Primary sigmoidectomy and appendicostomy for chronic idiopathic constipation

Purpose

To present our experience in patients with chronic idiopathic constipation complicated by megarectosigmoid and fecal incontinence who underwent a primary sigmoidectomy and appendicostomy.

Methods

We reviewed eight patients referred to the Colorectal Center from 2014 to 2016 with chronic idiopathic constipation and undergoing a sigmoidectomy and appendicostomy. We analyzed the previous medical treatment, indications for the surgical procedure, and outcomes.

Results

Age at operation was 5–19 years. Time with constipation was 4–15 years. All patients received multiple laxatives, mainly polyethylene glycol, and all had severe social problems. Four patients have autism. The indication for surgery was an unsuccessful laxative trial, refusal to continue with rectal enemas or both, and social fear of continued fecal incontinence. Post-operatively, all patients were having daily bowel movements without fecal accidents.

Conclusion

Selected patients with chronic idiopathic constipation complicated by megarectosigmoid and fecal incontinence can obtain great benefit from primary sigmoidectomy and appendicostomy.

     

Hypertension and prehypertension among adolescents in secondary schools in Enugu,South East Nigeria

Background

Hypertension is a prevalent cardiovascular disease risk factor among blacks and adolescent hypertension can progress into adulthood.

Objective

To determine the prevalence of hypertension and prehypertension among secondary school adolescents in Enugu South East Nigeria.

Methodology

A study of 2694 adolescents aged 10-18 years in Enugu metropolis was carried out. Socio-demographic profile anthropometric and blood pressure readings were obtained. Derived measurements such as Prehypertension, hypertension and BMI were obtained.

Results

The results showed that the mean systolic blood pressure and diastolic blood pressure for males were 106.66+ 11.80 mmHg and 70.25 + 7.34 mmHg respectively. The mean SBP and DBP for females were 109.83+ 11.66 mmHg and 72.23 + 8.26 mmHg respectively (p < 0.01). Blood pressure was found to increase with age. Prevalence of hypertension and prehypertension was 5.4% and 17.3% respectively with a higher rate in females (6.9%) than males (3.8%). Prevalence of prehypertension among males and females were 14.3% and 20.1% respectively. The prevalence of obesity was 1.9%.

Conclusion

Modifiable risk factors exist among adolescents. Early lifestyle modification and a strengthened school health are recommended.

     

Long-term outcome and need of re-operation in gastro-esophageal reflux surgery in children

Background

Fundoplication is considered a mainstay in the treatment of gastro-esophageal reflux. However, the literature reports significant recurrences and limited data on long-term outcome.

Aims

To evaluate our long-term outcomes of antireflux surgery in children and to assess the results of redo surgery.

Methods

We retrospectively analyzed all patients who underwent Nissen fundoplication in 8 consecutive years. Reiterative surgery was indicated only in case of symptoms and anatomical alterations. A follow-up study was carried out to analyzed outcome and patients’ Visick score assessed parents’ perspective.

Results

Overall 162 children were included for 179 procedures in total. Median age at first intervention was 43 months. Comorbidities were 119 (73 %), particularly neurological impairments (73 %). Redo surgery is equal to 14 % (25/179). Comorbidities were risk factors to Nissen failure (p = 0.04), especially children suffering neurological impairment with seizures (p = 0.034). Follow-up datasets were obtained for 111/162 = 69 % (median time: 51 months). Parents’ perspectives were excellent or good in 85 %.

Conclusions

A significant positive impact of redo Nissen intervention on the patient’s outcome was highlighted; antireflux surgery is useful and advantageous in children and their caregivers. Children with neurological impairment affected by seizures represent significant risk factors.

     

Pyeloplasty in children: perioperative results and long-term outcomes of robotic-assisted laparoscopic surgery compared to open surgery

Background

A few studies have compared robotic-assisted laparoscopic pyeloplasty (RALP) with open pyeloplasty (OP) in children, but no previous study includes a long-term follow-up of renal function and hydronephrosis in combination with a thorough prospective follow-up of the RALP patients of at least 2 years.

Objective

To analyze perioperative results and long-term outcome of children with obstruction of the ureteropelvic junction, operated on with RALP compared to OP.

Patients and methods

Children ≤15 years operated on with RALP or OP from 2000 through 2013 were reviewed. Patient demographics, perioperative data, postoperative complications, and long-term outcome were evaluated. The outcome was based on pre- and postoperative examination of renal function, hydronephrosis and flank pain.

Results

129 pyeloplasties (84 OP, 39 RALP, 6 reoperations) on 123 patients were included. RALP had significantly longer operative time and shorter postoperative hospital stay, compared to OP. No difference was found in postoperative need of morphine or complication rates. Mean follow-up for RALP with ultrasound was 29 and 25 months with renal scan, compared to 34 and 28 months, respectively, for OP. The success rate for flank pain was 96 and 94 %, for hydronephrosis 93 and 95 %, and renal function 94 and 92 %, for RALP and OP, respectively.

Conclusions

RALP is a safe method, with advantages compared to OP, and with the same success rate. This study supports the use of RALP in children.

     

Pediatric rhabdomyosarcoma in India: A single-center experience

Objective

Analyze the profile and outcome of children with rhabdomyosarcoma from a pediatric-oncology unit.

Design

Retrospective analysis of case records over 23 years (1990–2012).

Setting

Government-run, tertiary-care, university hospital in Northern India.

Participants

159 children (<12-years) with a diagnosis of rhabdomyosarcoma were enrolled. The median age was 4 years; 13% were infants.

Main outcome measure

Five-year event free survival.

Results

The median symptom interval was 2-months. Head and neck region was the most frequent site (44%), followed by tumors in the extremity (15.7%). The majority (67%) of the tumors were located at ‘unfavorable’ sites; 68% were >5 cm in size. The most frequent (58%) pathological subtype was embryonal. Treatment was based on the ‘Intergroup Rhabdomyosarcoma Study (IRS) Group’ risk-stratification. 33% were ‘low-risk’ children, 11% were ‘high-risk’. Treatment-refusal (18%) and abandonment (33%) were major impediments. The median ± SE five-year event free survival of those taking treatment was 43.6 ± 6%.

Conclusions

Large sized tumors, tumors at unfavorable locations, and treatment refusal/abandonment contributed to inferior outcome in children with rhabdomyosarcoma.

     

Current practice regarding timing of patent processus vaginalis ligation for idiopathic hydrocele in young boys: a survey of UK surgeons

Purpose

The aim of this study was to determine the current UK practice regarding timing of surgical repair of hydroceles in young boys.

Methods

Through a validated, online survey, participants were asked their preferred management option in five different clinical scenarios across five age ranges.

Results

71 responses were included in the analysis. The most common age to offer surgical intervention for a congenital hydrocele that is stable or increasing in size, or a hydrocele of the cord is 24–36 months. For a stable hydrocele presenting after 12 months of age, the most common age to offer repair is between 36 and 48 months. Approximately ¼ of respondents defer surgery until 4 years of age for any stable hydrocele. For a congenital hydrocele that is decreasing in size, the majority of respondents (57%) do not offer surgical intervention even over 4 years of age. The majority of respondents (61%) do not differentiate between communicating and non-communicating hydroceles when considering age for repair.

Conclusion

These results suggest that there is uncertainty regarding the optimum age for PPV ligation and adequate underlying variability in practice to support a prospective study of the optimum age for hydrocele repair and the natural history of PPV closure.

     

Pediatric Asthma and Food Allergy

Objective

To quantitatively summarize the evidence from observational studies on the relation between pediatric asthma and food allergy.

Methods

A literature search was conducted in Medline and EMBASE (August 2016). Two independent reviewers appraised the studies and extracted the estimates of interest. Methodological quality of the included studies was assessed using National Heart Lung and Blood Institute (NHLBI) Quality Assessment Tools. Data were pooled using random-effects meta-analysis.

Results

A total of 32 relevant studies were identified but only 8 studies met the inclusion criteria. Using random-effect model, food allergy showed strong association with asthma in children (OR = 2.87 [95% CI: 2.05–4.00]; P < 0.0001).

Conclusions

This study suggested that food allergy is associated with an increased risk of asthma in children.

     

Are IgM-enriched immunoglobulins an effective adjuvant in septic VLBW infants?

Aim

To investigate the effectiveness of IgM-enriched immunoglobulins (IgM-eIVIG) in reducing short-term mortality of neonates with proven late-onset sepsis.

Methods

All VLBW infants from January 2008 to December 2012 with positive blood culture beyond 72 hours of life were enrolled in a retrospective cohort study. Newborns born after June 2010 were treated with IgM-eIVIG, 250 mg/kg/day iv for three days in addition to standard antibiotic regimen and compared to an historical cohort born before June 2010, receiving antimicrobial regimen alone. Short-term mortality (i.e. death within 7 and 21 days from treatment) was the primary outcome. Secondary outcomes were: total mortality, intraventricular hemorrhage, necrotizing enterocolitis, periventricular leukomalacia, bronchopulmonary dysplasia at discharge.

Results

79 neonates (40 cases) were enrolled. No difference in birth weight, gestational age or SNAP II score (disease severity score) were found. Significantly reduced short-term mortality was found in treated infants (22% vs 46%; p?=?0.005) considering all microbial aetiologies and the subgroup affected by Candida spp. Secondary outcomes were not different between groups.

Conclusion

This hypothesis-generator study shows that IgM-eIVIG is an effective adjuvant therapy in VLBW infants with proven sepsis. Randomized controlled trials are warranted to confirm this pilot observation.

     

Dose optimisation for intraoperative cone-beam flat-detector CT in paediatric spinal surgery

Background

During surgery for spinal deformities, accurate placement of pedicle screws may be guided by intraoperative cone-beam flat-detector CT.

Objective

The purpose of this study was to identify appropriate paediatric imaging protocols aiming to reduce the radiation dose in line with the ALARA principle.

Materials and methods

Using O-arm® (Medtronic, Inc.), three paediatric phantoms were employed to measure CTDI_w doses with default and lowered exposure settings. Images from 126 scans were evaluated by two spinal surgeons and scores were compared (Kappa statistics). Effective doses were calculated. The recommended new low-dose 3-D spine protocols were then used in 15 children.

Results

The lowest acceptable exposure as judged by image quality for intraoperative use was 70 kVp/40 mAs, 70 kVp/80 mAs and 80 kVp/40 mAs for the 1-, 5- and 12-year-old-equivalent phantoms respectively (kappa = 0,70). Optimised dose settings reduced CTDI_w doses 89–93%. The effective dose was 0.5 mSv (91–94,5% reduction). The optimised protocols were used clinically without problems.

Conclusions

Radiation doses for intraoperative 3-D CT using a cone-beam flat-detector scanner could be reduced at least 89% compared to manufacturer settings and still be used to safely navigate pedicle screws.

     

ARSH 4: Parental Understanding of Adolescent Issues: Parent-Adolescent Dyad Agreement

Objective

To elicit areas of discordance between the parent-adolescent dyad with regard to reproductive sexual health issues using the same questions to both and to elicit the gender sensitivity of the parents.

Methods

This study was conducted using similar questions for both adolescents and young adults and their parents in three districts of Kerala. Data analysis was done comparing unmarried adolescents and young adults’ response to reproductive and sexual health issues and the parental agreement status with their ward’s responses.

Results

There were a total of 3,625 parent-unmarried young adults dyads. Parental attitudinal difference towards their sons and daughters on selected parenting issues was observed. With regard to the following reproductive and sexual health problems, (i) knew about menstruation before menarche (64.1 %), (ii) got information on hygiene practices from home (80.8 %), (iii) have menstrual problems (66.4 %), agreement with adolescent response was high, whereas with regard to (i) anxious about adolescent physical and mental changes (29.2 %), (ii) received information on reproductive sexual health (RSH) from mother (26.7 %), (iii) do not have any abnormal vaginal discharge (46.7 %), (iv) parents taken precautions to prevent sexual abuse (17.5 %), (v) have been sexually abused (15.6 %), agreement with unmarried young adults’ response was low and all these differences were statistically significant.

Conclusions

The results of 3,625 parent-unmarried adolescents and young adults dyad data showed poor agreement on vital issues like sexual abuse apart from gender inequality favouring sons.

     

Airway reconstruction using decellularized tracheal allografts in a porcine model

Purpose

Tracheal cartilage reconstruction is an essential approach for the treatment of tracheal congenital abnormalities or injury. Here, we evaluated the use of allogeneic decellularized tracheas as novel support scaffolds.

Methods

Six weaned pigs (4-week-old domestic males) were transplanted with allogeneic tracheal graft patches (three decellularized and three fresh tracheal scaffolds) onto artificial defects (approximately 15 × 15 mm). After 11 weeks, the tracheas were evaluated by bronchoscopy and histological studies.

Results

No pigs displayed airway symptoms during the observation period. Tracheal lumen restored by fresh graft patches showed more advanced narrowing than that treated with decellularized grafts by bronchoscopy. Histologically, fresh grafts induced typical cellular rejection; this was decreased with decellularized grafts. In addition, immunohistochemistry demonstrated regenerating foci of recipient cartilage along the adjacent surface of decellularized tracheal grafts.

Conclusion

Decellularized allogeneic tracheal scaffolds could be effective materials for restoring impaired trachea.

     

Clinical safety of 3-T brain magnetic resonance imaging in newborns

Background

The effects and potential hazards of brain magnetic resonance imaging (MRI) at 3 T in newborns are debated.

Objective

Assess the impact of 3-T MRI in newborns on body temperature and physiological parameters.

Material and methods

Forty-nine newborns, born preterm and at term, underwent 3-T brain MRI at term-corrected age. Rectal and skin temperature, oxygen saturation and heart rate were recorded before, during and after the scan.

Results

A statistically significant increase in skin temperature of 0.6 °C was observed at the end of the MRI scan (P<0.01). There was no significant changes in rectal temperature, heart rate or oxygen saturation.

Conclusion

Core temperature, heart rate and oxygen saturation in newborns were not affected by 3-T brain MR scanning.

     

Clinical and laboratory predictors of blood loss in young swine: a model for pediatric hemorrhage

Background

The pediatric patient’s response to hemorrhage as a function of young age is not well understood. As a result, there is no consensus on optimal resuscitation strategies for hemorrhagic shock in pediatric patients, or on the identification of clinical triggers to prompt implementation. The study objective was to develop a model of pediatric hemorrhage using young pigs to simulate school-aged children, and determine clinical and laboratory indicators for significant hemorrhage.

Materials and methods

29 non-splenectomized female pigs, aged 3 months, weighing 30–40 kg, were randomized into groups with varying degrees of hemorrhage. Bleeding occurred intermittently over 5 h while the animals were anesthetized but spontaneously breathing. Various physiologic and biochemical markers were used to monitor the piglets during hemorrhage.

Results

Swine experiencing up to 50% hemorrhage survived without exception throughout the course of hemorrhage. 80% (4/5) of the animals in the 60% hemorrhage group survived. Need for respiratory support was universal when blood loss reached 50% of estimated blood volume. Blood pressure was not useful in classifying the degree of shock. Heart rate was helpful in differentiating between the extremes of blood loss examined. Arterial pCO_2, pH, lactate, HCO₃ and creatinine levels, as well as urine output, changed significantly with increasing blood loss.

Conclusions

Young swine are resilient against hemorrhage, although hemorrhage of 50% or greater universally require respiratory support. In this animal model, with the exception of heart rate, vital signs were minimally helpful in identification of shock. However, change in select laboratory values from baseline was significant with increasing blood loss.

Level of evidence

This was a level II prospective comparative study.

     

School Based Adolescent Care Services: A District Model

Objective

To study the perceived problems of higher secondary school students in a district and to document the effect of a family life and life skill education package.

Methods

A survey was conducted among 11501 adolescents belonging to 103 higher secondary schools in Thiruvananthapuram district, using Teenage Screening Questionnaire-Trivandrum (TSQ-T). Family life and life skill education package was given to class XI students and post intervention evaluation of improvement in knowledge level was assessed after 6 months by a structured pre-tested self-administered questionnaire.

Results

61.2% adolescents reported scholastic problem, 22.1% family related problems, 31.9% personal problems and 15.2% adjustment problems, with boys reporting higher percentage. 65.8% reported body image related problems, 26.4% had dental, 21.3% ENT and 16.2% had dermatological complaints. Among girls 50.2% reported menstrual problems. 506 adolescents volunteered for medical check-up and 1247 for detailed psychological assessment. Family life and life skill education package showed consistent improvement in knowledge even after a gap of 6 months.

Conclusions

The study results showed that a school based adolescent care service programme is effective and feasible.

     

Outcomes of fundoplication for paediatric gastroesophageal reflux disease

Purpose

Outcomes of fundoplication in children.

Methods

In this monocentric retrospective study, chart review was performed on children who underwent fundoplication between 2006 and 2013. Outcomes were defined as the need for redo fundoplication and recommencement of anti-reflux medication (ARM) at 6-month follow-up.

Results

119 patients underwent fundoplication with a mean age of 4.76 years and 55.5 % of these were male. At 6-month follow-up, 21 (17.6 %) required redo fundoplication and 64 (53.8 %) were recommenced on ARM. Post-operative complications occurred in 50 (42.2 %) of children; 30 % of those with complications had surgery at less than 1 year of age, and 36 % had an associated comorbid condition. Neither being under the age of one nor associated comorbidity was significantly associated with a poor outcome. Concurrent gastrostomy was associated with a higher risk of being back on ARM at 6-month follow-up (p = 0.003). Neither gastrointestinal or respiratory symptoms pre-surgery nor abnormal pre-operative investigations including pH monitoring and endoscopy were predictive of poor outcome post-fundoplication.

Conclusion

Although fundoplication has a role in the treatment of severe GORD in children, the majority of children in this study needed to restart their anti-reflux medications within 6 months of surgery.

     

Post-resection outcomes for pediatric ovarian neoplasm: is ovarian-preserving surgery a good option?

Purpose

Pediatric surgeons often care for children with ovarian tumors. Few studies report long-term outcomes for these patients. This study characterizes intermediate-term results for patients who underwent surgical resection of ovarian neoplasms as children.

Methods

Patients who underwent surgery for ovarian neoplasms at a children’s hospital were identified. They were invited to participate in a telephone-based survey assessing post-surgical recurrence, dysmenorrhea, quality of life, and fertility.

Results

188 patients were identified; 79 met criteria. 31 patients had ovarian-sparing tumor resection; 48 had oophorectomy; five had recurrences. 56 were successfully interviewed at a median follow-up of 4.6 years. Dysmenorrhea rates of 52 and 78 % were reported (p = 0.07), respectively. Two patients suffered from infertility. Quality of life was generally reported as good.

Conclusion

Intermediate outcomes are good for patients who underwent ovarian-sparing tumor resection or oophorectomy for pediatric ovarian tumors. Additional long-term monitoring would be beneficial to better assess fertility and dysmenorrhea outcomes.

     

Hämorrhagischer Schock im frühen Kindesalter – Besonderheiten der Kreislaufregulation

Background

Acute hemorrhages in neonates and young children can be compensated for a long period of time until a decrease in blood pressure and manifest shock occur.

Objective

To determine the characteristics of the pathophysiology of the circulation in children and to recognize critical signs and symptoms of hemorrhage.

Material and methods

Pathophysiology and discussion of the literature

Results

Shock in neonates and children can be present long before a decrease in blood pressure occurs. It is characterized by tachycardia, tachy(dys)pnea, prolonged capillary refilling time, disorders of consciousness (apathy), disturbance of temperature regulation and reduced urine output. Laboratory markers are metabolic acidosis and elevated lactate and a normocytic anemia earlier than in adults.

Conclusion

In contrast to adults a decrease in blood pressure in neonates and young children is a late sign of shock, whereas normocytic anemia occurs earlier than in adults.

     

Effect of timing of cannulation on outcome for pediatric extracorporeal life support

Purpose

Literature reports worse outcomes for operations performed during off-hours. As this has not been studied in pediatric extracorporeal life support (ECLS), we compared complications based on the timing of cannulation..

Methods

This is a retrospective review of 176 pediatric ECLS patients between 2004 and 2015. Patients cannulated during daytime hours (7:00 A.M. to 7:00 P.M., M-F) were compared to off-hours (nighttime or weekend) using t-test and Chi-square.

Results

The most common indications for ECLS were congenital diaphragmatic hernia (33 %) and persistent pulmonary hypertension (23 %). When comparing regular hours (40 %) to off-hours cannulation (60 %), there were no significant differences in central nervous system complications, hemorrhage (extra-cranial), cannula repositioning, conversion from venovenous to venoarterial, mortality on ECLS, or survival-to-discharge. The overall complication rate was slightly lower in the off-hours group (45.7 % versus 61.9 %, P = 0.034).

Conclusion

Outcomes were not significantly worse for patients undergoing ELCS cannulation during off-hours compared to normal weekday working hours.