Editorial: Advances and challenges in neonatal surgery: congenital and acquired conditions

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Congenital anomalies (CA) requiring surgery represent the fourth leading cause of death in children under 5 years of age in 2019, accounting for 9.4% of global deaths. 1 Prematurity is a high-risk condition for morbidities, some of which requires surgical intervention, such as necrotizing enterocolitis (NEC) or post-hemorrhagic hydrocephalus (PHH) following intraventricular hemorrhage (IVH). Improving survival of infants with neonatal surgical conditions (NSCs) is challenging, and advances in diagnostic techniques and surgical strategies are needed. To this end, Frontiers developed a Research Topic titled "Advances and Challenges in Neonatal Surgery: Congenital and Acquired Conditions" to focus on different aspects of the management of NSCs.CA impact healthcare costs, although the overall financial impact of infants with CA requiring surgery is not fully known. Jeon et al. 2 found that surgical care of CA in infants was associated with significant healthcare utilization, accounting for $4.8 billion (73.4%) of all inpatient charges in 2021 in Texas, despite representing a minority of admissions.The management of NSCs also requires long-term neurological follow-up and rehabilitative therapy. Lowdermilk et al. 3 reported a high incidence of neurodevelopmental delay documented as early as the first six months of life in infants with esophageal atresia (EA), regardless of gestational age, type of surgery, concurrent anomalies, and frequency of early patient and family support. Similarly, Bai et al. 4 found neurodevelopment problems in infants with congenital diaphragmatic hernia (CDH), highlighting how pulmonary hypoplasia may negatively impact neurodevelopment.NEC is one of the most life-threatening gastrointestinal emergencies in neonates, involving mainly preterm infants, although the presence of CA may trigger its onset, as reported by Zhang et al. 5 and by Wang et al. 6 NEC requires a multimodal evaluation including clinical signs, laboratory markers, and imaging to guide timely and individualized surgical decision-making. Shang et al. 7 identified peritonitis, portal venous gas, and elevated inflammatory markers as independent risk factors for early surgical intervention in neonates with NEC. Particularly, the authors found that interleukine-6 demonstrated the highest predictive accuracy, suggesting its potential value as an objective biomarker for surgical timing.Limiting resection to necrotic bowel, preserving viable bowel after NEC, is crucial to avoid complications such as anastomotic leakage and short bowel syndrome. Pfennigs et al. 8 suggested that indocyanine green fluorescent imaging could be a reliable method for visualizing intestinal perfusion in real time, improving the assessment of intestinal viability during laparotomy, overcoming the limitations of standard visual inspection.Temporary enterostomy serves as a crucial surgical procedure for treating several NSCs. Despite advancements in surgical techniques and perioperative management, complications related to the enterostomy still remain high. Zeng et al. 9 identified smaller weight at surgery, small intestinal stoma, and longer duration of postoperative high-level C-reactive protein as independent risk factors for enterostomy-related complications and constructed a risk prediction model in infants with stomas.Focusing on NEC, Tomaselli et al. 10 provided a comprehensive review on the use of mesenchymal stromal cells and their derivatives, such as exosomes or secretomes, for the treatment of this neonatal intestinal emergency, emphasizing the need to generate more robust and comparable results to facilitate their translation to the bedside.Liu J et al. 11 observed that robotic-assisted surgery can significantly improve efficiency in the more complex suturing steps during hepaticojejunostomy, also offering a smoother learning curve compared to conventional laparoscopic surgery. Although this observation was based on a retrospective study, it highlighted the potential advantage of robotic-assisted surgery for complex paediatric procedures.Neonatal thoracoscopic repair of EA requires one-lung ventilation (OLV), which requires finding strategies to limit volotrauma and barotrauma. Kaimin et al. 12 compared pressure-controlled ventilation with volume guarantee (PCV-VG) with conventional volume-controlled ventilation (VCV) for improving respiratory outcomes during OLV, observing that PCV-VG offered better ventilation parameters and faster recovery in thoracoscopic repair of neonatal EA, while not affecting postoperative complication rates.Brandau et al. 13 reported a case that highlighted the potential complications associated with thoracoscopic clip closure of tracheoesophageal fistula, showing an alternative closure through the application of endoscopic transfixing sutures.Youssef et al. 14 presented their single-center experience with the surgical management of PHH in premature infants, hypothesizing a possible advantage of ventricular access devices over other temporary surgical measures, such as ventriculosubgaleal shunts and external ventricular drainage, in terms of neurological outcomes.Zhang et al. 15 shared their experience with prenatal ultrasound (US) diagnosis of fetal cervical masses, highlighting how prenatal US can accurately assess the size and location of the cervical mass and dynamically monitor fetal airway pressure and amniotic fluid flow. Prenatal US, combined with fetal MRI, seemed to be useful for choosing the mode of delivery, such as the ex-utero intrapartum treatment (EXIT) and planning postpartum management.The EXIT procedure is a surgical technique used during caesarean section to perform life-saving fetal interventions while maintaining placental circulation. A narrative review by Gaffuri et al. 16 emphasized that the success of EXIT depends on accurate prenatal diagnosis via fetal US and MRI, and that neonatal mortality and complications vary depending on the indications and postnatal management.Zhuang et al. 17 aimed to identify risk factors for significant liver fibrosis in prenatally diagnosed choledochal cysts (CDCs), identifying type IV CDCs and GGT > 327 U/L as risk factors suggesting the need for close clinical monitoring and timely surgical intervention.Wang et al. 18 reported their experience with two-dimensional and three-dimensional prenatal US diagnosis of congenital ear anomalies. They found that prenatal US can be useful for identifying fetal ear deformities and associated craniofacial anomalies, representing a valuable tool for providing essential information for clinical management and prenatal counseling.The appropriate length of dilated segment resection (DSRL) in Hirschsprung's disease (HSCR) remains a matter of debate, and its correlation with postoperative clinical outcomes has not yet been clarified. Jia et al. 19 explored the relationship between DSRL and short-term clinical outcomes in HSCR. The authors found that not only DSRL, but also the length of aganglionosis, were relevant to outcomes. For short-segment HSCR, DSRL, total length of bowel resection and length of aganglionosis did not show a significant impact on short-term clinical outcomes. In contrast, these parameters in long-segment HSCR were significantly associated with fecal incontinence and perianal erosion, although overall patient quality of life remained satisfactory. Furthermore, the results of this study suggested that optimal clinical outcomes were associated with a DSRL of 7.25 cm for shortsegment HSCR and 13.00 cm for long-segment HSCR.Youssef et al. 20 observed that delayed extubation in infants undergoing extramucosal pyloromyotomy was associated with metabolic alkalosis, hypothesizing that metabolic disturbances, particularly alkalosis, may influence respiratory drive.Zhou et al. 21 and Cai et al. 22 emphasized that multidisciplinary management is essential to address life-threatening neonatal surgical conditions, such as extrarenal malignant rhabdoid tumor and

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