s diverticulum (MD)) result from failed embryologic obliteration. This study aimed for characteristics in symptomatic versus asymptomatic VDA, analyzing clinico-laboratory data from 73 children, aged 1 day to 17 years, treated at a tertiary Pediatric Surgery Institution from 2002–2017. A male preponderance was obtained (ratio 3.6:1). MD accounted for 85% of VDA. Incidence of symptomatic VDA decreased with older age. Leading symptoms were intestinal obstruction and hemorrhage. Mucosal heterotopia (present in 39% of symptomatic MD) was associated with anemia and lowered CRP-levels. On ROC-analysis, hemoglobin < 8.6 g/dL, CRP < 0.6 mg/dL and MD distance to ileocecal valve >40 cm were predictors of ectopic tissue in symptomatic MD. Our data confirmed known characteristics as male preponderance, declined incidence of symptomatic cases with age and predominance of gastric ectopia in symptomatic MD. Moreover, anemia and prolonged distance of MD to ileocecal valve were predictors of ectopic mucosa in symptomatic MD. Full article

(This article belongs to the Special Issue Abdominal Surgery in Pediatrics)

11 pages, 2721 KiB

Open AccessArticle

Innovative Techniques Associated with Traditional Abdominal Surgery in Complex Pediatric Cases: A Tertiary Center Experience

by Rebecca Pulvirenti, Costanza Tognon, Silvia Bisoffi, Filippo Ghidini, Federica De Corti, Francesco Fascetti Leon, Luca Maria Antoniello and Piergiorgio Gamba

Children 2021, 8(10), 898; https://0-doi-org.brum.beds.ac.uk/10.3390/children8100898 - 09 Oct 2021

Viewed by 1414

Abstract

Pediatric abdominal surgery is constantly evolving, alongside the advent of new surgical technologies. A combined use of new tools and traditional surgical approaches can be useful in the management of complex cases, allowing less invasive procedures and sometimes even avoiding multiple interventions. This combination of techniques has implications even from the anesthetic point of view, especially in post-operative pain control. Thereby, tertiary level centres, including highly-specialized professionals and advanced equipment, can maximize the effectiveness of treatments to improve the final outcomes. Our paper aims to present some possible combinations of techniques recently used at our institution to provide a one-session, minimally invasive treatment within different areas of abdominal surgery. Full article

(This article belongs to the Special Issue Abdominal Surgery in Pediatrics)

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7 pages, 921 KiB

Open AccessArticle

Extended Adhesion-Sparing Liver Eversion during Kasai Portoenterostomy for Infants with Biliary Atresia

by Filippo Parolini, Giovanni Boroni, Pietro Betalli, Maurizio Cheli, Domenico Pinelli, Michele Colledan and Daniele Alberti

Children 2021, 8(9), 820; https://0-doi-org.brum.beds.ac.uk/10.3390/children8090820 - 17 Sep 2021

Viewed by 1727

Abstract

Background: Despite the fact that Kasai portoenterostomy (KPE) is the primary treatment for biliary atresia (BA), liver transplantation (LT) remains the ultimate surgery for two-thirds of these patients. Their true survival rate with the native liver reflects the original KPE and the burden of post-operative complications. We report an original modification of the adhesion-sparing liver eversion (ASLE) technique during KPE that facilitates the total native hepatectomy at time of transplantation. Methods: All consecutive patients with BA who underwent KPE at our department and subsequent LT at Paediatric Liver Transplant Centre at Papa Giovanni XXIII Hospital between 2010–2018 were retrospectively enrolled. All patients underwent ASLE during KPE. Patients’ demographic data, type of KPE, total transplant time (TTT), hepatectomy time (HT), intra-operative packed red blood cells and plasma transfusions, intra- and post-operative complications were noted. Results: 44 patients were enrolled. Median TTT and HT were 337 and 57 min, respectively. The median volume of packed red blood cell transfusion was 95 mL. No patients presented bowel perforation during the procedure or in the short post-operative course. No mortality after LT was recorded. Conclusions: In addition to the well-known advantages of the standard liver eversion technique, ASLE reduces the formation of intra-abdominal adhesions, lowering significantly the risk of bowel perforation and bleeding when liver transplantation is performed for failure of KPE. Full article

(This article belongs to the Special Issue Abdominal Surgery in Pediatrics)

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10 pages, 216 KiB

Open AccessArticle

Is There a Role for Elective Early Upper Gastrointestinal Contrast Study in Neurologically Impaired Children following Laparoscopic Nissen Fundoplication?

by Thomas M. Benkoe, Katrin Rezkalla, Lukas Wisgrill and Martin L. Metzelder

Children 2021, 8(9), 813; https://0-doi-org.brum.beds.ac.uk/10.3390/children8090813 - 16 Sep 2021

Viewed by 1368

Abstract

Assessment of discomfort as a sign for early postoperative complications in neurologically impaired (NI) children is challenging. The necessity of early routine upper gastrointestinal (UGI) contrast studies following laparoscopic Nissen fundoplication in NI children is unclear. We aimed to evaluate the role of scheduled UGI contrast studies to identify early postoperative complications following laparoscopic Nissen fundoplication in NI children. Data for laparoscopic Nissen fundoplications performed in NI children between January 2004 and June 2021 were reviewed. A total of 103 patients were included, with 60 of these being boys. Mean age at initial operation was 6.51 (0.11–18.41) years. Mean body weight was 16.22 (3.3–62.5) kg. Mean duration of follow up was 4.15 (0.01–16.65 years) years. Thirteen redo fundoplications (12.5%) were performed during the follow up period; eleven had one redo and two had 2 redos. Elective postoperative UGI contrast studies were performed in 94 patients (91%). Early postoperative UGI contrast studies were able to identify only one complication: an intrathoracal wrap herniation on postoperative day five, necessitating a reoperation on day six. The use of early UGI contrast imaging following pediatric laparoscopic Nissen fundoplication is not necessary as it does not identify a significant number of acute postoperative complications requiring re-intervention. Full article

(This article belongs to the Special Issue Abdominal Surgery in Pediatrics)

8 pages, 579 KiB

Open AccessArticle

The Histopathology of the Appendix in Children at Interval Appendectomy

by Federica Pederiva, Rossana Bussani, Vennus Shafiei, Daniela Codrich, Edoardo Guida and Jurgen Schleef

Children 2021, 8(9), 811; https://0-doi-org.brum.beds.ac.uk/10.3390/children8090811 - 16 Sep 2021

Cited by 2 | Viewed by 2615

Abstract

Whilst most surgeons agree that conservative treatment of appendiceal abscess in children is an adequate treatment, the need for subsequent interval appendectomy is still controversial. We analyzed the histopathology in interval appendectomy in search of signs of inflammation. All patients admitted between 2010 and 2017 with appendiceal abscess and scheduled for interval appendectomy were reviewed. The specimens were evaluated for grade of inflammation, type and distribution of cellular infiltrate, presence of necrosis or hemorrhage and infiltrate in the serosa. Forty-two patients had appendiceal abscess and were treated conservatively. Seven underwent emergent appendectomy. Thirty-three out of 35 patients underwent elective interval appendectomy. Thirty-two specimens were revised. Carcinoid tumor or other malignant lesions were not found. All of them presented some amount of inflammation, grade 1 to 2 in 53%, grade 3 to 4 in 47%. Twenty-five percent of the specimens had signs of necrosis accompanied by hemorrhage and in more than the half (53%) the infiltrate extended to the serosa. Conclusions: Although the appendix was mostly found not macroscopically inflamed intraoperatively, histology confirmed a certain grade of inflammation even months after the conservative treatment. No correlation was found between histopathologic findings and lapse of time between abscess treatment and interval appendectomy. Full article

(This article belongs to the Special Issue Abdominal Surgery in Pediatrics)

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10 pages, 429 KiB

Open AccessEditor’s ChoiceArticle

Validity of Appendicitis Inflammatory Response Score in Distinguishing Perforated from Non-Perforated Appendicitis in Children

by Zenon Pogorelić, Jakov Mihanović, Stipe Ninčević, Bruna Lukšić, Sara Elezović Baloević and Ozren Polašek

Children 2021, 8(4), 309; https://0-doi-org.brum.beds.ac.uk/10.3390/children8040309 - 19 Apr 2021

Cited by 28 | Viewed by 4962

Abstract

Background: This prospective observational study aimed to evaluate the validity of appendicitis inflammatory response (AIR) score in differentiating advanced (perforated) from simple (non-perforated) appendicitis in pediatric patients. Methods: A single-center prospective cross-sectional study was conducted between 1 January 2019 until 1 May 2020 including 184 pediatric patients who underwent appendectomy. Based on the intraoperative finding of advanced (n = 38) or simple (n = 146) appendicitis the patients were divided into two groups. Recipient-operator curve (ROC), with calculation of sensitivity and specificity of best cutoff and the area under the curve (AUC), were used to measure the diagnostic value and the potential for risk stratification of the AIR score, among the patients with simple or advanced acute appendicitis. Results: The median value of the AIR score in the perforated and non-perforated groups was 10 (interquartile range, IQR 9, 11), and was 7 (IQR 6, 9), respectively (p < 0.001). Based on the calculated value of AIR score, the patients were classified with a high precision into low, indeterminate and high risk groups for acute appendicitis (p < 0.001). A cutoff value of ≥9 was demonstrated to serve as a reliable indicator of perforated appendicitis with a sensitivity and a specificity of 89.5% and 71.9%, respectively (AUC = 0.80; 95% CI: 0.719–0.871; p < 0.001). Conclusions: Acute appendicitis can be detected with a high level of sensitivity and specificity using the AIR score. Also, the AIR score may differentiate perforated from non-perforated appendicitis in pediatric patients with a high level of accuracy. Full article

(This article belongs to the Special Issue Abdominal Surgery in Pediatrics)

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9 pages, 262 KiB

Open AccessReview

Update on Metabolic Bariatric Surgery for Morbidly Obese Adolescents

by Holger Till, Oliver Mann, Georg Singer and Susann Weihrauch-Blüher

Children 2021, 8(5), 372; https://0-doi-org.brum.beds.ac.uk/10.3390/children8050372 - 09 May 2021

Cited by 5 | Viewed by 3210

Abstract

Despite worldwide public attention and intense medical efforts, the prevalence of severe morbid obesity in children and adolescents is still rising. Similar to adults, excess adipose tissue triggers multiple immunological and metabolic pathways leading to serious co-morbidities such as impaired glucose tolerance or even type 2 diabetes (T2D), dyslipidemia, arterial hypertension, non-alcoholic fatty liver disease, and hyperuricemia. The management of severe childhood obesity requires a life-long multidisciplinary approach with a combination of lifestyle changes, nutrition, and medications. Standardized life-style intervention programs remain the first-line treatment for morbid obese children and adolescents, but unfortunately reveal limited long-term success. In such cases, metabolic bariatric surgery (MBS) has evolved from being a controversial issue to being included in distinct recommendations. According to the American Society for Metabolic and Bariatric Surgery (ASMBS) Pediatric Committee, indications for bariatric surgery in adolescence must follow very strict criteria. Adolescents with class II obesity (BMI > 120% of the 95th percentile) and a diagnosed co-morbidity or with class III obesity (BMI ≥ 140% of the 95th percentile) should be considered for MBS. These interventions represent high-risk operations, and adolescents should be treated in specialized, multidisciplinary high-volume obesity centers with long-term follow-up programs. The Roux-en-Y gastric bypass (RYGB) remains the gold standard of all malabsorptive procedures. Laparoscopic sleeve gastrectomy (LSG), which the authors pioneered as a stand-alone procedure in morbidly obese adolescents in 2008, has become the most commonly performed operation in morbidly obese adolescents at present. Recent literature proves that MBS is safe and effective in morbidly obese adolescents. Mid-term data have revealed significant improvement or even resolution of major co-morbidities. Thus, MBS for the treatment of morbidly obese adolescents has evolved from being a controversial issue to being included in distinct recommendations by several medical societies as a therapeutic strategy to reduce severe co-morbidities potentially causing end-organ damage in adulthood. Full article

(This article belongs to the Special Issue Abdominal Surgery in Pediatrics)

Other

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12 pages, 3135 KiB

Open AccessCase Report

Laparoscopic–Endoscopic “Rendezvous” Procedure in Pediatric Gastrointestinal Surgery—Case Series

by Radoica Jokić, Jelena Antić, Svetlana Bukarica, Miloš Pajić and Ivana Fratrić

Children 2021, 8(9), 770; https://0-doi-org.brum.beds.ac.uk/10.3390/children8090770 - 01 Sep 2021

Viewed by 1761

Abstract

Laparoscopic–endoscopic “rendezvous” procedures were introduced in surgery for common bile duct stone treatment but are now widely used in other fields of abdominal surgery. An endoscopist navigates a surgeon during the same operative procedure and, thus, enables a better visualization of the location, resection margins, bleeding control, less thermal damage, etc. Here, we present case series of 11 patients that were treated using a “rendezvous” procedure for gastrointestinal lesions on different parts of the gastrointestinal tract such as juvenile polyps on the colon (transversum, ascendens, cecum, sigma), leiomyomatosis of the stomach, Peutz–Jeghers intestinal polyposis, hyperplastic gastric polyp, ectopic pancreatic tissue in the stomach, gastric trichobezoar, and gastric schwannoma. “Rendezvous” procedures are suitable for intestinal lesions that could not be resected endoscopically due to their size, morphology and/or location. In our experience this procedure should be used for endoscopically unresectable lesions as it decreases the time of surgery, possibility of iatrogenic injury, bleeding and technical inability. Furthermore, this procedure has been shown to better navigate the surgeon during laparoscopic surgery, especially in treating polyps in particularly difficult locations such as the duodenum or cecum, and it decreases conversion rates. However, conversion is sometimes necessary, in order to assure all oncological principals are respected, and the best option in some cases. Full article

(This article belongs to the Special Issue Abdominal Surgery in Pediatrics)

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10 pages, 945 KiB

Open AccessCase Report

Massive Gastric Hemorrhage after Indomethacin Therapy: A Rare Presentation and Critical Management in an Extremely Preterm Infant

by Yen-Ju Chen, Wei-Ying Chu, Wen-Hao Yu, Chau-Jing Chen, Shu-Ti Chia, Jieh-Neng Wang, Yung-Chieh Lin and Yu-Jen Wei

Children 2021, 8(7), 545; https://0-doi-org.brum.beds.ac.uk/10.3390/children8070545 - 24 Jun 2021

Cited by 1 | Viewed by 3524

Abstract

Indomethacin has been widely used in preterm infants with hemodynamically significant patent ductus arteriosus (PDA). Gastrointestinal complications of indomethacin have been reported in 5% of treated neonates. However, massive gastric mucosa hemorrhage is a rarely reported complication. To the best of our knowledge, the infant in this report is the smallest reported in the literature to have undergone successful surgery for such a complication. A male preterm infant weighing 566 g was born at 25^2/7 weeks of gestational age without a complicated maternal history. Soon after birth, he received nasal noninvasive respiratory support and minimal feeding. PDA was observed since the first day of life (DOL), treatments were initiated on the second DOL for the hemodynamical significance, and PDA was closed after two courses of indomethacin therapy (0.2 mg/kg). At midnight on the seventh DOL, generalized pallor, bloody gastric drainage, and a distended stomach were observed. Massive gastric bleeding was suspected. He suffered from intermittent hypotension, which was corrected with blood products and fluid resuscitation under monitoring with a radial arterial line. Gastric lavage with cooling saline was performed twice but in vain. Prior to surgical consultation, intravascular volume transfusion was given twice. An exploratory laparotomy was arranged after obtaining the parents’ consent. Blood oozing from the gastric mucosa was observed through gastrostomy and was successfully stopped via epinephrine-soaked gauze compression. After the operation, his clinical course remained uneventful, and he was discharged without neurological anomaly at two-year follow-up. Physicians need to be cautious of indomethacin’s effect on platelet dysfunction in preterm infants with multiple predisposing factors. The tendency for mucosal bleeding should be continuously monitored after indomethacin therapy. Full article

(This article belongs to the Special Issue Abdominal Surgery in Pediatrics)

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