The long-term outcome following thoraco-amniotic shunting for congenital lung malformations

AIM OF THE STUDY

Insertion of a thoraco amniotic shunt (TAS) during fetal life is a therapeutic option where there is a high risk of death secondary to large congenital lung malformations (CLM). The aim of this study is to present our center's long-term experience.

METHODS

Retrospective single center review of the period (Jan 2000-Dec 2020). We included all fetuses that underwent TAS insertion for CLM with detailed analysis of those live newborns managed in our center. Data are quoted as median (range).

MAIN RESULTS

Thirty one fetuses underwent 37 TAS insertions at a 25 (20-30) weeks gestational age. This was successful on 1st attempt in 30 (97%) fetuses. In 6 cases a 2nd shunt was required at 6.5 (2-10) weeks following the 1st insertion. Twenty-eight survived to be born. Sixteen (9 male) infants were delivered in our center at 39 (36-41) weeks gestational age and birth weight of 3.1 (2.6-4.2) kg. All infants underwent surgery at 2 (0-535) days (emergency surgery, n = 9; expedited n = 4; elective surgery, n = 3). Final histopathology findings were CPAM Type 1 (n = 14, n.b. associated with mucinous adenocarcinoma, n = 1), CPAM Type 2 (n = 1) and an extralobar sequestration (n = 1). Postoperative stay was 16 (1-70) days with survival in 15/16 (94%). One infant died at 1 day of life secondary to a combination of pulmonary hypoplasia and hypertension. Median follow up period was 10.7 (0.4-20.4) years. Nine (60%) children developed a degree of chest wall deformity though none have required surgical intervention. Clinically, 14/15 (93%) have otherwise normal lung function without limitations of activity, sporting or otherwise. One child has a modest exercise limitation (FVC - 70% predicted).

CONCLUSIONS

TAS insertion is associated with high perinatal survival and should be considered in fetuses at risk of hydrops secondary to large cystic lung malformation. Their long term outcome is excellent although most have a mild degree of chest wall deformity.

Neonatal congenital pulmonary airway malformation associated with mucinous adenocarcinoma and KRAS mutations

AIM OF THE STUDY

Congenital pulmonary airway malformation (CPAM) has an estimated prevalence in Europe of 1.06/10,000 live births with most being detected using maternal ultrasound screening. Malignant transformation is a possible complication though its prevalence is unknown and previous reports have usually been in older children. We reviewed our experience to identify those CPAM cases associated with malignancy.

METHODS

Single centre retrospective review of all surgically treated children with antenatally-detected CPAM, with detailed review of cases associated with malignancy.

MAIN RESULTS

210 infants and children underwent resectional surgery for CPAM during the period 1994-2020, with 43(20.5%) undergoing surgery during the neonatal period. Of these, 3 infants, all males, had undergone surgical resection for respiratory distress (at 3, 4 and 8 days of life) with subsequent histological confirmation as Stocker type 1 CPAM with clear foci of mucinous adenocarcinoma. Subsequent genetic analysis showed somatic KRAS (Kirsten Rat Sarcoma Viral Oncogene) mutations in all three cases. No adjuvant treatment was required, and all are asymptomatic and disease-free at most recent follow-up (8 months, 2 and 6 years) CONCLUSIONS: This series highlights a clear association between type 1 CPAM and mucinous adenocarcinoma with KRAS point mutations, suggesting that the process of carcinogenesis has the potential to start in utero. This underlines the importance of discussing the risk of malignancy in prenatal and postnatal counselling.

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

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 middle-income 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 low-income 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 low-income, 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.

FUNDING

Wellcome Trust.

Major abdominal wall defects in the low- and middle-income setting: current status and priorities

Major congenital abdominal wall defects (gastroschisis and omphalocele) may account for up to 21% of emergency neonatal interventions in low- and middle-income countries. In many low- and middle-income countries, the reported mortality of these malformations is 30-100%, while in high-income countries, mortality in infants with major abdominal wall reaches less than 5%. This review highlights the challenges faced in the management of newborns with major congenital abdominal wall defects in the resource-limited setting. Current high-income country best practice is assessed and opportunities for appropriate priority setting and collaborations to improve outcomes are discussed.

Developing and implementing an interventional bundle to reduce mortality from gastroschisis in low-resource settings

Background: Gastroschisis is associated with less than 4% mortality in high-income countries and over 90% mortality in many tertiary paediatric surgery centres across sub-Saharan Africa (SSA). The aim of this trial is to develop, implement and prospectively evaluate an interventional bundle to reduce mortality from gastroschisis in seven tertiary paediatric surgery centres across SSA. Methods: A hybrid type-2 effectiveness-implementation, pre-post study design will be utilised. Using current literature an evidence-based, low-technology interventional bundle has been developed. A systematic review, qualitative study and Delphi process will provide further evidence to optimise the interventional bundle and implementation strategy. The interventional bundle has core components, which will remain consistent across all sites, and adaptable components, which will be determined through in-country co-development meetings. Pre- and post-intervention data will be collected on clinical, service delivery and implementation outcomes for 2-years at each site. The primary clinical outcome will be all-cause, in-hospital mortality. Secondary outcomes include the occurrence of a major complication, length of hospital stay and time to full enteral feeds. Service delivery outcomes include time to hospital and primary intervention, and adherence to the pre-hospital and in-hospital protocols.  Implementation outcomes are acceptability, adoption, appropriateness, feasibility, fidelity, coverage, cost and sustainability. Pre- and post-intervention clinical outcomes will be compared using Chi-squared analysis, unpaired t-test and/or Mann-Whitney U test. Time-series analysis will be undertaken using Statistical Process Control to identify significant trends and shifts in outcome overtime. Multivariate logistic regression analysis will be used to identify clinical and implementation factors affecting outcome with adjustment for confounders. Outcome: This will be the first multi-centre interventional study to our knowledge aimed at reducing mortality from gastroschisis in low-resource settings. If successful, detailed evaluation of both the clinical and implementation components of the study will allow sustainability in the study sites and further scale-up. Registration: ClinicalTrials.gov Identifier NCT03724214.

Global Surgery Symposium

This article describes the Global Surgery Symposium held within the 65th British Association of Paediatric Surgeons (BAPS) Annual Congress in 2018. Global surgery is a rapidly expanding and developing field and is of particular importance in paediatrics since children account for up to 50% of the population in low- and middle-income countries (LMICs). It is estimated that up to a third of childhood deaths in LMICs are the result of a surgical condition, and congenital anomalies have risen to become the 5th leading cause of death in children less than 5-years of age globally. Trainees in high-income countries (HICs) are increasingly interested in global surgery engagement through clinical placements, research, or education, or a combination of these. There is considerable controversy regarding the ethics, practicalities, usefulness, safety, and sustainability of these initiatives. In addition, there is debate as to whether such placements should occur within the paediatric surgery training pathway. LEVEL OF EVIDENCE: 5 (Expert Opinion).

Improving outcomes for neonates with gastroschisis in low-income and middle-income countries: a systematic review protocol

INTRODUCTION

There is a significant disparity in outcomes for neonates with gastroschisis in high-income countries (HICs) compared with low-income and middle-income countries (LMICs). Many LMICs report mortality rates between 75% and 100% compared with <4% in HICs.

AIM

To undertake a systematic review identifying postnatal interventions associated with improved outcomes for gastroschisis in LMICs.

METHODS AND ANALYSIS

Three search strings will be combined: (1) neonates; (2) gastroschisis and other gastrointestinal congenital anomalies requiring similar surgical care; (3) LMICs. Databases to be searched include MEDLINE, EMBASE, Scopus, Web of Science, ProQuest Dissertations and Thesis Global, and the Cochrane Library. Grey literature will be identified through Open-Grey, ClinicalTrials.gov, WHO International Clinical Trials Registry and ISRCTN registry (Springer Nature). Additional studies will be sought from reference lists of included studies. Study screening, selection, data extraction and assessment of methodological quality will be undertaken by two reviewers independently and team consensus sought on discrepancies. The primary outcome of interest is mortality. Secondary outcomes include complications, requirement for ventilation, parenteral nutrition duration and length of hospital stay. Tertiary outcomes include service delivery and implementation outcomes. The methodology of the studies will be appraised. Descriptive statistics and outcomes will be summarised and discussed.

ETHICS AND DISSEMINATION

Ethical approval is not required since no new data are being collected. Dissemination will be via open access publication in a peer-reviewed medical journal and distribution among global health, global surgery and children's surgical collaborations and international conferences.

CONCLUSION

This study will systematically review literature focused on postnatal interventions to improve outcomes from gastroschisis in LMICs. Findings can be used to help inform quality improvement projects in low-resource settings for patients with gastroschisis. In the first instance, results will be used to inform a Wellcome Trust-funded multicentre clinical interventional study aimed at improving outcomes for gastroschisis across sub-Saharan Africa.

PROSPERO REGISTRATION NUMBER

CRD42018095349.

Care of infants with gastroschisis in low-resource settings

There is great global disparity in the outcome of infants born with gastroschisis. Mortality approaches 100% in many low income countries. Barriers to better outcomes include lack of antenatal diagnosis, deficient pre-hospital care, ineffective neonatal resuscitation and venous access, limited intensive care facilities, poor access to the operating theatre and safe neonatal anesthesia, and lack of neonatal parenteral nutrition. However, lessons can be learned from the evolution in management of gastroschisis in high-income countries, generic efforts to improve neonatal survival in low- and middle-income countries as well as specific gastroschisis management initiatives in low-resource settings. Micro and meso-level interventions include educational outreach programs, and pre and in hospital management protocols that focus on resuscitation and include the delay or avoidance of early neonatal anesthesia by using a preformed silo or equivalent. Furthermore, multidisciplinary team training, nurse empowerment, and the intentional involvement of mothers in monitoring and care provision may contribute to improving survival. Macro level interventions include the incorporation of ultrasound into World Health Organisation antenatal care guidelines to improve antenatal detection and the establishment of the infrastructure to enable parenteral nutrition provision for neonates in low- and middle-income countries. On a global level, gastroschisis has been suggested as a bellwether condition for evaluating access to and outcomes of neonatal surgical care provision.

Resection and Primary Anastomosis in Necrotizing Enterocolitis

Necrotizing enterocolitis (NEC) is the most common surgical emergency in the newborn. Up to half of babies with NEC develop advanced disease requiring surgical intervention. Options include peritoneal drainage under local anaesthetic, enterostomy only, resection and enterostomies, and resection with primary anastomosis. Resection with enterostomies is favoured by many paediatric surgeons but management of neonatal enterostomies can be difficult. The outcome of 26 infants undergoing surgery for advanced NEC over a 2-year period is reviewed.

Resection and primary anastomosis was possible in 18 infants of whom two (11%) died. Recurrent NEC developed in four (22%) and strictures in three (17%) of these infants. An initial enterostomy was fashioned in eight infants, three following resection of necrotic intestine and five as a proximal diverting stoma in infants with pan-intestinal involvement. Five of these eight infants died (63%), giving an overall mortality of 27%.

Primary anastomosis is an effective procedure following resection of grossly involved intestine in infants with NEC. The mortality and morbidity in this series compared well with those reported for staged procedures.

The management of boys under 3 months of age with an inguinal hernia and ipsilateral palpable undescended testis

AIMS

The optimal management for boys under 3 months of age with an indirect inguinal hernia (IIH) and ipsilateral palpable undescended testis (IPUDT) is unknown. We aimed to: 1) determine the current practice for managing these boys across the UK, and 2) compare outcomes of different treatment strategies.

METHODOLOGY

We undertook two studies. Firstly, we completed a National Survey of all surgeons on the British Association of Paediatric Surgeons email list in 2014. Subsequently, we undertook a multi-centre, retrospective, 10-year (2005-2015) review across 4 pediatric surgery centers of boys under 3months of age with concomitant IIH and IPUDT. Primary outcome was testicular atrophy. Secondary outcomes included need for subsequent orchidopexy, testicular ascent and hernia recurrence. Data are presented as median (range). Chi-squared test and multivariate binomial logistic regression analysis were used for analysis; p<0.05 was considered significant.

RESULTS

Survey: Consultant practice varies widely across the UK, with a tendency towards performing concurrent orchidopexy at the time of herniotomy under 3 months of age. Concurrent orchidopexy is favored less in cases where the hernia is symptomatic. Case Series Review: Forty-one boys with 43 concomitant IIH and IPUDT were identified, and all included. 32 (74%) hernias were reducible, 11 (26%) were symptomatic requiring urgent or emergency repair. Post-conceptual age at surgery was 45weeks (36-65). Primary operations included: 29 (67%) open hernia repair and standard orchidopexy, 8 (19%) open hernia repair with future orchidopexy if required, 4 (9%) laparoscopic hernia repair with future orchidopexy if required, 2 (5%) open hernia repair and suturing of the testis to the inverted scrotum without scrotal incision. Variation in atrophy rate between different surgical approaches did not reach statistical significance (p=0.42). Overall atrophy rate was 18%. If hernia repair alone was undertaken (8 open and 4 laparoscopic), the testis did not descend in 8 patients, requiring subsequent orchidopexy (67%); if orchidopexy was undertaken at the time of hernia repair, 1 in 29 required a repeat orchidopexy (3%) (p=0.0001). No hernia recurred.

CONCLUSION

This study suggests that orchidopexy at the time of inguinal herniotomy does not increase the risk of testicular atrophy in boys under 3months of age.

Central Vein Preservation in Critical Venous Access

Introduction The lack of suitable veins in children with critical central venous access requirements is a major obstacle to optimal care and is potentially life-threatening. We present outcomes following the use of vein-preserving (VP) surgical techniques, notably the sheath exchange for tunneled lines (SETL). Materials and Methods A retrospective, single observer analysis of a prospectively maintained departmental logbook as well as the medical records of patients. Two broad groups of central line replacements were identified; those inserted following removal of a previous line and a traditional "plastic-free" (PF) period and those exchanged without such an interval. Results Overall, 19 lines were directly exchanged during the study period and compared with 34 inserted after a PF period. Similar catheter life spans and infection rates were demonstrated in each group; 125 (range, 78-173) days in VP exchanges versus 122 (range, 70-175) days in PF replacements (p = 0.41). Line Sepsis resulting in removal or change of line occurred at 103 (range, 60-147) days in VP group versus 104 (range, 45-164) days in PF (p = 0.73). Conclusion For children with critical venous access requirements, direct line exchange procedures are a robust and reproducible means of vein preservation. The outcomes compare favorably with those following the more traditional removal, a PF period and reinsertion.

Gastroschisis: Bellwether for neonatal surgery capacity in low resource settings?

INTRODUCTION

Economic disadvantage may adversely influence the outcomes of infants with gastroschisis (GS). Gastroschisis International (GiT) is a network of seven paediatric surgical centres, spanning two continents, evaluating GS treatment and outcomes.

MATERIAL AND METHODS

A 2-year retrospective review of GS infants at GiT centres. Primary outcome was mortality. Sites were classified into high, middle and low income country (HIC, MIC, and LIC). MIC and LIC were sometimes combined for analysis (LMIC). Disability adjusted life years (DALYs) were calculated and centres with the highest mortality underwent a needs assessment.

RESULTS

Mortality was higher in the LICs and LMICs: 100% in Uganda and Cote d'Ivoire, 75% in Nigeria and 60% in Malawi. 29% and 0% mortality was reported in South Africa and the UK, respectively. Septicaemia was the commonest cause of death. Averted and non-avertable DALYs were nil in Uganda and Cote d'Ivoire (no survivors). In the UK (100% survival) averted DALYs (met need) was highest, representing death and disability prevented by surgical intervention. Performance improvement measures were agreed: a prospectively maintained GS register; clarification of the key team members of a GS team and management pathway.

CONCLUSIONS

We propose the use of GS as a bellwether condition for assessing institutional capacity to deliver newborn surgical care. Early access to care, efficient multidisciplinary team working, appropriate resuscitation, avoidance of abdominal compartment syndrome, stabilization prior to formal closure and proactive nutritional interventions may reduce GS-associated burden of disease in low resource settings.

Is single incision pediatric endoscopic surgery more painful than standard laparoscopy in children? Personal experience and review of the literature

AIM

It has been speculated that single incision pediatric endoscopic surgery (SIPES) in children could result in more postoperative pain given the device size for a child umbilicus. Herein, we compare the postoperative pain in children who underwent SIPES or standard laparoscopy (SL).

METHODS

Patients who underwent SIPES via Olympus TriPort™ Access system between 2010 and 2011 were prospectively compared with SL controls (similar age, sex and type of operation). Primary endpoint was analgesic requirement (number of doses and dose/kg). A systematic review of the literature included all articles (2008-2012) comparing postoperative pain following transumbilical SIPES and SL in children. Data were analyzed using non-parametric tests.

RESULTS

Ten patients (8 males, median age 9 years, range 4-15) underwent 11 SIPES procedures: appendicectomy (N.=6), orchidopexy (N.=2), cholecystectomy (N.=2), and total colectomy (N.=1). There was no difference in paracetamol requirement between SIPES (median 74 mg/kg, range 14-149) and SL (median 59 mg/kg, range 13-108, P=0.76) patients. Morphine was required by only two patients per group (no difference in dosage or frequency). Eight studies (2010-2012) comparing 334 SIPES vs. 343 SL patients were analysed. Three studies showed advantage of SIPES, and four no difference between SIPES and SL. One randomized trial reported greater pain in SIPES appendicectomy, but no difference with SL once patients were discharged home.

CONCLUSION

SIPES does not seem to be associated with more postoperative pain than SL in children. In appropriate cases, SIPES is a valid alternative to SL for a good range of pediatric procedures.

Interstitial cells of Cajal are decreased in patients with gastroschisis associated intestinal dysmotility

BACKGROUND

Gastroschisis associated intestinal dysmotility (GAID) is poorly understood. Animal experiments suggest that interstitial cells of Cajal (ICC), play an important role.

METHODS

Infants with gastroschisis (GS) and GAID (time to full feed >42days) were selected. Age matched GS and control (NEC, ileal atresia, malrotation, and volvulus) samples from primary (T1) and secondary (T2) time points underwent standard histopathology and immunohistochemistry for identification of ICC, followed by evaluation of ICC numbers, distribution, morphology, relation to ganglion cells, and myenteric plexus architecture. Groups were compared using parametric and nonparametric tests.

MAIN RESULTS

Twelve patients had samples available for histopathological evaluation. GAID patients had a significantly lower total number of ICCs than controls (3 vs. 8, P<0.0029). ICC number at T1 was 2.5 vs. 6 (P=0.0629) and significantly lower at T2. (3.5 vs. 11, P=0.0124). GAID patients did not show a significant increase of ICC from T1 to T2. Controls showed a significant increase of ICC over time (6 vs. 11, P=0.0408).

CONCLUSION

Intestinal samples from infants with GAID who underwent stoma formation demonstrated fewer ICC than controls. There was no improvement or cell recovery during the study period. The ability to modulate ICC may have significant implications for the management of GAID.

The role of preformed silos in the management of infants with gastroschisis: a systematic review and meta-analysis

BACKGROUND

The pre-formed silo (PFS) is increasingly used in the management of gastroschisis, but its benefits remain unclear. We performed a systematic review and meta-analysis of the literature comparing use of a PFS with alternate treatment strategies.

METHODS

Studies comparing the use of a PFS with alternate strategies were identified and data extracted. The primary outcome measure was length of time on a ventilator. Mean difference (MD) between continuous variables and 95% confidence intervals were calculated. Risk difference and 95% CI were determined for dichotomous data.

RESULTS

Eighteen studies, including one randomised controlled trial, were included. Treatment strategy and outcome measures reported varied widely. Meta-analysis demonstrated no difference in days of ventilation, but a longer duration of parenteral nutrition (PN) requirement [MD 6.4 days (1.3, 11.5); p = 0.01] in infants who received a PFS. Subgroup analysis of studies reporting routine use of a PFS for all infants demonstrated a significantly shorter duration of ventilation with a PFS [MD 2.2 days (0.5, 3.9); p = 0.01] but no difference in duration of PN requirement. Other outcomes were similar between groups.

CONCLUSION

The quality of evidence comparing PFS with alternate treatment strategies for gastroschisis is poor. Only routine use of PFS is associated with fewer days on a ventilator compared with other strategies. No strong evidence to support a preference for any strategy was demonstrated. Prospective studies are required to investigate the optimum management of gastroschisis. Standardised outcome measures for this population should be established to allow comparison of studies.

Epidemiology, management and outcome of gastroschisis in Sub-Saharan Africa: Results of an international survey

BACKGROUND

The aim was to compare gastroschisis (GS) epidemiology, management and outcome in low-income countries (LIC) in Sub-Saharan Africa (SSA) with middle- (MIC) and high-income countries (HIC).

MATERIALS AND METHODS

A 10-question survey was administered at the 2012 Pan-African Paediatric Surgery Association Congress. RESULTS are presented as median (range); differences were analysed using contingency tests.

RESULTS

A total of 82 delegates (28 countries [66 institutions]) were divided into LIC (n = 11), MIC (n = 6) and HIC (n = 11). In LIC, there were fewer surgeons and more patients. LIC reported 22 cases (1-184) GS/institution/year, compared to 12 cases (3-23)/institution/year in MICs and 15 cases (1-100)/institution/year in HICs. Antenatal screening was less readily available in LIC. Access to parenteral nutrition and neonatal intensive care in LIC was 36% and 19%, compared to 100% in HIC. Primary closure rates were similar in LIC and HIC at 58% and 54%, respectively; however, the majority of staged closure utilised custom silos in LIC and preformed silos in HIC. In LIC, mortality was reported as >75% by 61% delegates and 50-75% by 33%, compared to <25% by 100% of HIC delegates (P < 0.0001).

CONCLUSIONS

Gastroschisis is a problem encountered by surgeons in SSA. Mortality is high and resources in many centres inadequate. We propose the implementation of a combined epidemiological research, service delivery training and resource provision programme to help improve our understanding of GS in SSA whilst attempting to improve outcome.

Is early delivery beneficial in gastroschisis?

PURPOSE

Gastroschisis neonates have delayed time to full enteral feeds (ENT), possibly due to bowel exposure to amniotic fluid. We investigated whether delivery at <37weeks improves neonatal outcomes of gastroschisis and impact of intra/extra-abdominal bowel dilatation (IABD/EABD).

METHODS

A retrospective review of gastroschisis (1992-2012) linked fetal/neonatal data at 2 tertiary referral centers was performed. Primary outcomes were ENT and length of hospital stay (LOS). Data (median [range]) were analyzed using parametric/non-parametric tests, positive/negative predictive values, and regression analysis.

RESULTS

Two hundred forty-six patients were included. Thirty-two were complex (atresia/necrosis/perforation/stenosis). ENT (p<0.0001) and LOS (p<0.0001) were reduced with increasing gestational age. IABD persisted to last scan in 92 patients, 68 (74%) simple (intact/uncompromised bowel), 24 (26%) complex. IABD or EABD diameter in complex patients was not significantly greater than simple gastroschisis. Combined IABD/EABD was present in 22 patients (14 simple, 8 complex). When present at <30weeks, the positive predictive value for complex gastroschisis was 75%. Two patients with necrosis and one atresia had IABD and collapsed extra-abdominal bowel from <30weeks.

CONCLUSION

Early delivery is associated with prolonged ENT/LOS, suggesting elective delivery at <37weeks is not beneficial. Combined IABD/EABD or IABD/collapsed extra-abdominal bowel is suggestive of complex gastroschisis.

Tracheomegaly in infants with severe congenital diaphragmatic hernia treated with fetal endoluminal tracheal occlusion

OBJECTIVE

To measure and evaluate the effects of tracheal dimensions on survival and ventilation in a large series of infants with congenital diaphragmatic hernia (CDH) treated antenatally with fetal endoluminal tracheal occlusion (FETO).

STUDY DESIGN

Tracheal dimensions on chest radiograph (CR) were measured by 2 blinded radiologists. Survival, day 1 best oxygenation index and duration of ventilation, continuous positive airway pressure, and hospital stay were recorded. Survivors with a minimum 12-month follow-up were longitudinally compared for incidence of gastroesophageal reflux, chest infections, chest deformities, and hernia recurrence.

RESULTS

Seventy infants with CDH (41 who underwent FETO) were treated between 2004 and 2010. Hernia repair was performed in 26 infants without FETO (8 with patch repair) and 35 infants with FETO (26 with patch repair; P = .0015). Infants with FETO had a wider trachea than those without FETO at T1 (P < .0001) and between T1 and the carina (P < .0001). Tracheal diameter was similar in survivors and nonsurvivors in the FETO group. Tracheal size was not correlated with day 1 best oxygenation index in the FETO group (R2 = 0.17) or the non-FETO group (R2 = 0.07). There were no between-group differences in duration of mechanical ventilation (P = .30), continuous positive airway pressure (P = .20), or hospital stay (P = .30). In the longitudinal study, tracheal widths were larger on the last CR than on preoperative CR in patients without FETO (T1, P = .02; widest point, P = .001; carina, P = .0001), and for patients with FETO at the widest point (P < .0001) and at the carina (P < .0001), but not at T1 (P = .12). There were no differences in clinical variables between the FETO and non-FETO groups.

CONCLUSION

FETO has a significant impact on tracheal size of infants with CDH; however, tracheal size does not affect survival or the requirement for early respiratory support.

Paediatric laparoscopic hernia repair: Ex vivo skills in the reduced training era

INTRODUCTION

Changes to surgical working hours have resulted in shorter training times and fewer learning opportunities. Tools that develop surgical skills ex-vivo are of particular interest in this era. Laparoscopic skills are regarded as essential by many for modern paediatric surgery practice. Several generic skills models have been reported and validated. However, there is limited evidence regarding the role of procedure specific models. Here, a laparoscopic paediatric hernia repair model is trialled with surgical trainees and their competence compared with consultant colleagues.

PATIENTS AND METHODS

An ex-vivo paediatric inguinal hernia repair model was devised. Surgical trainees from 5 specialist centres were recruited and performed multiple standardised repairs.

RESULTS

23 trainees performed 192 repairs. Experts performed 10 repairs for comparison. Trainees were timed performing the repair and their accuracy measured. With repeated attempts trainee's timings and accuracy improved until by the 10 th repair they were no different from benchmark consultant scores.

CONCLUSION

A simple, procedure specific ex-vivo training model has been evaluated for laparoscopic hernia training in paediatric surgery. The results suggest improvements in competence with repetition. Trainee and benchmark consultant scores are no different by the 10 th trainee attempt. We conclude that this model may have a valuable role in the training and assessment of future paediatric surgeons.

Is there unity in Europe? First survey of EUPSA delegates on the management of gastroschisis

AIM

To report the first European survey on the current management of gastroschisis and ascertain the degree of variability between centers.

METHODS

A 10-question survey was administered at the 2011 European Paediatric Surgeons' Association (EUPSA) Congress. Questionnaires were completed by 205 delegates from 39 countries. A total of 21 responses (10%) were incomplete and voided. The remaining 184 were divided on the basis of following region of practice: Western Europe (WE, n = 102), Eastern Europe (EE, n = 59), and non-European countries (n = 23). Differences between WE and EE were analyzed using contingency tests. p < 0.05 was considered significant.

RESULTS

A total of 15% WE and 2% EE responders work in centers where antenatal magnetic resonance imaging scans are routinely used. Nonplanned delivery is the most popular approach (WE 46%, EE 58%). Primary closure is the preferred choice (WE 92%, EE 86%), and it is achieved by operative fascial closure in the majority (WE 80%, EE 75%) rather than by Bianchi technique (WE 20%, EE 25%). Staged reduction and closure is less popular (WE 8%, EE 14%), and it is achieved by custom-made silo (WE 25%, EE 12.5%), preformed silo (PFS) followed by surgical closure (WE 63%, EE 75%), or PFS followed by sutureless closure (WE 12%, EE 12.5%). Objection to PFS in WE is mainly related to surgeons' lack of confidence in the technique (40%), whereas in EE it is due to unavailability and high cost (62%, p = 0.01). In case of associated intestinal atresia, immediate resection and anastomosis is preferred by 60% of WE surgeons versus 35% of EE surgeons (p = 0.03), who equally favor primary closure and delayed surgery (33%). Nutrition is preferably delivered by peripheral long line in WE (64%) and by central line inserted in the first week of life in EE (62%, p = 0.003).

CONCLUSIONS

Primary fascial closure is currently the preferred method of gastroschisis closure across Europe. Aspects of care such as strategy for intestinal atresia and delivery of parenteral nutrition differ significantly between WE and EE. Economic considerations appear to influence management strategy particularly in EE. A Europe-wide audit appears warranted to identify whether this survey reflects actual practice.

The "diamond port configuration": a standardised laparoscopic technique for adolescent intestinal resection and anastomosis

BACKGROUND

Familiarity with technique and repetition enhance efficiency during laparoscopic surgery. This is particularly important when undertaking complex bowel resections. We report a standardised protocol that includes theatre layout, patient position and port insertion, which we believe facilitates excellent abdominal access and ergonomics and has the potential to shorten the duration of the team-learning curve.

MATERIALS AND METHODS

A strategic unit development plan led to the commencement of a laparoscopic service for adolescents with bowel disorders. A standardised protocol for intestinal resections was agreed upon at a monthly Paediatric Minimal Access Group meeting. This covered patient position, port insertion, technical aspects of intestinal resection and perioperative management. In particular, a diamond configuration for ports was agreed upon. Data were prospectively collected, and included patient demographics, operative times, conversion rates and postoperative outcomes. Unless otherwise indicated, data are presented as medians with ranges.

RESULTS

Seven procedures were carried out in six patients (three female) aged 14 (11-14) years. Access to the entire abdominal cavity, vision and ergonomics were excellent in all. There were no conversions to open surgery. In all procedures, the technique was considered safe and effective. The length of hospital stay was 6.5 (5.8-14) days.

CONCLUSION

A standardised protocol including the use of the diamond port configuration has several putative advantages for laparoscopic bowel resections and anastomoses. These include efficiency, reproducibility, predictability, good visibility and excellent ergonomics. We recommend this approach as a means to shorten the procedure-specific learning curve of the laparoscopic team.

Gastroschisis: a multi-centre comparison of management and outcome

BACKGROUND

Anecdotal evidence and a handful of literature reports suggest that the outcome for infants born with gastroschisis in many African countries is poor when compared to Western nations. We wished to evaluate current management strategies and outcomes in African and Western units that treat infants with gastroschisis.

PATIENTS AND METHODS

We conducted a retrospective review of case-notes for infants with gastroschisis who presented to a hospital between 1 January 2004 and 31 December 2007. There were five participating centres, divided for analysis into an African cohort (three centres) and a Western cohort (two centres).

RESULTS

Fewer infants presented to a hospital with gastroschisis in the African cohort when compared to the Western cohort, particularly when the size of catchment area of each hospital was taken into account. The physiological state of the infant on presentation and management strategy varied widely between centres. Primary closure, preformed silo and surgical silo with delayed closure were all utilised in the African cohort. Use of the preformed silo and delayed abdominal wall closure was the strategy of choice in the Western cohort. The 30-day mortality was 23% and 1% respectively. This primary outcome measure varied considerably in the African cohort but was the same in the two Western units.

CONCLUSIONS

Gastroschisis in the African cohort was characterised by fewer infants presenting to a hospital and a more variable outcome when compared to the Western cohort. A detailed epidemiological study to determine the incidence of gastroschisis in African countries may provide valuable information. In addition, interventions such as prompt resuscitation, safe neonatal transfer, the use of the preformed silo and parenteral nutrition could improve outcomes in infants with gastroschisis.

Flexible-tip laparo-endoscopic surgery: a bridge to single port appendicectomy in children

INTRODUCTION

Single port surgery (SPS) has been demonstrated to have some advantages over conventional laparoscopy. However, currently available port sizes may limit the application in younger children or those with a small umbilicus. Moreover, the consultant learning curve required to master single port surgery may have a negative impact on surgical training. We report the first series of children who were treated with a reduced incision technique for appendicectomy using flexible-tip laparo-endoscopic surgery (FLES).

PATIENTS AND METHODS

FLES was set up using one 11-mm and 2 × 5-mm bladeless ports (Ethicon XCEL™) via umbilical and low left iliac fossa incisions. A 10-mm flexible-tip laparo-endoscope was utilized. Tip angulation ensured visibility while minimising instrument clashing. A database of children undergoing FLES was kept prospectively. Demographic and peri-operative information and complications were recorded. Data are presented as medians with ranges.

RESULTS

Between March and June 2010, 5 children (4 females) aged 9 (4-13) years underwent FLES for right iliac fossa pain. 2 procedures were performed by the admitting consultant, 3 by a supervised inexperienced laparoscopic trainee. 4 children had acute appendicitis including 1 with an inflammatory mass. Another had a haemorrhagic ovarian cyst. Appendicectomy was performed in all. The duration of surgery was 104 (93-130) min, and postoperative hospital stay was 2 (1-6) days. At 7 (5-8) months' follow-up no complications have been recorded. At follow-up, the cosmetic results were judged to be excellent in all by the children, their parents and the reviewing surgeon.

CONCLUSIONS

FLES is an alternative to standard laparoscopy and SPS in children, and be performed effectively and safely by junior trainees. Cosmetic results are excellent. It may represent a bridge technology, particularly for younger children, until single port products and techniques more suitable for appendicectomy in this age group are available. Finally, flexible-tip technology may play a useful role as SPS evolves.

Nipple pain at presentation predicts success of tongue-tie division for breastfeeding problems

INTRODUCTION

In mother-infant pairs experiencing breastfeeding difficulties, frenulotomy for tongue-tie may improve breastfeeding. We tested the hypothesis that those experiencing nipple pain are most likely to benefit from the procedure in a prospective cohort study.

MATERIALS AND METHODS

Mother-infant pairs attending a dedicated clinic for the assessment and treatment of tongue-tie completed a standardised, structured symptom questionnaire. Three months later outcome was assessed by questionnaire. Multivariate logistic regression analysis was used to determine preoperative predictors of successful outcome.

RESULTS

Sixty-two infants <90 days old underwent frenulotomy and completed follow-up. At presentation, 52 mothers (84%) reported nipple pain, and 32 mothers (52%) nipple trauma. Three months after frenulotomy, 78% of respondents were still breastfeeding. Feed lengths (mean reduction: 17 mins; p<0.001) and time between feeds (mean increase: 38 mins; p<0.001) had significantly improved, as had difficulty of feeding (mean improvement in self-rated difficulty score: 42%; p<0.001). Those having difficulty breastfeeding due to nipple pain showed a significant long-term benefit from frenulotomy; pre-frenulotomy nipple pain was associated with an increased likelihood of breastfeeding at 3 months in adjusted multivariate analysis (OR 5.8 [95% CI 1.1-31.6]).

CONCLUSION

Mother-infant pairs with tongue-tie and breastfeeding difficulties due to nipple pain are most likely to benefit from frenulotomy.

GABBY: an ex vivo model for learning and refining the technique of preformed silo application in the management of gastroschisis

BACKGROUND

Gastroschisis (GS) is a congenital full-thickness defect of the anterior abdominal wall, whose incidence is increasing. Traditional postnatal management options include primary reduction and closure under general anaesthetic or operative silo construction for defects judged to be unsuitable for immediate repair. The cot-side application of the preformed silo (PFS) with delayed abdominal wall closure has recently been advocated as the management method of choice for infants with GS. We report a novel trainer designed to facilitate acquisition and refinement of the skills to apply the PFS.

MATERIALS AND METHODS

A model of an infant with GS was constructed to allow application of a PFS. Each step of the clinical application of a PFS could be simulated. Paediatric surgeons at a regional meeting participated in evaluating the model. This cohort was surveyed with regards to previous clinical experience applying the PFS, invited to apply the silo on the model and then resurveyed with regard to the technique, ease of the application of the PFS on the model, its robustness and potential use as a training tool.

RESULTS

Seventeen paediatric surgeons completed the surveys and applications of the PFS on the model. Under supervision, each step of the procedure was completed by all participants. Feedback was enthusiastic and positive and participants judged the model to be realistic and potentially very useful as a training tool (median score 8 out of 10).

CONCLUSIONS

We have developed and evaluated a reproducible, low-cost model of an infant with GS. This ex vivo trainer may be a useful adjunct in the acquisition and refinement of the skills of surgeons who manage GS using a PFS.

Systematic review and meta-analysis of the postnatal management of congenital cystic lung lesions

BACKGROUND

Antenatally detected asymptomatic congenital cystic lung lesions may be managed conservatively or by surgical resection. We undertook a systematic review and meta-analysis to quantify the risks of elective surgery, emergency surgery, and observation.

METHODS

All series published between 1996 and 2008, where the postnatal management of congenital cystic lung lesions was described, were reviewed. A meta-analysis was performed to determine whether elective or emergency surgery was associated with a higher risk of adverse outcomes.

RESULTS

There were 41 reports describing 1070 patients (of whom 79% were antenatally detected). Five hundred five neonates survived without surgery into infancy, of whom only 16 (3.2%) became symptomatic. For all ages, elective surgery was associated with significantly less complications than emergency surgery. The risk ratio was 2.8 (95% confidence interval, 1.4-5.5; P < .005) when comparing complications after elective surgery with emergency surgery.

CONCLUSIONS

The risk of asymptomatic cases developing symptoms is small. However, elective surgery is associated with a better outcome than emergency surgery. If elective surgery is undertaken, it should be performed before 10 months. Although no prognostic indicators have so far been identified in the literature, a conservative approach may be appropriate for small lesions.

A parent in the operating theater: a survey of attitudes

INTRODUCTION

A parent is often present during anesthetic induction of their child. Some ask to see surgery. We sought views regarding the prospect of a parent in theater during surgery.

METHODS

A questionnaire survey of parents, theater staff, and surgeons was used. Visual analog scales were also used. A standard error of the mean was calculated for each parameter. Statistical analysis was by Student's t test. Comparisons were made between groups, and a P value of less than .05 was considered significant.

RESULTS

Three hundred seven respondents--204 parents, 75 theater personnel, and 28 surgeons. Parents favored the option to be present in theater. Across groups, support declined with intensity of intervention; minor surgery under local anesthetic, parental score of 8.43, declining to 6.5 for minor elective surgery under general anesthetic, and 5.1 for emergency surgery. There were also declines for theater personnel (2.7, 1.1, and 0.9) and surgeons (4.29, 1.5, and 0.6). Scores for theater personnel and surgeons were significantly lower than the parents (P < .001).

CONCLUSION

This study confirms a desire by parents to be present in theater during surgery on their child but demonstrates the concerns of professionals. We propose a randomized study to test the hypothesis that having a parent in theater has measurable benefits.

Outcomes of the "clip and drop" technique for multifocal necrotizing enterocolitis

BACKGROUND

The "clip and drop" (CD) has been proposed as a useful strategy in the management of severe multifocal necrotizing enterocolitis (NEC). There is little published data on clinical outcomes after this intervention. We report a 2-center experience with this technique.

METHODS

A retrospective review of infants who underwent CD between 1998 and 2006 at 2 tertiary pediatric surgery centers. Data recorded included intestinal resections, interval between laparotomies, anastomoses at subsequent surgery, time to full feeds, and complications including mortality. Data are reported as median with ranges.

RESULTS

Thirteen infants (7 male, 6 female) with a birth weight of 811 (514-2110) g underwent CD of up to 5 bowel segments. In 8 of 9 early survivors, all CD segments were viable. Six patients (46%) were alive at 29 (9-96) months. Survivors underwent 4 (3-4) laparotomies and 4 (2-6) bowel anastomoses and had intestinal continuity restored at 67 (51-162) days.

CONCLUSIONS

With multiple interventions, half the infants in this high-risk group survived and achieved full enteral feeds. The CD is a valuable technique in a selected group of infants with fulminant NEC.

Closing gastroschisis: diagnosis, management, and outcomes

PURPOSE

Gastroschisis (GS) is defined as a full-thickness abdominal wall defect (usually right-sided) with intestinal prolapse and occasionally other viscera. The defect itself may close around the viscera causing exit or entry level intestinal atresia and ischaemia or midgut infarction, previously described as closed GS. We now report the largest series of infants born with various stages of closing GS describing features, management, and outcome.

METHODS

The study used a single-centre retrospective review of infants with GS and evidence of defect closure at birth.

RESULTS

Nine infants (6 girls) with a median of 35 (range, 32-36) weeks of gestation fulfilled criteria for closing GS from a series of 146 (6%) infants born from August 1994 to December 2007. Delivery had been expedited in 6 based on increasing intraabdominal bowel dilatation and suspicion of closing GS on serial antenatal ultrasound. At delivery, 5 had compromised but viable bowel and required intestinal surgery. Three fetuses, all with midgut necrosis, had antenatal scans typical of GS with no additional features. After a variety of surgical procedures, 7 patients are now fully enterally fed, one is parenteral nutrition-dependent. One died of end-stage liver failure secondary to short bowel syndrome. The length of follow-up was 6 (range, 0.5-11) years.

CONCLUSIONS

Of infants with GS, 6% present with closing abdominal ring. Close antenatal monitoring may prevent severe bowel loss in some cases. After multiple surgical interventions, most have a favorable outcome.

Acute neonatal arterial occlusion: is thrombolysis safe and effective?

PURPOSE

We report our experience of the management of arterial occlusion in the newborn.

METHODS

A case note review was carried out after ethical approval. Doppler ultrasonography confirmed the occlusion. Thrombolysis was the primary intervention. Surgery was used selectively. A good outcome was one without tissue loss or functional impairment or minimal tissue loss without functional impairment. Data are presented as medians with ranges.

RESULTS

Ten patients (9 male; median gestational age, 35.5 weeks [range, 28-39 weeks]) presented on day 1 (range, 1-8 days). Initial management included systemic tissue plasminogen activator (8 patients) and surgery (2 infants in whom thrombolysis was contraindicated). Improvement was noted in 7 of 8 infants treated medically and in both who underwent surgery. Three infants had significant tissue loss. Outcome at 29 months (range, 1.3-95.4 months) was good in the remaining 7.

CONCLUSIONS

A multidisciplinary approach, thrombolysis and selective surgery achieved tissue preservation and function in the majority while minimizing complications. Early referral to centers with multidisciplinary teams is recommended.

Benefit of preformed silos in the management of gastroschisis

Gastroschisis is traditionally managed by primary closure (PC) or delayed closure after surgical silo placement. Bedside insertion of preformed silos (PFS) and delayed closure has become more widespread, although its benefits remain unclear. To identify differences in outcome of infants managed with PFS compared with traditional closure (TC) techniques. Single-centre retrospective review of 53 consecutive neonates admitted between February 2000 and January 2006. Data expressed as median (range). Non-parametric statistical analysis used with P < 0.05 regarded as significant. Forty infants underwent TC and 13 had PFS and delayed closure. Median ventilation time in both groups was 4 days (P = 0.19) however this was achieved with higher mean airway pressures (MAPs) (day 0, 10 (5-16) versus 8 (5-10) cmH(2)O; P = 0.02) and inspired oxygen (40 (21-100) versus 30 (21-60)%; P = 0.03) in TC group. Urine output on day-1 of life was significantly higher in PFS group (1.1 (0.16-3.07) versus 0.45 (0-2.8) ml/kg/h; P = 0.02). Inotrope support was required in 17/40 (43%) of TC versus 0/13 (0%) in PFS (P < 0.01). After exclusion of infants with short bowel syndrome and/or intestinal atresia (n = 9), there was a shorter time to full enteral feeds in the TC group (22 (12-36) versus 27 (17-45); P = 0.07), although there was no difference in the period of parenteral nutrition (PN) (P = 0.1) or overall hospital stay (P = 0.34). No deaths or episodes of necrotizing enterocolitis occurred. The use of PFS for gastroschisis closure is associated with a reduction in pulmonary barotrauma, better tissue perfusion and improved early renal function, consistent with a reduction in abdominal compartment syndrome.

Postnatal outcome in gastroschisis: effect of birth weight and gestational age

INTRODUCTION

Early elective delivery of antenatally diagnosed gastroschisis has been proposed as a strategy to minimize postnatal morbidity. This hypothesis was tested by analyzing outcome in relationship to gestational age and birth weight at delivery.

METHODS

Single-center retrospective review of infants born with gastroschisis over a 13-year period (January 1993-December 2005). Standard outcome measures were compared using nonparametric methods. Data are quoted as median values (range).

RESULTS

The study population consisted of 110 infants with gastroschisis. They were divided according to gestational age (group A, <35 weeks; group B, 35-37 weeks; group C, >37 weeks) and birth weight (group D, <2 kg; group E, 2-2.5 kg; group F, >2.5 kg). Duration in hospital (P < .01) and time to full enteral feeding (P = .05) was increased in group A vs groups B and C. In comparison, duration in hospital (P < .01), days ventilated (P = .03), establishment of full feeds (P = .01), and parenteral nutrition (P = .02) were all prolonged in group D vs groups E and F. Six (5%) infants died (group D, n = 3; group E, n = 3). Necrotizing enterocolitis was found in 7 infants, and confined to groups D and E (chi2 for trend P = .06).

CONCLUSION

There is no evidence that prematurity confers an advantage in restitution of gastrointestinal function in infants with gastroschisis; indeed, the opposite appears true. Birth weight, rather than gestational age, appears a better predictor of outcome.

Traumatic pancreatic duct injury in children: minimally invasive approach to management

BACKGROUND

The management of children with main pancreatic duct injuries is controversial. We report a series of patients with pancreatic trauma who were treated using minimally invasive techniques.

METHODS

Retrospective review of children with pancreatic trauma treated at a UK tertiary referral institution between 1999 and 2004.

RESULTS

Fifteen children (11 boys) were admitted with pancreatic trauma. Twelve (80%) were less than 50th centile for body weight. Contrast-enhanced computed tomography (CT) scans were used to define organ injury, supplemented by magnetic resonance cholangiopancreatography (MRCP) in 7. Twelve (80%) underwent diagnostic endoscopic retrograde cholangiopancreatography (ERCP) with a median time after injury of 11 (range, 6-29) days. The degree of pancreatic injury was defined by ERCP and CT/MRCP as grade II (n = 2), grade III (n = 4), grade IV (n = 9) (American Association for the Surgery of Trauma grades). Nine children had a transductal pancreatic stent inserted endoscopically. Computed tomography/ultrasound-guided drainage was performed in 4 children for acute fluid collections. Two children later underwent endoscopic cyst-gastrostomy, one of whom later required conversion to an open cyst-gastrostomy.

CONCLUSION

Body habitus may predispose to pancreatic duct trauma. Contrast-enhanced CT scan (and MRCP) should dictate the need for ERCP. Transductal pancreatic stenting allows internal drainage of peripancreatic collections and may reestablish duct continuity, although a proportion still requires percutaneous or endoscopic cyst-gastrostomy drainage. Open surgery for pancreatic trauma should now be an exception.

Natural history and long-term follow-up of antenatally detected liver cysts

BACKGROUND/PURPOSE

Antenatally detected liver cysts are rare; their diagnostic accuracy is unknown, and their management is controversial. This study assessed the natural history of these lesions.

METHODS

We conducted a retrospective review of infants with isolated intrahepatic cysts that were detected antenatally. Data are expressed as median (range).

RESULTS

Fifteen infants presented during the period 1991-2004 with an antenatally detected liver cyst. Their gestational age at detection was 22 (18-34) weeks, and the maximum diameter of their cyst was 23 (10-120) mm. Serial scans, which were performed in 9 fetuses, showed cyst enlargement in 5 cases, diminution in 1 case, and no change in 3 cases. In utero percutaneous aspiration was required in 1 infant. Three infants underwent postnatal surgery. One fetus (postfetal intervention) had a subtotal excision of a large subcapsular cyst filling the abdominal cavity on day 2. Another infant required partial excision and marsupialization (complex cyst arising from segment IV) at 5 months, and a third infant underwent a cyst cholecystostomy at 4 months. Postnatal investigations (including hepatic scintigraphy) suggested that the remaining lesions were either simple parenchymal (n = 10) or isolated intrahepatic choledochal (ie, type V; n = 2) cysts. The median follow-up for these patients was 44 (27-167) months. Serial postnatal ultrasonography showed cyst diminution in 4 cases, an enlargement in 1 case, and no dimensional change in 7 cases.

CONCLUSIONS

Most antenatally detected liver cysts appear to be simple and of parenchymal origin and do not require fetal intervention. Their postnatal history is variable, but regression without treatment is seen in most cases.

Surgical skills training in the laparoscopic era: the use of a helping hand

The aim of this study was to evaluate whether a training programme involving an assessment exercise performed on a laparoscopic trainer model leads to an improvement in the acquisition of laparoscopic skills in surgical trainees. Subjects were recruited from a cross-section of surgical trainees at the Great Ormond Street Hospital, Department of Surgery and the Institute of Child Health. All subjects completed both a baseline laparoscopic surgical skills questionnaire and three exercises on a new laparoscopic trainer model. Thirteen subjects completed both the baseline questionnaire and all three assessment exercises. These subjects exhibited a wide range of previous experience in laparoscopic surgery. Sixty-nine percent of subjects showed a significant improvement in the assessment exercise score with training (ANOVA; P = 0.01). Sixty-two percent of subjects showed a greater improvement between exercises 2 and 3 than between exercises 1 and 2. The difference in score between exercises 1 and 2 was not statistically significant (P = 0.597), whereas the difference in score between both exercises 2 and 3 and exercises 1 and 3 was statistically significant (P = 0.018 and P = 0.005, respectively). The double glove training model is thus a simple, inexpensive, and easily reproducible tool that elicits a significant improvement in laparoscopic surgical skills in surgical trainees with a broad range of previous laparoscopic experience. It can therefore be used as part of a training programme to facilitate the acquisition of laparoscopic skills in a paediatric surgery setting.

Pilot study of new training model for laparoscopic surgery

The aim of this study was to evaluate whether an assessment exercise performed on a laparoscopic trainer model reliably reflects previous laparoscopic experience and can therefore be used to accurately assess laparoscopic skills in surgical trainees. Subjects were recruited from a cross-section of surgical trainees and students at the Great Ormond Street Hospital for Children and the Institute of Child Health. Subjects were required to complete a baseline laparoscopic surgical skills questionnaire and an exercise on a new laparoscopic trainer model. Nine subjects completed both the baseline questionnaire and the exercise. These subjects exhibited a wide range of previous experience in laparoscopic surgery. Subjects with higher self-assessment scores had the lowest exercise scores (i.e. better scores; P=0.003). Furthermore, the exercise score was strongly negatively correlated with the baseline number of training modalities received (P=0.007) and the laparoscopic experience score (P=0.027). The assessment exercise on a novel laparoscopic trainer was capable of differentiating between subjects with little laparoscopic experience and those with more extensive previous laparoscopic training. The correlation between the exercise score and measured baseline variables suggests that the scoring system used in this model is sensitive and specific to measuring skills relevant to laparoscopic surgery.

Outcome of antenatally diagnosed sacrococcygeal teratomas: single-center experience (1993-2004)

AIMS

Sacrococcygeal teratomas (SCTs) are the commonest neonatal tumors with an incidence of approximately 1:30,000. There are few large single-center series and even fewer describing both their antenatal and postnatal course. We report the outcome of all fetuses investigated at a tertiary fetal medicine center with this diagnosis.

METHOD

Demographic details were obtained from a prospectively maintained database. Patient records were examined for additional data including antenatal and postnatal interventions. Data were described as median (range).

RESULTS

Forty-one SCTs were diagnosed antenatally during the period 1993 to 2004. Twelve were excluded from subsequent analysis (single antenatal visit or attending for second opinion [n = 6] and termination of pregnancy [n = 6]). Twelve underwent fetal intervention (laser vessel ablation [n = 4], alcohol sclerosis [n = 3], cyst drainage [n = 2], amniodrainage [n = 2], vesicoamniotic shunt [n = 1]) for fetal hydrops and polyhydramnios to aid in delivery and to prevent obstructive uropathy developing in the fetus. Of these, 3 died in utero and 9 survived to be born (median gestational age, 33 weeks [27-37 weeks]). A further 3 died in the neonatal period. There are 6 long-term survivors (50%) from this group. Seventeen infants, without intervention, were born at median gestational age 38 weeks (26-40 weeks). One infant with severe cardiac anomalies died on the day of birth. All surviving infants had definitive excisional surgery at a median of 2 days (1-16 days). Current median follow-up of survivors is 39 months (8-86 months). There have been no recurrences. One child has mild constipation, and 3 are awaiting cosmetic revision of their scars.

CONCLUSIONS

The overall survival of antenatally diagnosed SCT is approximately 77%, with the development of hydrops and others requiring in utero intervention carrying a poor prognosis. Otherwise, the outcome after surgical excision is excellent.

Bacterial contamination of central venous catheters during insertion: a double blind randomised controlled trial

Static electricity within sterile packaging may result in bacterial contamination of central venous catheters (CVCs) prior to insertion. To prevent this, some surgeons inject saline into the pack before opening it. This trial was designed to determine the effect of this procedure. A double blind randomised controlled trial of 47 CVCs comparing injection of 2 ml of sterile saline into the pack prior to opening with no injection was performed. Five centimetre lengths cut from the tip of the catheter before and after subcutaneous tunnelling were sent for microbiological culture. Eight catheters (17%) showed evidence of bacterial contamination prior to insertion into the vein. Two (4.2%) were contaminated prior to tunnelling and seven (14.9%) afterwards. One catheter was contaminated before and after tunnelling. All but one of the contaminating bacteria were coagulase negative staphylococci. There was no significant difference in the contamination rate between catheters from packs that had been injected (5/25) and those that had not (3/22), P = 0.56. Just under one-fifth of the catheters were contaminated with bacteria prior to insertion into the vein but this was not influenced by prior injection of saline into the pack. We conclude that there is no evidence to support the practice of injecting the catheter pack prior to opening.

Antenatally diagnosed duplication cyst of the tongue: modern imaging modalities assist perinatal management

When a foetal abnormality is detected during routine antenatal screening, further information is required in order to plan the remainder of the pregnancy and perinatal management. If a lesion is detected in the foetal mouth or neck, there may be compromise of the foetal airway. The ex-utero intrapartum (EXIT) procedure has recently been developed to allow lifesaving foetal surgery to be performed during delivery of such cases whilst relying on placental support. Detailed antenatal assessment is essential when planning the EXIT procedure, and modern imaging modalities may be implemented. We illustrate this by reporting a rare case of enteric duplication cyst arising from the base of the tongue, which was detected on routine antenatal ultrasound scan. Subsequent imaging using foetal MRI and colour Doppler ultrasound reassured us that the foetal airway was patent, and an EXIT procedure was avoided.

Retrospective comparison of open versus laparoscopic pyloromyotomy

BACKGROUND

Laparoscopic pyloromyotomy is gaining popularity in the management of pyloric stenosis. However, there is no unequivocal evidence in favour of the laparoscopic over the open approach. This paper reports an experience with laparoscopic pyloromyotomy and an attempt to identify any benefit over the open procedure.

METHODS

This was a retrospective review of all 87 pyloromyotomies performed at this institution for pyloric stenosis over the 39 months since the first laparoscopic pyloromyotomy was performed.

RESULTS

Data for 39 infants who underwent laparoscopic pyloromyotomy were compared with those for 38 infants who underwent pyloromyotomy via a periumbilical incision. Patient demographics were similar between the two groups. The duration of operation was longer for laparoscopic pyloromyotomy than for the open procedure (median 50 versus 30 min; P = 0.001). There were no differences in recovery time, postoperative length of hospital stay, complication rates and postoperative analgesia requirements between the two groups.

CONCLUSION

Laparoscopic pyloromyotomy has been incorporated successfully into the authors' standard working practice. Complication rates recovery times were similar to those achievable with the open procedure. There was no clear benefit of one approach over the other.

Reduction in visceral slide is a good sign of underlying postoperative viscero-parietal adhesions in children

BACKGROUND/PURPOSE

Viscera stuck to the anterior abdominal wall from previous surgery risk injury during laparoscopic surgery. A prospective study was conducted to determine if these adhesions are detectable on ultrasound scan by showing a reduction in the normal visceral slide.

METHODS

Patients undergoing laparoscopic procedure after a previous laparotomy underwent preoperative real-time ultrasound scan to observe if viscera slides freely under the abdominal wall. A reduction in slide was considered a positive sign of underlying adhesions. These findings were correlated with the operative findings.

RESULTS

Anterior abdominal wall scans were performed on 17 children. Reduced visceral slide was seen in 10. Viscero-parietal adhesions were found in 9 of 10 patients. Visceral slide was reduced in a very localized area in 6 patients, and, in these, a loop of bowel (n = 3), liver and bowel (n = 2), or liver (n = 1) was adherent. In 4, reduced visceral slide was seen over a wide area. Extensive adhesions were found in 3 of 4. One renal transplant patient with peritonitis had a false-positive ultrasound scan. At laparotomy there were no adhesions. The peritonitis is thought to have prevented an adequate examination. Seven patients had normal visceral slide. Of these, 4 had no adhesions, but 3 children had flimsy omental adhesions. The sensitivity and specificity of visceral slide in predicting adhesions were 75% and 80%, respectively.

CONCLUSIONS

Reduction in visceral slide is a good sign of underlying postoperative viscero-parietal adhesions. Ultrasonographic mapping of the abdominal wall may be useful in selecting an adhesion-free site for trocar insertion in children with previous operations requiring laparoscopic procedures.

Is intralesional injection of OK-432 effective in the treatment of lymphangioma in children?

BACKGROUND

Intralesional injection of OK-432 has been proposed as an effective treatment of lymphangioma. The aim of this study was to review our experience with OK-432 injection of lymphangioma and to identify factors associated with successful outcome.

METHODS

We made a case note review of 19 children who received OK-432 injection. Median duration of follow-up was 17 months.

RESULTS

Lesions were diagnosed antenatally in 4 children, at birth in 4 children, and between 1 month and 11 years in the remainder. Anatomic locations were head/neck in 14, axilla in 1, and multiple locations in 4. Median number of injections per child was 2 (range, 1 to 5). Disappearance of the lesion was achieved after OK-432 injection in 2 patients (11%) and a marked reduction in 5 (26%); all these lesions were in the head and neck. Lesions larger than 5 cm and those outside the head and neck region did not respond well to OK-432 injection. Fourteen children (74%) required surgical excision after injection. Complications of OK-432 injection included partial tracheal obstruction, fever, local inflammatory response, and abscess formation.

CONCLUSIONS

OK-432 injection was effective in approximately one third of children with lymphangioma. Lesions outside the head and neck and those larger than 5 cm are unlikely to respond to this therapy. Injection of lymphangioma surrounding the airways may be hazardous.

Conservative management of pneumatosis intestinalis and pneumoperitoneum following bone-marrow transplantation

Pneumatosis intestinalis (PI), with or without pneumoperitoneum (PP), may complicate allogenic bone-marrow transplantation (BMT). The aim of our study was to establish the incidence and outcome of this complication following BMT in children. A departmental database was used to identify children who underwent BMT in the 4-year period up to December 1999. The medical records of children who developed PI with or without PP were obtained for further study. All patients were managed without recourse to surgery. Conservative management included 7 days of intravenous antibiotics and 10 days of intestinal rest supported by parenteral nutrition. In the study period, 138 BMTs were carried out. Six children (4%) with a total of 7 episodes of PI/PP were identified, 1 boy and 5 girls with a median age of 8.5 years (range 0.8-11). Neutropenia was noted in 3 children at the time of presentation. Other risk factors identified included alternative BMT donors (5/6), steroid therapy (6/7), and graft-versus-host disease (5/6). Organisms were isolated from stool cultures sent at the time of diagnosis in 3 out of 7 instances. Diarrhoea was the predominant presenting symptom. All patients recovered from the acute episode, but 5 died at a mean of 12 months from the development of PI/PP (range 6-17 months). This mortality of 83% compares with a mortality of 33% (43 of 132) for the remainder of children who underwent BMT during the study period. Thus, while initial recovery can be anticipated, the medium-term mortality in this group of children is high.

T cryptantigen activation is associated with advanced necrotizing enterocolitis

BACKGROUND/PURPOSE

Thomsen-Friedenreich cryptantigen activation (TCA) exposes neonates with necrotizing enterocolitis NEC to the risk of hemolysis after transfusion of blood products. The authors aimed to determine the prevalence of TCA in neonates with NEC and to correlate TCA with severity of disease and outcome.

METHODS

One hundred four neonates with NEC were tested for TCA on admission. Patients with TCA requiring transfusion were given packed red cells, low-titer anti-T fresh frozen plasma, and washed platelets to avoid hemolysis.

RESULTS

Twenty-three infants had TCA, and 96% of these had stage III disease. The incidence of TCA was significantly higher in infants with stage III disease compared with those with stage II (30% v 4%; P <.01). A total of 91% of infants with TCA required laparotomy compared with 81% of those with no activation. At laparotomy, widespread disease was more common in the TCA group (71% v 55%). TCA did not significantly increase mortality rate (TCA, 39% v no TCA, 28%); this may reflect the transfusion policy of our unit.

CONCLUSIONS

Twenty-two percent of neonates with NEC referred to our unit had TCA. There is an association between TCA and advanced NEC. Screening of neonates with advanced NEC for TCA is advised to identify those at risk of hematologic complications.

Oesophageal atresia: a simplified approach to early management

Management following the repair of oesophageal atresia (OA) with tracheooesophageal fistula (TOF) in the past included the routine use of an intercostal chest drain, a gastrostomy, or a transanastomotic tube (TAT) for enteral nutrition and a routine contrast swallow (CS) before oral feeds. There has been a trend towards simplification of the management, but this is not universal. The aim of this study was to evaluate the safety of a simplified management regime in infants undergoing primary repair of OA in a retrospective case note review of infants undergoing surgery for OA with TOF under the care of one consultant over a 12-year period. Intercostal chest drains, TATs, and CSs were not routinely used. Early enteral feeding was initiated and oral feeding was allowed in babies of adequate birth weight (BW) and gestation. A CS was only performed when there were specific anastomotic concerns. Parameters recorded included demographic details, time to first enteral feed by tube or mouth, time to full oral feeds, and complications. Forty patients were studied; 17 were managed without (group 1) and 23 with (group 2) a TAT. Sex distribution, gestational age, and BW were comparable in the two groups. In group 1, the time to the establishment of full oral feeds was 2-8 days (average 3.9). Four infants developed strictures; 2 were managed with dilatation alone and 2 required surgery. In group 2, the time to the establishment of full enteral feeds was 2-12 days (average 5.9). Four patients developed strictures; 2 underwent an anti-reflux procedure and a 3rd resection of a cartilaginous remnant. There was 1 death in a patient with intractable cardiac failure. The majority of infants with OA and TOF can thus be safely managed without routine chest drainage or CS. A sizeable minority do not require a TAT. Early introduction of oral feeds in the non-TAT group is not associated with an increased complication rate.

Upper pole heminephrectomy: is complete ureterectomy necessary?

OBJECTIVE

To determine the re-operation rate on the distal ureter after upper pole heminephrectomy with incomplete ureterectomy.

PATIENTS AND METHODS

The case notes from one institution were reviewed retrospectively; 60 upper pole heminephrectomies with incomplete ureterectomy were undertaken in 39 girls and 16 boys (mean age at primary surgery 27 months, range 3--88).

RESULTS

Thirty-two children (58%) had an antenatal diagnosis while 12 (22%) presented with a urinary tract infection (UTI) and six (11%) with urinary incontinence. Twenty-nine of the 60 renal units (48%) had an associated ureterocele and in nine (15%) the ureter was ectopic. Ten infants (18%) underwent initial puncture of a ureterocele. Five patients (8%), all females, required lower urinary tract re-operation. The indications for secondary surgery were recurrent UTIs in all and a prolapsed ureterocele in one. All five had ultrasonographic evidence of a dilated ureteric stump. Reflux into the retained stump was detected in one child.

CONCLUSIONS

The re-operation rate for a redundant ureteric stump in this series was 8%. The risk of injury to the good ureter may outweigh the benefits of a complete ureterectomy.

Adverse outcome after prenatal diagnosis of gastroschisis: the role of fetal monitoring

Fifty-seven fetuses with gastroschisis presented between 1982 and 1995 were studied by retrospective review of medical records. There were three late intrauterine deaths (IUD). Fetal distress, as determined by reduced fetal movements or abnormal cardiotopograph (CTG), was encountered in 23 of the 54 liveborn infants (43%), all of whom had delivery expedited either by emergency caesarean section (n = 19) or induction (n = 4). Six infants had abnormal neurological outcome: two died in the neonatal period of severe perinatal brain injury, neonatal fits were observed in four, two of whom developed cerebral palsy, and one died at the age of 7 years. All six of these infants had suffered fetal distress. If the three intrauterine deaths are included, 16% of all cases were associated with abnormal neurological outcome. The introduction of regular CTG monitoring from 32 weeks' gestation in 1990 increased the ability to detect fetal distress twofold. This resulted in a similar increase in obstetric intervention and an associated reduction in adverse neurological outcome. Pregnancies associated with gastroschisis should be considered at significant risk of fetal distress, which itself may culminate in late intrauterine death, neonatal death, or adverse neurological outcome. Careful, repeated fetal monitoring in the third trimester is indicated.