Annals of Pediatric Surgery

Negative appendicectomy rates in adolescent girls compared with boys: The role of ultrasound and serum inflammatory markers

Olugbenga M. Aworanti, Deirdre Nally, Sri P. Thambipillai — Tue, 22 Jan 2019 00:00:00 +0000

Background Adolescent girls are frequently seen with more differentials for abdominal pain than boys. We aim to determine if this infers that a negative appendectomy (NA) is more likely in girls, and if the use of ultrasonography
(USS) and inflammatory markers reduce the likelihood of a NA.
Participants and methods Over a 17-year period, we reviewed the histology of appendix specimens removed nonincidentally from adolescents aged 12–16 years. Specimens with normal histology were grouped as NAs. The preoperative white cell count, C-reactive protein and USS were analysed.
Results Data were available for 430 boys and 273 girls. The overall NA rate was 9.1%, with 7.2 and 12.1% in boys and girls, respectively. This represented an increased odds of a NA in girls [odds ratio (OR): 1.77, 95% confidence interval (95% CI): 1.06–2.96; P = 0.030]. When the variance in the preoperative use of USS and inflammatory markers was accounted for, the new odds of a NA in girls compared with boys were now not significantly increased (OR: 2.27, 95% CI:0.09–60.64; P = 0.624). USS did not significantly reduced the odds of a NA (OR: 0.98, 95% CI: 0.48–2.02; P=0.960). There were significantly increased odds of a NA in adolescents with normal white cell count and C-reactive protein (OR: 15.84, 95% CI: 2.12–118.50; P = 0.007).
Conclusion Adolescent girls are more likely to undergo a NA. When inflammatory markers are elevated, this increased likelihood of a NA is not seen in girls, but rather reduced odds of a NA are seen in both girls and boys. adolescents, boys, girls, inflammatory markers, negative appendicectomy, ultrasonography

Keywords: adolescents, boys, girls, inflammatory markers, negative appendicectomy, ultrasonography

Acute pancreatitis in children: efficacy of computed tomography severity index in the assessment, management, and prediction of complications

Rizwan A. Khan, Shagufta Wahab, Imran Ghani — Tue, 22 Jan 2019 00:00:00 +0000

Aim The aim of the study was to describe the assessment and management aspects and the role of computed tomography severity index (CTSI) in children with acute pancreatitis.
Materials and methods All the children (≤14 years) admitted to the pediatric surgery unit of our institution with acute pancreatitis from 2003 to 2014 were included. This retrospective analysis studied the demographic, clinical, diagnostic, and treatment aspects and the role of CTSI.
Results The male-to-female ratio out of a total of 45 patients studied was 4 : 1. The differences in mean leukocyte count, mean serum amylase, and mean serum lipase were not significant in children with different CTSI scores. The children with higher CTSI scores are more likely to have both early and late complications, need for intensive care, and overall longer hospital stay.
Conclusion CTSI plays an important role in early determination of the clinical severity, guiding the need for intensive care and in predicting the occurrence of early and late complications in children with acute pancreatitis.

Keywords: acute pancreatitis, children, computed tomography severity index

Primary torsion of the greater omentum: An overlooked cause of acute abdomen

Tue, 22 Jan 2019 00:00:00 +0000

Background/purpose Primary torsion of the greater omentum is an uncommon cause of acute abdomen in children. It was estimated to be found in 0.1% of cases operated for acute appendicitis and is almost impossible to be diagnosed preoperatively. Surgical excision of the infarcted omentum is the treatment of choice. In this study, we aimed to highlight the importance of suspecting primary omental torsion when operating upon a child presenting with a picture of acute appendicitis with normal appearing appendix intraoperatively.
Patients and methods Through the period from June 2009 to May 2016, medical records of patients who had definite diagnosis of primary omental torsion were retrospectively reviewed. Clinical presentations, laboratory findings, imaging studies results, intraoperative findings, and histopathological findings were reviewed.
Results During the specified time period, out of 1344 patients operated upon for acute appendicitis in our department, only four patients proved to have primary torsion of the greater omentum. All the patients were obese with clinical picture mimicking acute appendicitis. The postoperative histopathological examination showed normal appendix and ischemic necrosis of the resected omental segment.
Conclusion Inspection of the greater omentum is essential when finding a normal appearing appendix in any case operated for suspicion of acute appendicitis.

Keywords: acute abdomen, appendix, greater omentum, omental torsion

Isolated ileocecal valve atresia

Maher AlZaiem, Abdulhai F. Al-Garni, Abdulrahman Almaghrebi, Fadi Zaiem — Tue, 22 Jan 2019 00:00:00 +0000

Ileocecal valve atresia is a rare variety of gastrointestinal atresia. There have been only 10 cases reported in the literature. In this paper, we report the case of a 4-day-old male preterm, who presented with signs of neonatal intestinal obstruction. Contrast enema showed microcolon with no reflux of the contrast into the terminal ileum. Exploratory laparotomy showed an isolated ileocecal valve atresia. The atretic segment was resected and an ileocolic anastomosis was performed. The histopathological report confirmed the diagnosis of ileocecal valve atresia. The postoperative recovery was uneventful.

Keywords: atresia of ileocecal junction, ileocecal valve atresia, intestinal atresia, neonatal intestinal obstruction

Enhanced recovery protocols versus traditional methods after resection and reanastomosis in gastrointestinal surgery in pediatric patients

Mohamed Fathy, Mohamed M. Khedre, Mohamed A.M. Nagaty, Naser M. Zaghloul — Tue, 22 Jan 2019 00:00:00 +0000

Background Enhanced recovery after surgery (ERAS) is a group of changes in perioperative care that represent a fundamental shift from the traditional management of the gastrointestinal (GI) surgical patient.
Objective To compare the results of applying enhanced recovery after GI resection in children versus the traditional methods.
Patients and methods This prospective study included 60 patients who underwent GI resectional surgery between February 2016 and February 2017 at our institution. The patients were divided into two groups: group A (30 patients) was managed with ERAS protocol and group B (30 patients) was managed with traditional methods. All the patients underwent standard hand-sewn technique of GI resection reanastomosis. The protocol of ERAS included no routine nasogastric tube, early diet advancement, minimization of narcotic analgesics, early ambulation, and physical rehabilitation.
Results The most frequent cause of GI resection reanastomosis surgery was intussusception (33.3% in group A and 36.7% in group B). Patients in group A had a significant lower frequencies of postoperative fever (33.3 vs. 66.7%, P<0.01) and chest infection (26.7 vs. 60%, P<0.01). Moreover, group A showed a significant shorter postoperative length of hospital stay (4 ± 1.2 days in group A vs. 7.1 ±2.05 days in group B, P<0.001).
Conclusion Adopting ERAS protocol for resectional GI surgery in pediatric patients should be encouraged as it is results in lower incidences of postoperative fever and chest infection and is associated with less postoperative length of hospital stay.

Keywords: enhanced recovery after surgery, enteral nutrition, gastrointestinal surgery, length of hospital stay, pediatric surgery

Bipolar diathermy as another method for testicular vascular division in laparoscopic two-stage Fowler–Stephens orchidopexy: A retrospective study

Hamdan H. Alhazmi — Tue, 22 Jan 2019 00:00:00 +0000

Objective The current study assessed the outcome of the two-stage laparoscopic Fowler–Stephens orchidopexy (LFSO) for intra-abdominal testis (IAT). Testicular blood vessels were divided by two different methods, bipolar diathermy or the conventional clipping method.
Summary background data The shortness of testicular vessels may play a role in making the surgical approach in IAT a technical challenge and can hinder the dragging of the testicles to the scrotum.
Patients and methods We reviewed 31 records of pediatric patients who underwent operations for IAT between July 2010 and July 2017, using the two-stage LFSO. We evaluated methods used for dividing the testicular vessels in the first stage. We evaluated the intrascrotal position and testicular size. Success was defined as a nonatrophic, intrascrotal testis.
Results Two-stage LFSO was performed in 31 boys with 39 IAT. The mean age at the first stage was 32.18 months and at the second stage was 42.25 months. Two methods were used to divide the testicular vessels in the first stage of the LFSO, which were clipping by metallic clips (5 mm) in 25 testes and bipolar diathermy (3 mm) in 14 testes. With an average follow-up of 16 months, the preoperative volume was maintained in 97.43% of the testes, whereas 94.87% of the testes were intrascrotal. One testicular atrophy was reported in the clipping group. Two testicles were outside the scrotum within the bipolar coagulation group.
Conclusion Two-stage LFSO is safe and feasible. Bipolar diathermy could be used as an alternate method for dividing testicular vessels.

Keywords: Fowler–Stephens, intra-abdominal testis, laparoscopic, laparoscopic Fowler–Stephens orchidopexy, nonpalpable testes, orchidopexy, pediatrics

Modified Bianchi pyloromyotomy versus laparoscopic pyloromyotomy for patients with infantile hypertrophic pyloric stenosis: Intraoperative considerations and parents’ satisfaction

Tue, 22 Jan 2019 00:00:00 +0000

Introduction Infantile hypertrophic pyloric stenosis is a common cause of persistent nonbilious vomiting during infancy. Ramstedt pyloromyotomy through right upper quadrant transverse incision is the conventional treatment. The laparoscopic and Tan-Bianchi approaches were introduced to improve the cosmesis and decrease postoperative morbidity. In this study, we compared between laparoscopic and modified Bianchi approaches regarding intraoperative technical considerations and postoperative outcomes.
Patients and methods The study included 40 patients with infantile hypertrophic pyloric stenosis. Overall, 20 patients underwent laparoscopic pyloromyotomy (LP) and the other 20 patients underwent modified Bianchi pyloromyotomy (MBP). Patients’ characteristics, including age, sex, gestational age, and associated comorbidities, were documented. Intraoperative details and complications and postoperative outcomes were recorded.
Results The operative time and intraoperative complications including mucosal perforation and bleeding did not significantly differ between both the groups. From the laparoscopic group, one (5%) case was complicated by mucosal perforation and converted to open and another case (5%) developed hypercapnia. There was no statistically significant difference between the two groups regarding time till full feed (P=0.648) and postoperative hospital stay (P=0.082). In addition, there was no statistically significant difference between the two groups regarding postoperative complications, with one (5%) case from the laparoscopic group underwent incomplete myotomy and required redo-operation and another case (5%) developed wound infection. MBP had a significantly more parent satisfaction regarding cosmesis than LP (P=0.016).
Conclusion MBP is comparable to LP regarding intraoperative complications and postoperative outcomes; however, the modified Bianchi approach offered more parent satisfaction than laparoscopic approach.

Keywords: laparoscopic, modified Bianchi, pyloric stenosis, pyloromyotomy

British Association of Paediatric Surgeons International Affairs Committee: A report of international fellowships

Tue, 22 Jan 2019 00:00:00 +0000

Objective This paper describes the fellowship programme of the International Affairs Committee of the British Association of Paediatric Surgeons.

Patients and methods The selection of low-income and middle-income country (LMIC) fellows from 2005 to 2016, their funding, experience, and current roles are described. Qualitative and quantitative analysis was performed.

Results Thirty-eight trainees from 21 LMIC were awarded fellowships over the 11-year period. Thirty-two have completed the fellowship at time of writing, all are now in consultant positions. Obtaining a visa was the single most cited barrier to starting the fellowship. Twenty completed the questionnaire. Hundred percent felt the fellowship had contributed to personal development and 71% had altered clinical practice subsequent to their experience. Thirty-three percent have gained research opportunities.

Conclusion This evaluation supports LMIC-high-income country partnerships and highlights the benefits of fellowships to both the individual surgeon, their department and patient population.

Keywords: BAPS, fellowship, low- and middle-income country, partnership

Clinical impact of open versus laparoscopic approach on the outcome in cases of congenital duodenal obstruction: A comparative study

Ahmed Arafa, Wesam Mohamed, Tamer Y.M. Yassin, Ahmed M.K. Wishahy, Seham Anwar — Tue, 22 Jan 2019 00:00:00 +0000

Introduction Congenital duodenal atresia/partial duodenal obstruction/duodenal stenosis is one of the most common variants of intestinal atresia, occurring 1 in 2500–5000 live births. The aim of this study was to compare between both the laparoscopic and open approaches for repair of congenital duodenal obstruction regarding their effects on outcome.
Patients and methods A total of 20 cases diagnosed with congenital duodenal obstruction (atresia, web, and stenosis) in the neonatal and pediatric surgical units of Cairo University Specialized Pediatric Hospital were studied. All cases underwent either laparoscopic or open repair. Cases associated with malrotation or multiple atresias were excluded. Patients’ characteristics, including age, sex, presenting symptoms, associated anomalies, preoperative investigations, intraoperative details, and postoperative outcomes, were documented.
Results A total of 20 cases of duodenal obstruction were included in this study over 1 year, from January 2017 to January 2018. We did duodenoduodenostomy in 15 cases (web in the second part of duodenum, types II and III) and excision of the web in the first part of duodenum in five cases. Laparoscopic repair was done in 11 (55%) cases (diamond-shaped duodenoduodenostomy in nine cases and web excision in two cases) whereas open technique was performed in nine (45%) cases (diamond duodenoduodenostomy in six cases, and excision of the web in three cases). The average operative time in cases of laparoscopic duodenoduodenostomy was 120 min whereas in the cases of open technique was 90 min. The average time needed until full feeding to be achieved was 6–7 days in cases done laparoscopically, whereas other group was 10–20 days. In this cohort, no stricture or leakage or wound dehiscence was found in both groups. Laparoscopic group afforded a better cosmesis and more parent satisfaction.
Conclusion Use of the laparoscope in duodenal obstruction in either neonates or children is a safe and easy technique, and despite being a lengthier operation, feeding could be established earlier.

Keywords: duodenal atresia, laparoscopic, TPN

Five years’ experience of laparoscopic-assisted dismembered pyeloplasty versus open dismembered pyeloplasty

Ahmed Abdelghaffar Helal, Mohammad Daboos — Tue, 22 Jan 2019 00:00:00 +0000

Purpose Pyeloplasty for ureteropelvic junction obstruction (UPJO) in children has traditionally been performed using an open technique. However, the large lumbar incision in open pyeloplasty necessitates several weeks before a return to normal activity and requires significant tissue retraction to expose the field; hence, the damage is often more than that anticipated. We present our long-term experience with laparoscopic-assisted pyeloplasty in the treatment of UPJO, to evaluate the feasibility, safety, and long-term outcome of this technique in children.
Patients and methods In total, 40 children with UPJO requiring operative repair were included in the study. Twenty patients with UPJO were randomly selected to undergo open dismembered pyeloplasty (group A) and the remaining 20 patients to undergo laparoscopic-assisted dismembered pyeloplasty (group B) at the Pediatric
Surgery Department between January 2013 and December 2017. All patients were followed-up for 5 years postoperatively. The outcome was measured by the ultrasonography and diuretic renography with resolution of obstructive symptoms.
Results The mean laparoscopic procedure time was 25 min. There was a slight relationship between age and operative time. No major perioperative complications
occurred in any cases. Renal pelvic anterior–posterior diameter at postoperative ultrasonography significantly decreased (P<0.05). Postoperative split renal function on diuretic renography significantly improved. Overall, successful resolution of UPJO was observed in all patients.
Conclusion Laparoscopic-assisted pyeloplasty appears to be a safe, feasible, and effective alternative to open pyeloplasty in children. There are shorter operative times in the laparoscopic-assisted pyeloplasty and shorter overall hospitalization. It avoids large lumbar incision and gives excellent functional and cosmetic results.

Keywords: laparoscopy-assisted pyeloplasty, minimally invasive surgery, ureteropelvic junction obstruction