Contralateral inguinal exploration in premature neonates: is it necessary?

Purpose  

The purpose of this study was to review our management of neonatal inguinal hernias in premature infants over a 5-year period to ascertain any change in practice.     

Is surgical exploration necessary in bilateral anorchia?

ObjectiveTo review the current management of boys with bilateral anorchia and assess whether surgical exploration is necessary when endocrine investigation indicates absent testicular function.Patients and methodsThe medical records of 11 boys being managed for bilateral anorchia were reviewed in relation to clinical presentation, pituitary-gonadal function, surgical and histological findings.ResultsAll boys had absence of testicular function based on undetectable levels of serum anti-Müllerian hormone, elevated basal or peak follicle-stimulating hormone and luteinising hormone levels and no testosterone response to human chorionic gonadotrophin stimulation. All boys underwent abdominal exploration, ten of whom showed no macroscopic signs of testis tissue, confirmed histologically in seven. Histology was not available in the remaining three boys. Abnormally small intra-abdominal testes were found bilaterally in one boy. These were sited in the scrotum at orchidopexy but had subsequently atrophied. Endocrine tests confirmed absent testicular function.ConclusionBased on the high degree of concordance between the surgical and histological findings and the results of the endocrine tests, it is suggested that surgery is unnecessary in bilateral anorchia when endocrine tests confirm the absence of functioning testicular tissue.     

Incidence of pediatric metachronous contralateral inguinal hernia in children aged ≥1 year

Background

The management of the contralateral asymptomatic side when a child with initial unilateral inguinal hernia undergoes herniorrhaphy continues to be controversial. Age less than 6 months at initial herniorrhaphy is considered as a high risk factor of the occurrence of metachronous contralateral inguinal hernia (MCIH). We performed herniorraphy for patients ??1 year with initial unilateral hernia at oneday-set outpatient-surgery department without any intervention of contralateral groin. In this study, we reviewed the characteristics of development of MCIH in this condition and discuss the management strategies of MCIH.

Methods

The subjects of this study were children who were treated at our outpatient-surgery department from January 2006 to December 2006. A total of 2129 patients with initial unilateral hernia and aged ??1 year underwent an ipsilateral herniorhhaphy only. Patients were followed up for the development of MCIH to 60 months. The Chi-square test was used for intergroup comparison, a level of P<0.05 was considered as statistically signifi cant.

Results

Among these children 1341 (63.0%) were obtained 60 months follow-up data, 1146 (85.5%) were boys and 195 (14.5%) were girls. MCIH developed in 70 (5.2%) patients, 61 were boys and 9 were girls. In 570 patients aged 12?C23 months, 43 developed MCIH (7.5%); in 564 patients aged 24?C59 months, 21 developed MCIH (3.7%); and in 207 patients ??60 months, 6 patients developed MCIH (2.9%), the difference between these groups was highly significant (P=0.004). In male patients, 30 right-sided MCIHs occurred after 423 initial left-sided herniorrhaphies (7.1%) and 31 left-sided MCIHs occurred after 723 initial right-sided herniorrhaphies (4.3%), difference between these two groups was signifi cant (P=0.041). Seventy-seven percent of the MCIHs occurred within 1 year, 94% occurred within 2 years after initial herniorraphy.

Conclusions

As the overall incidence of MCIH in patients aged ??1 year was 5.2%, routine contralateral groin exploration is not suggested. Transinguinal laparoscopy could be considered as an alternative of conventional ??wait and see?? policy, especially in patients less than 2 years or left-sided initial unilateral inguinal hernia. If ??wait and see?? policy is adopted, patients should be closely followed up for 2 years.     

Atypical auditory event-related potentials in preterm infants during the first year of life: a possible sign of cognitive dysfunction?

We assessed auditory event-related potentials in small-for-gestational-age (SGA; 850 +/- 258 g, 28.9 +/- 3.3 gestational wk; n = 15) and appropriate for gestational age (AGA; 1014 +/- 231 g, 26.9 +/- 1.9 gestational wk; n = 20) preterm infants and healthy term infants (n = 22). An oddball paradigm was used with a harmonic tone of 500-Hz frequency as the standard and of 750-Hz frequency as the deviant stimulus. The preterm infants were studied at 40 gestational wk and at 6 and 12 mo of corrected age, and the control subjects were studied at 2-4 d and at 3, 6, 9, 12, and 15 mo of age. The peaks of interest were the main positive peak (P350), the negative peaks at 250 ms (N250) and 650 ms (Nc), and the mismatch negativity at 200 ms (MMN). At term, the P350 in the preterm infants was similar to that of the newborn control subjects. In response to the deviant, the Nc was smaller in the SGA than in the AGA (P < 0.02) and control (P < 0.005) infants. The N250 amplitude was also lower in the SGA infants. At 12 mo, the MMN was observed in the control but not in the preterm infants, whose broad difference positivity correlated with the Bayley developmental index. The decreased Nc and N250 peaks in the SGA infants may suggest an increased risk for cognitive dysfunction. The broad difference positivity at 1 y of age may indicate atypical cortical auditory processing. Whether cognitive dysfunction can be predicted by these findings needs to be assessed in a study with extended follow-up.     

Laparoscopic inguinal hernia repair in premature neonates: is it safe?

Objective

With advances in clinical medicine, many premature babies nowadays can have excellent survival outcomes. As the incidence of inguinal hernias in this group is high and there is scarce data in the literature regarding the optimal timing for repair, this study aims to review our experience in laparoscopic repair in premature infants.

Methods

In our centre, premature neonates with inguinal hernia noted during hospitalization were offered laparoscopic repair when the body weights reached 2.5 kg unless there is contraindication for laparoscopy. A retrospective review was carried out for all premature neonates who underwent laparoscopic inguinal hernia repair from 2001 to 2011. The operative results, complications, incarceration risk and postoperative apnea risk were recorded.

Result

A total of 79 premature neonates received laparoscopic inguinal hernia repair during this period. The mean gestational age at birth was 31.9 weeks (27–36 weeks) and the mean gestational age at operation was 46.5 weeks (33–92 weeks). One patient had incarceration and required emergency operation while waiting for the elective repair. The mean operative time was 44.9 min (25–93 min). One patient (1.3 %) had recurrence. No postoperative apnea was noted in any patient.

Conclusion

Laparoscopic hernia repair is safe and feasible in premature neonates when they attain reasonable body size, as long as there is excellent anaesthesia support. Low risk of incarceration was noted in this study and it is worth waiting for the body weight to build up and hence facilitate laparoscopic repair.     

Is it necessary to close the peritoneum over the deep inguinal ring during laparoscopic orchidopexy?

BackgroundDuring laparoscopic orchidopexy, some authors routinely close the peritoneum over the area of the deep inguinal ring (DIR). We report our experience, to determine whether leaving the peritoneum over the DIR without closure is associated with an increase in the occurrence of postoperative inguinal hernia.Patients & methodsThis is a retrospective review of patients who underwent laparoscopy for impalpable testes in 2004–2010. The patients were divided into two groups: I) cases in whom the peritoneum over the DIR was routinely closed, and II) cases in whom the DIR was left without closure. The patients were followed up in the outpatient clinic.ResultsDuring the study period, 442 boys underwent laparoscopy for 570 impalpable testes. The testis was found to be ‘vanishing’ or ‘atrophic’ in 182 (32%). The mobilized testis passed through the anatomical DIR in 198 (51%), and through a new deep ring in 190 (49%). The DIR was closed (I) in 178 (46%) and left open (II) in 210 (54%) cases. On follow up (mean 50 months for I and 41 months for II), there were no cases of inguinal hernia.ConclusionClosing the peritoneum over the area of the DIR may not be necessary, even in cases where the testis has to be passed through a medially created new deep ring, because of a short cord.     

Laparoscopic inguinal hernia repair in premature babies weighing 3?kg or less

Purpose

This retrospective study aims to evaluate the feasibility, safety and complication rate of laparoscopic inguinal hernia repair for small babies weighing 3?kg or less.

Methods

A retrospective analysis was performed on the surgical charts of 67 infants (47 boys and 20 girls) weighing 3?kg or less who underwent laparoscopic hernia repair in a 3-year period. A regular 5-mm scope was used for visualization, and 2 or 3-mm instruments were used for the closure of the inner inguinal ring using 3/0 non-absorbable suture. The median weight at surgery was 2,600?g (range 1,450–3,000?g). All except three were premature.

Results

Of the 67 infants, 15 (22.3?%) presented with an irreducible hernia. In three cases of irreducible hernias, we also performed a transumbilical appendectomy at the end of the hernia repair. Minor problems related with anesthesia were noted in four cases. Hernia recurrence was observed in three patients (4.4?%). No cases of testicular atrophy occurred. In 10 boys, we observed 12 cases of high testes, only 4 testes requiring subsequent orchiopexy.

Conclusions

Laparoscopic inguinal hernia repair for babies weighing 3?kg or less is feasible, safe and perhaps even less technically demanding than open inguinal herniotomy.     

Are influences during pregnancy associated with wheezing phenotypes during the first decade of life?

Aim: Recently, attention has focused on possible early life origins for asthma. We sought to identify whether factors present during pregnancy were associated with development of childhood wheezing phenotypes. Methods: A whole population birth cohort (n=1456) on the Isle of Wight, UK, was followed through to age 10 y. Where possible, information regarding environmental exposures and events during pregnancy was obtained from the maternity records (n=1238). Children were seen at ages 1, 2, 4 and 10 y, and wheezing symptoms were used to define wheezing phenotypes in the first decade (n=1034). Results: Risk of early-onsetpersistent wheeze (onset in the first 4 y, still present at age 10) was increased by environmental tobacco smoke exposure in pregnancy (OR=2.44; 95% CI: 1.37-4.34) plus maternal asthma (3.57; 1.84-6.94), but reduced by cat ownership (0.30; 0.13-0.62). Early transient wheeze (onset in the first 4 y, but not present at age 10) was increased by environmental tobacco smoke exposure (1.58; 1.02-2.45), male gender (1.68; 1.09-2.60) and low birthweight (3.65; 1.27-10.52). No environmental factors in pregnancy were associated with late-onset persistent wheeze (onset after age 4 y, still present at 10 y).

Conclusion: In addition to genetics, maternal exposures during pregnancy show association with childhood and especially early-life wheezing phenotypes.     

What is the role of the prevention of allergy in the first period of life?

The widespread increase in the prevalence of allergic disease, which has occurred over the last 20 y, has created general concern in Europe and in the rest of the world. The reason for this increase is still partially unknown. In this period, despite a greater understanding of the pathogenesis and risk factors of allergies plus the greater efficacy of drugs to control the symptoms, the cost of intervention and the socio-economic impact are still very high. For these reasons, prevention in the first period of life represents a goal for both developed and developing countries in order to reduce this upward trend.     

The diagnostic value of a single measurement of superior vena cava flow in the first 24?h of life in very preterm infants

Low superior vena cava (SVC) flow has been associated with intraventricular haemorrhage (IVH) in very preterm infants. We studied the diagnostic value of a single measurement of SVC flow within the first 24?h of life in very preterm infants and its association with occurrence or extension of IVH in a setting of limited availability of neonatal echocardiography. Preterm infants who were born at less than 30?weeks gestation and who had an echocardiogram within 24?h after birth were eligible. Baseline, clinical and ultrasound data were collected. A total of 165 preterm infants were included. Low SVC flow (<41?ml/kg/min) occurred in six infants and was associated with severe IVH and extension of IVH, although this was not significant after adjusting for confounders. The only independently associated variable with low SVC flow was admission temperature (odds ratio 0.27, p?=?0.001). A review of SVC flow values shows that these are higher now than initially reported. This study does not show an association of low SVC flow and severe IVH or extension of IVH after adjusting for confounders as a single measurement of SVC flow did not add any diagnostic value in this cohort. Thus, the exact role of SVC flow measurements in the circulatory assessment of preterm infants remains to be elucidated. However, admission temperature may have an effect on systemic blood flow in very preterm infants.     

Is a routine voiding cystourethrogram necessary in children after the first febrile urinary tract infection?

Aim: The aim of this study was to estimate the value of identifying vesicoureteral reflux (VUR) on a voiding cystourethrogram (VCUG) and the benefit of VUR management according to imaging strategies at the first febrile urinary tract infection (UTI). Methods: Children aged 1–144 months (n = 618) with the first febrile UTI admitted at our hospital from 2000 to 2009 were enrolled. In all patients, renal sonogram (US), ^99mTc‐dimercaptosuccinic acid (DMSA) renal scanning and VCUG were performed. Retrospective analyses per patient and per renal unit were performed. Results: Abnormal US or DMSA scans had a sensitivity of 100% and a negative predictive value (NPV) of 100% to detect high‐grade reflux. In hydronephrotic kidneys, DMSA scanning had a sensitivity of 88.2% and a NPV of 97.1% to detect high‐grade reflux. Conclusion: Routine VCUG is not required after the first febrile UTI in patients with normal US or normal DMSA scan. Even if the US reveals hydronephrosis, routine VCUG is not necessary if the DMSA findings are normal. It is recommended that children who did not receive both a DMSA scan and VCUG after the first febrile UTI should be followed up over the long term.     

Is routine use of transanastomotic tube justified in the repair of esophageal atresia?

Background

Transanastomotic feeding tube (TAFT) is commonly used for post-operative enteral nutrition after esophageal atresia (EA)/tracheoesophageal fistula (TEF) repairs. The purpose of this study is to analyze the therapeutic implications of avoiding a TAFT and its impact on the outcomes post-operatively.

Methods

The medical data of 33 inpatients with EA/TEF type C repair from 2009 to 2014 were retrospectively reviewed. Patients were divided into two groups for comparison based on the usage of TAFT during the repair: TAFT- (without) and TAFT+ (with) groups, without randomization. Both groups were compared statistically for post-operative complications and outcomes.

Results

Eighteen neonates were males and 15 females, with an average birth weight of 2.43±0.43 kg and a mean gestational age of 36.15 weeks. Nineteen (57.5%) in the TAFT- group and 14 (42.4%) were in the TAFT+ group. The post-operative complications, need for dilatations, duration of total parenteral nutrition (TPN) and length of hospital stay were similar in both groups. The incidence of pneumonitis was significantly higher in the TAFT+ group.

Conclusions

By avoiding a TAFT, there is no increase in complication rates nor does it entail a prolonged period of TPN. Besides, not using a TAFT may have the advantage of reducing incidence of aspiration and consequent pneumonitis.

     

Is early occupational therapy in extremely preterm infants of benefit in the long run?

A total of 126 infants with extremely low birth weight (ELBW; <1000 g) were enrolled in a prospective case-control study in order to examine the effect of occupational therapy based on sensory integration (SI) and neurodevelopmental therapy (NDT) on neurological development. The children were grouped as matched pairs on the basis of determined developmental risk scores assessed at the age of 3 months. The intervention children had a 6-month period of weekly occupational therapy from the corrected age of 6-12 months. The follow-up showed that the social development of the intervention children was significantly better at the age of 12 months, but at the age of 2 years the groups had equal developmental scores in neurological, neuropsychological and speech therapy assessments. The Miller assessment for pre-schoolers (MAP) performed in a total of 96 (92%) of the study children at the age of 4 years failed to demonstrate any significant differences between the groups. It is concluded that this amount of occupational therapy in ELBW infants does not have any detectable effect on long-term neurological development.