Undescended testes: Does age at orchiopexy affect survival of the testis?

Purpose

The optimal age at which to perform orchiopexy for cryptorchidism has long been debated. The aim of this study was to determine if age at orchiopexy affected testicular atrophy.

Methods

A retrospective review of patients undergoing orchiopexy from 2000 to 2010 was conducted. An individual testis, rather than patient, was used as the dependent variable. A total of 349 testicles from 1126 charts (ICD-9 = 752.51) were identified. Primary study outcome was testicular survival without atrophy.

Results

Mean follow up for the study was 25 months. There was postoperative atrophy in 27 testes (7.7%). Intraabdominal testicle was independently associated with increased postsurgical atrophy (p < 0.0001). The odds of postsurgical atrophy were 15.66 times higher for an abdominal vs. inguinal location (95% CI: 5.5–44.6). Testicular atrophy was highest for orchiopexy at ages 13–24 months (n = 16 of 133, 12%) vs. those less than 13 months (n = 3 of 64, 5%), and those greater than 24 months (n = 8 of 152, 5%) (p = 0.0024). After adjusting for location, age was not statistically significant with postsurgical atrophy (p = 0.055).

Conclusions

From this study we conclude that there is no increase in testicular atrophy in patients less than 13 months.     

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.     

Maternal medical and behavioral risk factors for congenital diaphragmatic hernia

Purpose

Maternal factors contributing to the etiology of congenital diaphragmatic hernia (CDH) remain unclear. We hypothesized that specific maternal medical conditions (pregestational diabetes, hypertension), and behaviors (alcohol, tobacco) would be associated with CDH.

Methods

We conducted a population-based case–control study using Washington State birth certificates linked to hospital discharge records (1987–2009). We identified all infants with CDH (n = 492). Controls were randomly selected among non-CDH infants. Maternal data were extracted from the birth record. Logistic regression was used to adjust for covariates.

Results

Cases and controls were generally similar regarding demographics, although CDH infants were more likely to be male than controls (58.5% vs. 52.5%). Isolated and complex (multiple-anomaly) CDH had similar characteristics. Each of the exposures of interest was more common among case mothers than among control mothers. In univariate analysis, alcohol use, hypertension, and pregestational diabetes were each significantly associated with the outcome. After multivariate adjustment, only alcohol use (OR = 3.65, p = 0.01) and pregestational diabetes (OR = 12.53, p = 0.003) maintained significance. Results were similar for both isolated and complex CDH.

Conclusions

Maternal pregestational diabetes and alcohol use are significantly associated with occurrence of CDH in infants. These are important modifiable risk factors to consider with regard to efforts seeking to impact the incidence of CDH.     

Epidural analgesia versus intravenous patient-controlled analgesia following minimally invasive pectus excavatum repair: a systematic review and meta-analysis

Background/Purpose

The minimally invasive pectus excavatum repair (MIPER) is a painful procedure. The ideal approach to postoperative analgesia is debated. We performed a systematic review and meta-analysis to assess the efficacy and safety of epidural analgesia compared to intravenous Patient Controlled Analgesia (PCA) following MIPER.

Methods

We searched MEDLINE (1946–2012) and the Cochrane Library (inception–2012) for randomized controlled trials (RCT) and cohort studies comparing epidural analgesia to PCA for postoperative pain management in children following MIPER. We calculated weighted mean differences (WMD) for numeric pain scores and summarized secondary outcomes qualitatively.

Results

Of 699 studies, 3 RCTs and 3 retrospective cohorts met inclusion criteria. Compared to PCA, mean pain scores were modestly lower with epidural immediately (WMD − 1.04, 95% CI − 2.11 to 0.03, p = 0.06), 12 hours (WMD − 1.12; 95% CI − 1.61 to − 0.62, p < 0.001), 24 hours (WMD − 0.51, 95%CI − 1.05 to 0.02, p = 0.06), and 48 hours (WMD − 0.85, 95% CI − 1.62 to − 0.07, p = 0.03) after surgery. We found no statistically significant differences between secondary outcomes.

Conclusions

Epidural analgesia may provide superior pain control but was comparable with PCA for secondary outcomes. Better designed studies are needed. Currently the analgesic technique should be based on patient preference and institutional resources.     

Infant car safety seats and risk of head injury

Background/Purpose

We observed a high incidence of traumatic brain injuries (TBI) in properly restrained infants involved in higher speed motor vehicle crashes (MVCs). We hypothesized that car safety seats are inadequately protecting infants from TBI.

Methods

We retrospectively queried scene crash data from our State Department of Transportation (2007–2011) and State Department of Public Health data (2000–2011) regarding infants who presented to a trauma center after MVC.

Results

Department of Transportation data revealed 94% of infants in MVCs were properly restrained (782/833) with average speed of 44.6 miles/h when there was concern for injury. Department of Public Health data showed only 67/119 (56.3%) of infants who presented to a trauma center after MVC were properly restrained. Properly restrained infants were 12.7 times less likely to present to a trauma center after an MVC (OR = 12.7, CI 95% 5.6–28.8, p < 0.001). TBI was diagnosed in 73/119 (61.3%) infants; 42/73 (57.5%) properly restrained, and 31/73 (42.5%) improperly/unrestrained (p = 0.34). Average head abbreviated injury scale was similar for properly restrained (3.2 ± 0.2) and improperly/unrestrained infants (3.5 ± 0.2, p = 0.37).

Conclusion

Car safety seats prevent injuries. However, TBI is similar among properly restrained and improperly/unrestrained infants involved in higher speed MVCs who present to a trauma center.     

Incidence and factors associated with sensorineural and conductive hearing loss among survivors of congenital diaphragmatic hernia

Purpose

The reported incidence of sensorineural hearing loss (SNHL) in long-term survivors of congenital diaphragmatic hernia varies widely in the literature. Conductive hearing loss (CHL) is also known to occur in CDH patients, but has been less widely studied. We sought to characterize the incidence and risk factors associated with SNHL and CHL in a large cohort of CDH patients who underwent standardized treatment and follow-up at a single institution.

Methods

We retrospectively reviewed charts of all CDH patients in our pulmonary hypoplasia program from January 2004 through December 2012. Categorical variables were analyzed by Fisher’s exact test and continuous variables by Mann–Whitney t-test (p ≤ 0.05).

Results

A total of 112 patients met study inclusion criteria, with 3 (2.7%) patients diagnosed with SNHL and 38 (34.0%) diagnosed with CHL. SNHL was significantly associated with requirement for ECMO (p = 0.0130), prolonged course of hospitalization (p = 0.0011), duration of mechanical ventilation (p = 0.0046), requirement for tracheostomy (p = 0.0013), and duration of loop diuretic (p = 0.0005) and aminoglycoside therapy (p = 0.0003).

Conclusions

We have identified hearing anomalies in over 30% of long-term CDH survivors. These findings illustrate the need for routine serial audiologic evaluations throughout childhood for all survivors of CDH and stress the importance of targeted interventions to optimize long-term developmental outcomes pertaining to speech and language.     

The long term physical consequences of gastroschisis

Purpose

To determine the progress, physical and metabolic outcomes of gastroschisis survivors.

Methods

Fifty children born with gastroschisis were assessed with a health questionnaire, physical assessment, bone density and nutritional blood parameters at a median age of 9 years (range 5–17).

Results

After initial abdominal closure, 27/50 (54%) required additional surgical interventions. Ten (20%) children had complex gastroschisis (CG). Abdominal pain was common: weekly in 41%; and requiring hospitalization in 30%. The weight, length and head circumference z-scores improved by a median 0.88 (p = 0.001), 0.56 (p = 0.006) and 0.74 (p = 0.018) of a standard deviation (SD) respectively from birth; 24% were overweight or obese at follow up. However, those with CG had significantly lower median weight z-scores (− 0.43 v 0.49, p = 0.0004) and body mass index (BMI) (− 0.48 v 0.42, p = 0.001) at follow up compared to children with simple gastroschisis. Cholesterol levels were elevated in 24% of children. Bone mineral density was reassuring. There were 15 instances of low blood vitamin and mineral levels.

Conclusions

Although gastroschisis survival levels are high, many children have significant ongoing morbidity. Children with simple gastroschisis showed significant catch up growth and a quarter had become overweight.     

Pepsin levels and oxidative stress markers in exhaled breath condensate of patients with gastroesophageal reflux disease

Aim

To evaluate the pepsin and oxidative stress markers in exhaled breath condensate (EBC) in patients with gastroesophageal reflux disease (GERD).

Patients and Method

Patients with a presumptive diagnosis of GERD with recurrent respiratory and gastrointestinal problems aged between 2 and 14 years were included in the study. All patients underwent pH monitoring. Patients with a reflux index (RI) ≥ 4 were assessed as the reflux group, and those with an RO < 4 were assessed as the non-reflux group. Pepsin levels and oxidative stress markers [NO metabolites (NOX) and total sulphydrile (TSH) levels] were measured in the EBC.

Results

There were 24 patients in the reflux group [RI 17.6 (6.6–46.4)] [median, interquartile range] and 23 in the non-reflux group [RI 0.8 (0.5–1.9) (p < 0.001). Pepsin levels in the EBC were below the level of detection. The median levels of NOx in the EBC of children with reflux [13.7 μmol/L (7.3–24.5)] were lower in than non-reflux group [21.0 μmol/L (14.0–25.2)] (p = 0.034). There was a negative correlation between reflux index and NOX levels in EBC (rs: − 0.331, p = 0.023). In contrast, there was no difference in TSH levels between the reflux and non-reflux groups [37.4 μmol/L (30.2–44.6) vs 40.1 μmol/L (37.4–44.9), respectively, (p > 0.05)].

Conclusion

Decreased levels of NOX in patients with GER disease suggest increased oxidative stress in airways of these patients.     

Douleur et troubles comportementaux après adénoïdectomie et pose d’aérateurs transtympaniques chez l’enfant

Objectives

The purpose of this study was to evaluate postoperative pain in the hospital and at home as well as behavioural changes at home following outpatient adenoidectomy (VG) and ear tube (ATT) surgery.

Study design

Prospective cohort study.

Patients and methods

Sixty-four children (mean age 4.3 ± 2.4 years): 28 VG, 16 (ATT), 20 dual surgeries (VG-ATT). Postoperative pain was evaluated (arrival in recovery room, departure from wake-up room, departure from hospital) using the Objective Pain Scale (OPS). Parents evaluated their child's pain at home over a period of seven days using a numeric pain scale. Behavioural changes were measured with the Post-Hospital Behaviour Questionnaire (PHBQ).

Results

At arrival in the recovery room, OPS = 3.5 [0–6]. A statistically significant difference (p < 0.05) was shown between the VG group (OPS = 5 [2.25–7.75]), and the ATT (OPS = 0 [0–5.5]) and VG-ATT (OPS = 2 [0–5.75]) groups. OPS was 1.0 [0–2] when leaving the recovery room, and OPS was 0 [0–1] when leaving the hospital. Numeric pain scale scores recorded at home were extremely low. Postoperatively, 75% of parents at Day 1 and 40.6% at Day 7 reported at least one postoperative behavioural change.

Discussion

In all three groups, parents reported frequent postoperative behaviour changes despite adequate analgesia.

Conclusion

The relatively high frequency of postoperative behaviour changes in this population demonstrates the need to systematically evaluate those changes in order to improve overall paediatric care.     

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.     

Gastric emptying in children with gastroesophageal reflux and in healthy children

Purpose

The aim of this report is to examine whether children with gastroesophageal reflux (GER) have delayed gastric emptying compared to healthy children.

Methods

All patients had GER verified by 24-hour pH monitoring. Gastric emptying of cow’s milk was examined by radionuclide scintigraphy in 51 patients with GER and in 24 controls. Gastric emptying rate was expressed as exponential half time (T_1/2).

Results

Median age was 4.4 years [range 0.1–15.4] in patients and 6.1 years [range 2.5–10.0] in controls (p = .10). A wide range of gastric emptying rates was observed both in GER patients [range 16–121] and controls [range 29–94]. One GER patient (2%) had slower gastric emptying (T_1/2 = 121 min) than the healthy child with the longest T_1/2 (94 min). Mean T_1/2 was 49 minutes (SD 20.1) and 46 minutes (SD 14.2) in GER patients and controls, respectively (p = .51).

Conclusions

Gastric emptying rate of milk was not significantly different between children with GER and healthy children. A wide range of gastric emptying rates was observed in both groups.     

Bowel symptoms in children with anorectal malformation — a follow-up with a gender and age perspective

Background

Gender specific outcome for children with anorectal malformations (ARM) is rarely reported although it is important for medical care and in parent counseling.

Purpose

To assess bowel function according to the Krickenbeck system in relation to ARM-subtype, gender and age.

Method

All children born with ARM in 1998–2008 and referred to two centers in two different countries were followed up. The bowel function in 50 girls and 71 boys, median age 8 years, was analyzed.

Results

Among those with a perineal fistula, incontinence occurred in 42% of the females and in 10% of the males (p = 0.005) whereas constipation occurred in 62% of the females and 35% of the males (p < 0.001). No bowel symptoms differed between the females with perineal and vestibular fistulas (p > 0.3 for every symptom). Sacral malformations were associated with incontinence only in males with rectourethral fistulas. Constipation among the males differed between the age groups: 58% versus 26% (p = 0.013). Bowel symptoms did not change with age among the females.

Conclusion

Gender differences in outcome for children with ARM must be considered. Males with perineal fistulas had less incontinence and constipation than the females with perineal fistulas. The females with perineal and vestibular fistulas had similar outcomes.     

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.     

Anorectal malformations with good prognosis: Variables affecting the functional outcome

Backgroud/Purpose

The purpose of this study was to investigate the outcome of patients operated for anorectal malformations (ARMs) with good prognosis.

Methods

Thirty patients underwent clinical evaluation by Rintala score and anorectal manometry recording anal resting pressure (ARP), rectoanal inhibitory reflex (RAIR), and rectal volume (RV). The results were analysed with regard to sex, type of ARM, surgical timing of posterior sagittal anorectoplasty (PSARP), neurospinal cord dysraphism (ND), neonatal colostomy, and institution where they underwent surgery.

Results

6/30 (20%) presented ND despite normal sacrum. 17/30 (57%) patients had a normal Rintala score. ND and neonatal colostomy were significantly associated with a pathologic score (p = 0.0029 and p = 0.0016). Patients with ND had significantly lower ARP compared to patients with normal spine (23.5 ± 7.2 mmHg vs 32 ± 7.9 mmHg, p = 0.023). ARP was significantly lower in patients with neonatal colostomy compared to patients with primary repair (25.22 ± 10.24 mmHg vs 32.57 ± 6.68 mmHg, p = 0.026). RAIR was present in only 2/6 (33%) patients with ND, while in 21/24 (87.5%) without ND (p = 0.015) and in 4/9 (44%) patients with neonatal colostomy, while in 19/21 (90.5%) patients submitted to primary repair (p = 0.014).

Conclusions

Neurospinal cord dysraphism may be present despite normal sacral ratio. From a clinical point of view, patients with good prognosis ARMs are not completely comparable to healthy children. Neurospinal cord dysraphism and neonatal colostomy seem to worsen the clinical and manometric (ARP and RAIR) outcomes of these patients.     

Élargissement des plages horaires de visites dans une unité de réanimation : l’avis des proches

Objective

The present study was aimed at assessing the opinion of the patient's relatives concerning the visiting hours in the ICU.

Method

The visiting relatives were questioned about the information delivered in the Unit (assessed as 0 for minimal and 10 for maximal assessments, respectively) and the hypothesis to extend the Unit's visiting hours. The responses were given independently by the relatives.

Results

Eighty-seven out of 64 relatives responded (63% females). The delivered information was assessed by a median note = 10 (interquartile: [8–10]). The current visiting times (2 h per day during the week, 6 h in weekend) were assessed as sufficient by 48 closest (58%). Fifty-four (67%, CI95% = [56–77]) requested more liberal visiting times and 38 (46%, CI95% = [36–57]) requested 24 h visiting policy. Five relatives (6%, CI95% = [1–11]) would like to be present during patient's care. Most relatives do not wish to assist to patient's care to avoid interfering with caregiver's workload (81%), to respect the patient's intimacy (49%) and by fear of being impressed by the care (23%). Forty percent of the relatives would like to help feeding the patient.

Conclusion

Most of the relatives wish for more liberal visiting times without interfering with patient's care.     

Transanal endorectal pull-through for classic segment Hirschsprung's disease: With or without laparoscopic mobilization of the rectosigmoid?

Background

It has been suggested that the outcome of transanal endorectal pull-through for classic Hirschprung's disease can be improved by laparoscopically mobilizing the colon before the pullthrough.

Methods

Charts of 43 patients (2005–2009) with proven recto-sigmoid aganglionosis were retrospectively analyzed with respect to postoperative outcomes. Twenty-one had been treated with the transanal endorectal pull through (TERPT) and 22 with the laparoscopically assisted TERPT (LTERPT).

Results

Gender ratio, congenital anomalies, preoperative enterostomy, and follow up did not differ between the groups. More colon was resected in the TERPT group: median 25 cm vs. 15 cm in the L-TERPT group (p < 0.001). The TERPT-procedure took less time: median 153 min. vs. L-TERPT 263 min (p < 0.001). Postoperatively, three patients showed colonic torsions after TERPT (p = 0.07). The long-term clinical outcomes did not differ significantly between both groups. There was a significant association between length of resection and obstructive symptoms (OR = 0.92, p = 0.01).

Conclusion

Postoperative and clinical outcomes are similar using the TERPT or L-TERPT to correct classic segment Hirschsprung's disease. Prevention of colonic torsion should be the prime concern during the TERPT procedure. L-TERPT requires laparoscopic equipment and takes more operation time, whereas TERPT leaves no visible scars. The positive relation between the larger length of resection and obstructive symptoms requires additional research.     

Systematic Review and Meta-Analysis of Robotic-Assisted versus Conventional Laparoscopic Pyeloplasty for Patients with Ureteropelvic Junction Obstruction: Effect on Operative Time,Length of Hospital Stay,Postoperative Complications,and Success Rate

Background

Although robotic-assisted procedures may theoretically be more advantageous than conventional laparoscopic ones, few studies have shown clear superiority of robotic-assisted laparoscopic pyeloplasty (RAP) over conventional laparoscopic pyeloplasty (CLP) for ureteropelvic junction obstruction (UPJO).

Objective

To undertake a systematic review and meta-analysis to evaluate the effect of RAP versus CLP for patients with UPJO, focusing on operative time, length of hospital stay, postoperative complications, and success rate.

Design, setting, and participants

We searched four electronic bibliographic databases, including the related articles PubMed feature, reference lists from articles, and program abstracts from scientific meetings. Consequently, 58 citations were identified. Two individuals independently screened the titles and abstracts of each citation to select the articles (90% agreement).

Intervention

Studies that compared RAP with CLP for treatment of UPJO were included. Case series on RAP or CLP were excluded because of large heterogeneity.

Measurements

We utilized weighted mean difference (WMD) to measure operative time and length of hospital stay and odds ratio (OR) and risk difference (RD) to measure complication and success rates. These ORs were pooled using a random effects model and were tested for heterogeneity.

Results

We identified eight publications that strictly met our eligibility criteria. Meta-analysis of extractable data showed that RAP was associated with a 10-min operative time reduction (WMD: −10.4 min; 95% CI: −24.6–3; p = 0.15) and significantly shorter hospital stay compared with CLP (WMD: −0.5 d; 95% CI: −0.6–−0.4; p < 0.01). There were no differences between the approaches with regard to rates of complication (OR: 0.7; 95% CI: 0.3–1.6; p = 0.40) and success (OR: 1.3; 95% CI: 0.5–3.5; p = 0.62).

Conclusions

RAP and CLP appear to be equivalent with regard to postoperative urinary leaks, hospital readmissions, success rates, and operative time.     

Transanal pullthrough for Hirschsprung disease: Matched case–control comparison of Soave and Swenson techniques

Background

Both the Swenson and the Soave procedures have been adapted to a transanal approach. The purpose of this study was to compare outcomes following the transanal Swenson and Soave procedures using a matched case control analysis.

Methods

A retrospective chart review was performed to identify all transanal Soave and Swenson pullthroughs done at 2 tertiary care children’s hospitals between 2000 and 2010. Patients were matched for gestational age, mean weight at time of the operation, level of aganglionosis, and presence of co-morbidities. Student’s t-test and chi-squared analysis were performed.

Results

Fifty-four patients (Soave 27, Swenson 27) had adequate data for matching and analysis. Mean follow-up was 4 ± 1.6 years and 3.2 ± 2.7 years for the Soave and Swenson groups, respectively. No significant differences in mean operating time (Soave:191 ± 55, Swenson:167 ± 61 min, p = 0.6), overall hospital stay (6 ± 4vs7.8 ± 5 days, p = 0.7), and number with intra-operative complications (3 vs 4, p = 1.0), post-operative obstructive symptoms (6 vs 9, p = 0.5), enterocolitis episodes (4 vs 4, p = 1.0), or fecal incontinence (0 vs 2, p = 0.4) were noted.

Conclusion

After controlling for potential confounders, there were no significant differences in the short and intermediate term outcome between transanal Soave and transanal Swenson pullthrough procedures.     

Long-term health-related quality of life after complex and/or complicated esophageal atresia in adults and children registered in a German patient support group

Background

Health-related quality of life (HRQoL) after esophageal atresia (EA) repair is postulated to be good. However, little is known about the long-term results after repair of complex and/or complicated EA regarding HRQoL. We investigated long-term HRQoL after delayed anastomosis, esophageal replacement, major revisions, or multiple dilatations in patients registered in a support group.

Methods

Patients registered in the German patient support group database (KEKS) were enrolled and allocated to subgroups according to surgical treatment and age. HRQoL was evaluated using validated questionnaires (GIQLI, WHO-5, KIDSCREEN27).

Results

Complete follow-up (mean 14.5 ± 9.8 years) was available for 90/92 patients. Patients were allocated to subgroups delayed anastomosis (n = 28), esophageal replacement (n = 27), major revisions (n = 15), and multiple dilatations (n = 20). Adult patients presented with impaired well-being according to WHO-score and gastrointestinal function (GIQLI). In contrast, HRQoL of children was comparable to controls in most KIDSCREEN27-dimensions. Delayed anastomosis was associated with most-favourable HRQoL. Regarding physical well-being, these children scored significantly better than controls [64.01 ± 10.40 vs. 52.36 ± 8.73;p = 0.0011], children after replacement [51.40 ± 5.70;p = 0.008], revisions [52.04 ± 6.97;p = 0.026], and multiple dilatations [50.22 ± 9.67,p = 0.04].

Conclusions

HRQoL after complex and/or complicated EA is excellent in children registered in a patient support group. In adults, disease-specific symptoms negatively affect HRQoL. Our data indicate that saving the esophagus may achieve the best HRQoL.     

The “weekend effect” in pediatric surgery — increased mortality for children undergoing urgent surgery during the weekend

Background

For a number of pediatric and adult conditions, morbidity and mortality are increased when patients present to the hospital on a weekend compared to weekdays. The objective of this study was to compare pediatric surgical outcomes following weekend versus weekday procedures.

Methods

Using the Nationwide Inpatient Sample and the Kids’ Inpatient Database, we identified 439,457 pediatric (< 18 years old) admissions from 1988 to 2010 that required a selected index surgical procedure (abscess drainage, appendectomy, inguinal hernia repair, open fracture reduction with internal fixation, or placement/revision of ventricular shunt) on the same day of admission. Outcome metrics were compared using logistic regression models that adjusted for patient and hospital characteristics as well as procedure performed.

Results

Patient characteristics of those admitted on the weekend (n = 112,064) and weekday (n = 327,393) were similar, though patients admitted on the weekend were more likely to be coded as emergent (61% versus 53%). After multivariate adjustment and regression, patients undergoing a weekend procedure were more likely to die (OR 1.63, 95% CI 1.21–2.20), receive a blood transfusion despite similar rates of intraoperative hemorrhage (OR 1.15, 95% CI 1.01–1.26), and suffer from procedural complications (OR 1.40, 95% CI 1.14–1.74).

Conclusion

Pediatric patients undergoing common urgent surgical procedures during a weekend admission have a higher adjusted risk of death, blood transfusion, and procedural complications. While the exact etiology of these findings is not clear, the timing of surgical procedures should be considered in the context of systems-based deficiencies that may be detrimental to pediatric surgical care.