Laparoscopic versus open appendicectomy in children: A UK District General Hospital experience

Aims

The aim of this study was to evaluate the potential role of laparoscopic appendicectomy in reducing morbidity and length of stay in children compared to open procedures in a UK District General Hospital setting.

Methods

A three-year retrospective review of children ≤ 15 years with histologically confirmed appendicitis who underwent laparoscopic (LA) and/or open (OA) appendicectomy was performed. Choice of operation was based on individual surgeon’s preference and on patient’s body size. Data collected included rate of histologically complicated appendicitis, post-operative length of stay (LOS), and collective and differential morbidity rates, i.e., wound infection, intra-abdominal collection, and ileus. Chi-square and Mann–Whitney tests were used for statistical analysis. P < 0.05 was regarded as significant.

Results

Eighty children (70% male) were identified at median age 11 (3–15) years. They could be divided into complicated (n = 18, 22%) and simple appendicitis (n = 62, 78%). Appendicectomy was performed in all as an OPEN (n = 53, 66%) or LAPAROSCOPIC (n = 27, 34%) procedure. Both groups were comparable in gender distribution (P = 0.11) and rate of complicated appendicitis (30% vs. 19%, respectively; P = 0.27). Median age was significantly lower in the OPEN group [10 (3–15) vs. 12 (7–15) years; P < 0.004]. Laparoscopic appendicectomy had a significantly lower rate of collective morbidity (3.8% vs. 25.9%; P < 0.003), including lower rate of intra-abdominal collection (1.9% vs. 14.8%; P < 0.01). Median LOS was not significantly different (1 day vs. 2 days; P = 0.14).

Conclusion

Laparoscopic appendicectomy in children in a UK District General Hospital is safe and was associated with significantly less post-operative morbidity than the open technique.     

Paediatric laparoscopic Heller’s cardiomyotomy: A single centre series

Background

The optimal management of oesophageal achalasia remains unclear in the paediatric population due to the rarity of the disease. This study reviews the institutional experience of the laparoscopic Heller’s cardiomyotomy (HC) procedure and attempts to define the most appropriate treatment.

Methods

A retrospective review of children undergoing HC at a single institution was performed. Demographics, pre-operative investigations, and interventions were reviewed. Post-operative outcomes and follow up were evaluated. Data is expressed as median (range).

Results

Twenty-eight children were included (13 male, 15 female) whose median age was 13 (3.2–17.4) years. Nine children underwent a pre-operative oesophageal balloon dilatation (OBD) a median of 1(1–6) times. Others included botulinum toxin injection (n = 1) and Nifedipine (n = 1). All had a pre-operative upper gastrointestinal contrast series, and twenty-five had upper gastrointestinal endoscopy and manometry. All had laparoscopic HC with no conversions, and ten had a concomitant fundoplication. Post-operative intervention occurred in eight (28%) incorporating OBD (n = 7), of whom four required a redo HC. One patient underwent a redo without intervening OBD. Follow-up was for a median of 0.83 (0–5) years with fourteen children discharged from surgical follow-up. Twenty-seven have thus far had a good outcome.

Conclusion

This study comprises the largest series of paediatric laparoscopic HC reported to date. It is effective with or without a fundoplication and is the best long term treatment modality available. OBD for persisting symptoms following HC may obviate the need for redo myotomy.     

Comparison of long-term outcomes between open and laparoscopic Thal fundoplication in children

Objectives

In recent years laparoscopic fundoplication is increasingly performed in pediatric surgery. The aim of this study was to compare the long-term outcomes between open and laparoscopic Thal fundoplication in children.

Methods

This retrospective study includes children who underwent a Thal fundoplication between 3/1997 and 7/2009. The minimum follow-up time to enter the study was 2 years; the overall median follow-up was 77 months (range, 29–176 months).

Results

A total of 101 patients were included, of which 47 underwent an open and 54 a laparoscopic Thal. Intraoperative problems, early postoperative complications, time to establish enteral feeds and length of stay did not differ among both groups. The mean duration of surgery was significantly less in the open group (OPG) (108.0 (± 7.72) versus 144.1 (± 6.36) minutes; p = 0.001) and this was mainly attributed to patients with neurological problems. Severe dysphagia requiring endoscopy was observed in 10 patients, but this did not differ significantly between groups (n = 2 in the OPG vs. n = 8 in the laparoscopic group (LAPG); p = 0.10). Overall 12 patients (11.9%) (6 in each group) required a redo-fundoplication after a median of 18.7 months (range, 6–36 months). In the whole study group, 80 patients (79.2%) were classified as having surgical results being excellent, good or satisfactory and this did not differ significantly between groups.

Conclusions

In the long-term open and laparoscopic Thal fundoplication have similarly good outcomes. The laparoscopic approach can be considered as an alternative, however there is not a clear superiority compared with the open counterpart.     

A standardised investigative strategy prior to revisional oesophageal surgery in children: High incidence of unexpected findings

Background/Purpose

Revisional oesophageal reconstructive surgery carries uncommon and unusual risks related to previous surgery. To provide maximum anatomical detail and facilitate successful outcome, we report a standardised pre-operative investigative strategy for all such patients.

Methods

Prospective 8-month cohort study following the introduction of this strategy. All patients underwent high resolution thoracic contrast CT scan and micro-laryngo-bronchoscopy by a paediatric ENT surgeon in addition to upper gastrointestinal contrast study, oesophagoscopy, and echocardiogram.

Results

Seven children (median age 5.6 months [range 2.2–60]) completed the pathway. Four were referred with recurrence of a previously divided tracheo-oesophageal fistula (3 congenital, 1 acquired) and 3 (all with oesophagostomy) for oesophageal replacement for congenital isolated oesophageal atresia (OA, n = 1) and failed repair of OA with distal TOF with wide gap (n = 2). Overall, unanticipated findings were demonstrated in 6/7 children and comprised severe tracheomalacia and right main bronchus stenosis requiring aortopexy (n = 1), vocal cord palsy (n = 2), extensive mediastinal rotation (n = 1), proximal tracheal diverticulum (n = 1), severe subglottic stenosis requiring airway reconstruction (n = 1), proximal tracheal diverticulum (n = 1), right sided aortic arch (n = 1) and left sided aortic arch (previously reported to be right sided, n = 1).

Conclusions

This standardised approach for this complex group of patients reveals a high incidence of unexpected anatomical and functional anomalies with significant surgical and possible medico-legal implications. We recommend these investigations during the pre-operative work-up prior to all revisional oesophageal surgery.     

Obesity Has Minimal Impact on Clinical Outcomes in Children with Inflammatory Bowel Disease

Purpose

Childhood obesity is an increasing problem in affluent societies throughout the world. We sought to identify the impact of obesity on the outcome of inflammatory bowel disease (IBD) and determine differences (if any) between ulcerative colitis (UC) and Crohn’s disease (CD).

Methods

The 2009 Kids’ Inpatient Database was explored for all children (≤ 20 years) admitted with IBD. ICD-9 codes were used to identify obesity and complications, including hemorrhage, perforation, and complex fistulas. Logistic regression analysis accounting for demographics, underlying disease, surgical procedures, and obesity was performed to identify factors associated with complication development. Data are expressed as odds ratios (OR) and a 95% confidence interval (CI). A P value of 0.05 was regarded as significant.

Results

From 12,465 admissions, 164 children were obese (1.3%), with no difference between CD and UC (1.3% vs. 1.4%; P = 0.60). Girls had a two-fold increase in obesity (OR: 2.06, CI: 1.48–2.86; P < 0.01). Obesity had no effect on elective/emergent admission rate (OR: 0.85, CI: 0.54–1.35; P = 0.49), perforation (OR: 0.76, CI: 0.13–4.46; P = 0.76), hemorrhage (OR: 0.64,CI: 0.34–1.21; P = 0.17), complex fistula (OR: 1.19, CI: 0.45–3.17; P = 0.72), or requirement for surgery (OR: 0.80, CI: 0.48–1.31; P = 0.37). While the overall clinical morbidity rate was 10.7%, obesity was not associated with the development of overall complications (OR 1.20, CI: 0.75–1.93; P = 0.45) or length of stay (6.36 vs. 6.10 days; P = 0.61). Obesity increased the rate of central venous catheter (CVC) infections (OR: 10.98, CI: 2.50–48.20; P < 0.01).

Conclusions

Obesity was more prevalent in girls with IBD. While obesity did not alter disease severity, rate of surgical intervention, or hospital length of stay, it was associated with higher CVC infections.     

Open versus needle biopsy in diagnosing neuroblastoma

Background

Open surgical biopsy is traditionally advocated prior to initiating therapy in UKCCLG neuroblastoma protocols. We report a single centre experience comparing the utility of open biopsy vs image guided needle biopsy in aiding the definitive diagnosis and risk stratification of neuroblastoma – (Shimada classification, MYCN expression, cytogenetics – 1p 11q, 17 q).

Methods

Medical records of all new cases of neuroblastoma presenting to a single UKCCLG centre during January 2002–July 2013 were examined.

Results

Thirty nine patients underwent a biopsy of primary tumour for neuroblastoma during the study. Twenty one children had open biopsy and eighteen cases had a needle biopsy. Staging of neuroblastoma revealed - stage 4 (n = 26), stage 3 (n = 7), stage 2 (n = 3) and stage 4S (n = 3). Sites of primary tumour were adrenal gland (n = 20), abdomen (n = 12), thoracic (n = 4), abdomino-thoracic (n = 2) and abdomino pelvic regions (n = 1). All patients (open vs needle) had adequate tissue retrieved for histological diagnosis of neuroblastoma. One needle and one open biopsy case did not have MYCN status determined despite adequate tissue sampling. Seventeen patients (7 open and 10 needle biopsies) had 1p and 17q status reported in MLPA testing (Multiplex Ligation-dependent Probe Amplification). No single patient required a repeat tumour biopsy. Morbidity in the series was minimal with only one child – open biopsy group, requiring emergent laparotomy to control bleeding from an abdominal primary tumour. No complications were recorded with needle biopsy.

Conclusions

Open and image guided needle biopsy appear to yield adequate tissue sampling for diagnosis, risk classification and staging of neuroblastoma. Further larger co-operative studies may usefully guide national and international protocols.     

Primary malignant pancreatic neoplasms in children and adolescents: A 20 year experience

Background

Malignant pancreatic neoplasms in children and adolescents are rare. The clinical presentation, pathologic characteristics, management, and outcomes at two institutions are discussed.

Methods

We retrospectively reviewed all pediatric patients (age < = 18 years) treated for malignant pancreatic neoplasms at two institutions between 1991 and 2011.

Results

Thirty-one patients were identified with median age of 14.7 years (4–18 years). The most common histology was solid pseudopapillary tumor (SPT) (n = 22, 71%) followed by neuroendocrine tumors (n = 4, 13%), pancreatoblastoma (n = 4, 13%), and one unclassified spindle cell neoplasm (3%). Most patients presented with abdominal pain (n = 22, 71%). Complications included pancreatic leak, pseudocyst formation, pancreatitis, pancreatic insufficiency, and small bowel obstruction. The overall 1- and 5-year survival was 96% (95% CI 74%–99%) and 78% (95% CI 43%–93%). Median follow-up among patients alive at the end of follow-up was 20 months (< 1 month–16.2 years). Patients with SPT had better overall survival compared to patients with neuroendocrine tumors or pancreatoblastomas (Log-rank; p = 0.0143).

Conclusion

The majority of pediatric and adolescent patients present with SPTs which are usually resectable and associated with an excellent prognosis. Other histologic subtypes more often present with distant metastases and portend a worse prognosis.     

The relationship between reticulated platelets,intestinal alkaline phosphatase,and necrotizing enterocolitis

Background

Necrotizing enterocolitis (NEC) affects up to 10% of extremely-low-birthweight infants, with a 30% mortality rate. Currently, no biomarker reliably facilitates early diagnosis. Since thrombocytopenia and bowel ischemia are consistent findings in advanced NEC, we prospectively investigated two potential biomarkers: reticulated platelets (RP) and intestinal alkaline phosphatase (iAP).

Methods

Infants born ≤ 32 weeks and/or ≤ 1500 g were prospectively enrolled from 2009 to 2012. Starting within 72 hours of birth, 5 weekly whole blood specimens were collected to measure RP and serum iAP. Additional specimens were obtained at NEC onset (Bell stage II or III) and 24 hours later. Dichotomous cut-points were calculated for both biomarkers. Non-parametric (Mann-Whitney) and Chi-square tests were used to test differences between groups. Differences in Kaplan-Meier curves were examined by log-rank test. The Cox proportional hazards model estimated hazard ratios.

Results

A total of 177 infants were enrolled in the study, 15 (8.5%) of which developed NEC (40% required surgery and 20% died). 14 (93%) NEC infants had “low” (≤ 2.3%) reticulated platelets, and 9 (60%) had “high” iAP (> 0 U/L) in at least one sample before onset. Infants with “low” RP were significantly more likely to develop NEC [HR = 11.0 (1.4–83); P = 0.02]. Infants with “high” iAP were at increased risk for NEC, although not significant [HR = 5.2 (0.7–42); P = 0.12]. Median iAP levels were significantly higher at week 4 preceding the average time to NEC onset by one week (35.7 ± 17.3 days; P = 0.02).

Conclusion

Decreased RP serves as a sensitive marker for NEC onset, thereby enabling early preventative strategies. iAP overexpression may signal NEC development.     

Laparoscopic pancreaticojejunostomy for pancreatic ductal dilatation in children

Purpose

The application of laparoscopic surgery in pancreatic surgery in children is limited. In this article, we describe laparoscopic pancreaticojejunostomy for children with congenital pancreatic ductal dilatation.

Methods

Four children with recurrent pancreatitis and pancreatic ductal dilatation underwent laparoscopic pancreaticojejunostomy between July 2009 and November 2011. Longitudinal incision of the dilated pancreatic ducts and side-to-side Roux-Y pancreaticojejunostomy were performed.

Results

Operative time ranged from 103 to 154 min, and blood loss was minimal. The average postoperative hospital stay was 4 to 6 days. There were no pancreatic leaks. None of the patients experienced recurrence of pancreatitis.

Conclusions

Laparoscopic pancreaticojejunostomy for children with congenital pancreatic ductal dilatation is safe and effective.     

Shifts towards pediatric specialists in the treatment of appendicitis and pyloric stenosis: Trends and outcomes

Background

Little data exists on temporal changes in the care of children with common surgical conditions. We hypothesized that an increasing proportion of procedures are performed at pediatric hospitals over time, and that outcomes are superior at these centers.

Methods

We conducted a retrospective cohort study using Washington State discharge records for children 0–17 years old undergoing appendectomy (n = 39,472) or pyloromyotomy (n = 3,500). Pediatric hospitals were defined as centers with full-time pediatric surgeons. Outcomes were examined for two time periods (1987–2000, 2001–2009).

Results

From 1987 to 2009, the proportion of procedures performed at pediatric hospitals steadily increased. The percentage for appendectomies increased from 17% to 32%, and that for pyloromyotomies increased from 57% to 99%. For pyloromyotomy, care at a pediatric hospital was associated with decreased risk of postoperative complications (OR = 0.36, p < 0.001) for both time periods. Appendectomy outcomes did not differ significantly in the early time period, but in the later time period specialist care was associated with lower risk of complications in children < 5 years (OR = 0.54, p = 0.03).

Conclusion

There has been a shift towards pediatric hospitals for certain procedures, with a widening disparity in outcomes for younger children. These results suggest that procedures in younger patients may best be performed by providers familiar with these patient populations.     

Implementation of laparoscopic splenectomy in children and the incidence of portal vein thrombosis diagnosed by ultrasonography

Background

The aim of this study is to evaluate if symptomatic or asymptomatic PVT, as diagnosed with ultrasonography (US), occurs more often in children after the introduction and implementation of LS compared to open splenectomy.

Methods

A retrospective cohort of 76 splenectomized patients for benign hematological disease were analyzed, 24 after open splenectomy (OS) and 52 after LS.

Results

In six of the OS and 40 after LS a postoperative US was obtained. In two patients after LS, a PVT was seen on US. Both patients were symptomatic and also underwent a laparoscopic cholecystectomy. The length of stay in the hospital was significantly shorter for LS (median 4.5 days, range 2–12) compared to OS (median 7 days, range 5–12), (P = .00). Median operation time of OS was 65 min (range 35–130 min) and of LS 170 min (range 85–275 min) (P = .00). There was no difference in postoperative complications.

Conclusion

The risk of developing a PVT after laparoscopic splenectomy seems low, and thus LS is not contraindicated in patients with benign hematological disease. When combining LS and laparoscopic cholecystectomy, prophylactic heparin might be considered.     

Transabdominal electrical stimulation increases colonic propagating pressure waves in paediatric slow transit constipation

Background and aims

In slow-transit constipation (STC) pancolonic manometry shows significantly reduced antegrade propagating sequences (PS) and no response to physiological stimuli. This study aimed to determine whether transcutaneous electrical stimulation using interferential current (IFC) applied to the abdomen increased colonic PS in STC children.

Methods

Eight children (8–18 years) with confirmed STC had 24-h colonic manometry using a water-perfused, 8-channel catheter with 7.5 cm sidehole distance introduced via appendix stomas. They then received 12 sessions (20 min/3 × per week) of IFC stimulation (2 paraspinal and 2 abdominal electrodes), applied at a comfortable intensity (< 40 mA, carrier frequency 4 kHz, varying beat frequency 80–150 Hz). Colonic manometry was repeated 2 (n = 6) and 7 (n = 2) months after IFC.

Results

IFC significantly increased frequency of total PS/24 h (mean ± SEM, pre 78 ± 34 vs post 210 ± 62, p = 0.008, n = 7), antegrade PS/24 h (43 ± 16 vs 112 ± 20, p = 0.01) and high amplitude PS (HAPS/24 h, 5 ± 2:10 ± 3, p = 0.04), with amplitude, velocity, or propagating distance unchanged. There was increased activity on waking and 4/8 ceased using antegrade continence enemas.

Conclusions and inferences

Transcutaneous IFC increased colonic PS frequency in STC children with effects lasting 2–7 months. IFC may provide a treatment for children with treatment-resistant STC.     

Preoperative multiple endocrine neoplasia type 1 diagnosis improves the surgical outcomes of pediatric patients with primary hyperparathyroidism

Background

Primary hyperparathyroidism (PHPT) is uncommon in children. The surgical management of PHPT in children has evolved over the past two decades.

Methods

A retrospective study of patients who underwent parathyroidectomy for PHPT diagnosed at age < 18 years and managed at a tertiary referral center for endocrine and familial disorders.

Results

Thirty-eight patients met eligibility criteria (1981–2012). Median age at PHPT diagnosis was 15 years. Two-thirds of patients were symptomatic (68%, n = 26), most commonly from nephrolithiasis. Twenty-six (68%) patients underwent a standard cervical exploration while 32% underwent a focused unilateral parathyroidectomy. Multiple endocrine neoplasia type 1 (MEN1) was diagnosed preoperatively in 22/26 patients. Patients with a preoperative diagnosis of MEN1 were more likely to undergo a complete initial operation (≥ 3 gland parathyroidectomy with transcervical thymectomy, 13/22, 59% vs. 0/4, 0%; P = 0.03) and less likely to have recurrent disease (10/22, 45% vs. 3/4, 75%; P < 0.001) during follow up than patients diagnosed postoperatively.

Conclusions

Children with PHPT should raise suspicion for MEN1. Preoperative MEN1 evaluation helped guide the extent of initial parathyroidectomy and was associated with lower rates of recurrence in sporadic and familial PHPT in pediatric patients. Management should occur at a high volume center with experienced clinicians and genetic counseling services.     

Technique and Outcomes of Robot-assisted Retroperitoneoscopic Partial Nephrectomy: A Multicenter Study

Background

Robot-assisted retroperitoneoscopic partial nephrectomy (RARPN) may be used for posterior renal masses or with prior abdominal surgery; however, there is relatively less familiarity with RARPN.

Objective

To demonstrate RARPN technique and outcomes.

Design, setting, and participants

A retrospective multicenter study of 227 consecutive RARPNs was performed at the Swedish Medical Center, the University of Michigan, and the University of California, Los Angeles, from 2006 to 2013.

Surgical procedure

RARPN.

Outcome measurements and statistical analysis

We assessed positive margins and cancer recurrence. Stepwise regression was used to examine factors associated with complications, estimated blood loss (EBL), warm ischemia time (WIT), operative time (OT), and length of stay (LOS).

Results and limitations

The median age was 60 yr (interquartile range [IQR]: 52–66), and the median body mass index (BMI) was 28.2 kg/m² (IQR: 25.6–32.6). Median maximum tumor diameter was 2.3 cm (IQR: 1.7–3.1). Median OT and WIT were 165 min (IQR: 134–200) and 19 min (IQR: 16–24), respectively; median EBL was 75 ml (IQR: 50–150), and median LOS was 2 d (IQR: 1–3). Twenty-eight subjects (12.3%) experienced complications, three (1.3%) had urine leaks, and three (1.3%) had pseudoaneurysms that required reintervention. There was one conversion to radical nephrectomy and three transfusions. Overall, 143 clear cell carcinomas (62.6%) composed most of the histology with eight positive margins (3.5%) and two recurrences (0.9%) with a median follow-up of 2.7 yr. In adjusted analyses, intersurgeon variation was associated with complications (odds ratio [OR]: 3.66; 95% confidence interval, 1.31–10.27; p = 0.014) and WIT (parameter estimate [PE; plus or minus standard error]: 4.84 ± 2.14; p = 0.025). Higher surgeon volume was associated with shorter WIT (PE: −0.06 ± 0.02; p = 0.002). Higher BMI was associated with longer OT (PE: 2.09 ± 0.56; p < 0.001). Longer OT was associated with longer LOS (PE: 0.01 ± 0.01; p = 0.002). Finally, there was a trend for intersurgeon variation in OT (PE: 18.5 ± 10.3; p = 0.075).

Conclusions

RARPN has acceptable morbidity and oncologic outcomes, despite intersurgeon variation in WIT and complications. Greater experience is associated with shorter WIT.

Patient summary

Robot-assisted retroperitoneoscopic partial nephrectomy has acceptable morbidity and oncologic outcomes, and there is intersurgeon variation in warm ischemia time and complications.     

Measured gap length and outcomes in oesophageal atresia

Aims

Oesophageal atresia (OA) with or without tracheoesophageal fistula (TOF) is the most common congenital anomaly of the oesophagus. There is limited literature suggesting a linear relationship between increasing gap length and the incidence of all major complications. We sought to assess whether measured gap length at the time of surgery was related to outcomes in our patients.

Methods

All patients with a diagnosis of OA +/− TOF who underwent repair under a single surgeon between 1983 and 2012 were included. The length between the oesophageal pouches was measured at the time of surgery. Patients were then divided into three groups; short ≤ 1 cm, intermediate > 1–≤2 cm and long > 2–≤5 cm. Outcome measures were anastomotic leak, strictures requiring dilatation, gastrooesophageal reflux disease (GORD) and need for fundoplication.

Results

122 patients were included in the study. The outcomes for patients with short (n = 53), intermediate (n = 51) and long gaps (n = 18) were as follows: anastomotic leak — 1.9%, 2%, 5.5% (P = 0.66), strictures requiring dilatation — 32%, 33%, 50% (P = 0.67), GORD — 51%, 59%, 72% (P = 0.58) and need for fundoplication — 11%, 20%, 44% (*P = 0.02). There were no deaths related to the repair.

Conclusions

Measured gap length at the time of surgery did not have a linear relationship with leak or stricture rate. Our experience suggests that when primary repair is possible absolute gap length is irrelevant to the development of post-operative complications. There is however a significant increase in the need for fundoplication in those with a long gap.     

Prognostic Significance of Gleason Score Discrepancies between Needle Biopsy and Radical Prostatectomy

Objectives

Discordance between the Gleason score (GS) on needle biopsy (NB) and the GS of the radical prostatectomy (RP) specimen is a common finding. The objective of this study was to evaluate the prognostic significance of these discrepancies with respect to outcomes following RP.

Methods

In the study, 6625 men treated by RP were categorized as having NB=RP (68.8%), NB<RP (25.0%) or NB>RP (6.2%) GS, and stratified for analyses into RP GS groups. The Kaplan-Meier method was used to analyze differences in biochemical recurrence–free survival (BRFS), and multivariate Cox analyses were performed to estimate the independent relative risk of progression associated with GS discrepancies.

Results

Across multiple RP GS strata (3+4, 7, 8, 8–10), patients with a lower NB GS experienced significantly better BRFS than patients with equal NB and RP GS (all p < 0.05). NB<RP GS was independently associated with better (pooled HR, 0.76, p = 0.001) BRFS, within and across RP GS strata. Similarly, patients with NB>RP GS had poorer BRFS than patients with NB=RP GS across multiple RP GS strata (≤3+3, 3+4, 7; all p < 0.05). NB>RP GS was independently associated with worse (pooled HR, 1.91, p < 0.001) BRFS probabilities, within and across RP GS strata.

Conclusions

Our data suggest that the GS of the NB adds additional prognostic value to the RP GS in a consistent manner that may be applicable to strategies of risk stratification and patient counseling after surgery.     

“Is the length of time in acute burn surgery associated with poorer outcomes?”

Background

Acute wound closure surgery improves outcomes, after burn particularly mortality, but also imposes physiological stress on the patient. The duration of surgery is associated with adverse outcomes in other populations. This study aimed to examine if extended acute burn surgery duration was associated with poorer in-hospital outcomes.

Methods

This retrospective cohort study included adult burn patients who required a single wound closure surgery at Royal Perth Hospital between 2004 and 2011. Multivariable regression analyses were used to assess the influence of patient and injury factors on surgery duration and length of stay (LOS).

Results

Surgery duration independently increased LOS (incidence rate ratio [IRR] = 1.004, p < 0.001). This translates to a predicted 13% increase in LOS for a 30 min increase in surgery ‘knife to skin’ time. Total body surface area (TBSA) was identified as a significant predictor of surgery duration (IRR = 1.047, p < 0.001), estimating that a 10% TBSA increase results in a 59% increase in surgery duration.

Conclusion

The results show that surgery duration is associated with LOS after adjusting for size of burn and other factors. The study justifies the need to explore strategies to reduce acute burn surgery duration.     

Laparoscopic Approach for Artificial Urinary Sphincter Implantation in Women with Intrinsic Sphincter Deficiency Incontinence: A Single-Centre Preliminary Experience

Background

Implantation of an artificial urinary sphincter (AUS) is used as a last resort in women with stress urinary incontinence (SUI).

Objective

To assess the early functional outcome after laparoscopic placement of an AUS in women.

Design, setting, and participants

Twelve women with type 3 SUI underwent a laparoscopic AUS placement between 2006 and 2008. Eleven (92%) had previously undergone anti-incontinence procedures.

Intervention

The AUS was implanted with laparoscopic access either preperitoneally or intraperitoneally. The cuff was placed around the bladder neck between the periurethral fascia and the vagina.

Measurements

Perioperative complications were reviewed. To assess resolution of urinary incontinence, all patients were seen at 1, 3, 6, and 12 mo after the surgery and yearly thereafter.

Results and limitations

The mean age of subjects was 56.7 ± 12 yr (33–78). The mean body mass index was 24 ± 2.3 (20–25). The mean preoperative closure pressure was 22 ± 10.9 cmH₂O (4–35). The mean operative time was 181 ± 39 min [110–240]. Intraoperative complications occurred in three women (25%), with bladder (n = 2) and vaginal (n = 2) injuries. These complications required open conversion. AUS implantation was postponed in one case. The mean hospital stay was 7 ± 2.3 d (3–11). The bladder catheter was removed after a mean time of 10 ± 8 d (2–30). Urinary retention was observed in five cases (45%) after bladder catheter removal. AUS activation was done 4–14 wk after implantation. Mean follow-up was 12.1 ± 8 mo (5.2–27). Incontinence was completely resolved in eight women (88%) who underwent complete laparoscopic procedure. The main limitation of the study was the limited length of follow-up.

Conclusions

AUS implantation can be successfully achieved by laparoscopy. It appears to be technically feasible. These results are still preliminary, and further studies of larger populations with longer follow-up are needed to make any statement regarding surgical strategy.     

Is routine chest radiograph necessary after chest tube removal?

Background

Obtaining a chest radiograph (CXR) after chest tube (CT) removal to rule out a pneumothorax is a universal practice. However, the yield of this CXR has not been well documented. Additionally, most iatrogenic pneumothoraces resulting from CT removal are atmospheric in origin, asymptomatic, and can be observed. Recently, we have begun to discontinue routine CXR for CT removal. We evaluated our experience with CT removal to clarify the usefulness of routine post CT removal CXR.

Methods

After IRB approval, a retrospective study was conducted on patients who had a CT placed in the past decade. Cardiac patients requiring a CT were excluded. Patient demographics, diagnosis, treatments, and outcomes were collected. Patients were divided into two groups, those with a CXR after CT removal (Group 1) and those without (Group 2). Percentages were compared with Chi square with Yates correction.

Results

462 patients were identified (group 1 = 327, group 2 = 135). Indications for CT included; empyema (n = 176), lung resection (n = 146), pneumothorax (n = 71), pleural effusion (n = 26), spinal fusion (n = 20), trauma (n = 16), and miscellaneous (n = 7). Seven patients (2.1%) in group 1 required reinsertion for pneumothorax (n = 4), empyema (n = 2), and pleural effusion (n = 1) compared to 1 patient (0.7%) in group 2 who required reinsertion for pleural effusion. This difference was not significant (P = 0.2).

Conclusions

In non-cardiac patients with a CT, tube reinsertion is uncommon and tube replacement is secondary to symptoms. Therefore, routine post CT removal CXR is not necessary. CXR in these patients should be obtained based upon clinical indications after CT removal.     

Laparoscopy utilization and outcomes for appendicitis in small children

Purpose

To examine the trends in laparoscopic appendectomy (LA) utilization and outcomes for children 5 years or younger.

Methods

We studied 16,028 inpatient admissions for children 5 years of age or less undergoing an appendectomy for acute appendicitis in 2000, 2003, and 2006 using the Kids' Inpatient Database (KID). Laparoscopy frequency, hospital length of stay, and complications were reviewed.

Results

In 2000, 2003 and 2006 appendectomies were done laparoscopically 11.4%, 18.7% and 31.3% of the time, respectively. Children were more likely to undergo LA at a children's hospital (P < 0.001). LA complications were less likely overall (OR: 0.80, CI: 0.70–0.92, P = 0.002) and in perforated cases (OR: 0.78, CI: 0.67-0.91, P = 0.001). LA decreased hospital length of stay by 0.54 days for all patients and 0.70 days for perforated cases (P < 0.001).

Conclusions

Open appendectomy has historically been the standard in children 5 years of age and younger. Laparoscopic appendectomy has slowly gained acceptance for the treatment of appendicitis in smaller children. The use of laparoscopy has increased significantly at all facilities. Furthermore, laparoscopic appendectomy in this age group has a comparatively low complication rate and short hospital length of stay, and is safe in complicated perforated appendicitis cases.