Management of intussusception in children: A systematic review

ObjectiveThe goal of this systematic review by the American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee was to develop recommendations for the management of ileocolic intussusception in children.MethodsThe ClinicalTrials.gov, Embase, PubMed, and Scopus databases were queried for literature from January 1988 through December 2018. Search terms were designed to address the following topics in intussusception: prophylactic antibiotic use, repeated enema reductions, outpatient management, and use of minimally invasive techniques for children with intussusception. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed. Consensus recommendations were derived based on the best available evidence.ResultsA total of 83 articles were analyzed and included for review. Prophylactic antibiotic use does not decrease complications after radiologic reduction. Repeated enema reductions may be attempted when clinically appropriate. Patients can be safely observed in the emergency department following enema reduction of ileocolic intussusception, avoiding hospital admission. Laparoscopic reduction is often successful.ConclusionsRegarding intussusception in hemodynamically stable children without critical illness, pre-reduction antibiotics are unnecessary, non-operative outpatient management should be maximized, and minimally invasive techniques may be used to avoid laparotomy.Level of EvidenceLevel 3–5 (mainly level 3–4)Type of studySystematic Review of level 1–4 studies     

Fibrin glue obliteration is safe,effective and minimally invasive as first line treatment for pilonidal sinus disease in children

Background / PurposeSacrococcygeal pilonidal sinus disease (PSD) has an incidence of 1.2–2.5/1000 in children. Onset is around puberty. Symptoms of recurrent abscess and chronic suppuration may interfere with education and social integration. Treatments should cause minimal disruption while having good cure and recurrence rates. Curettage and Fibrin glue obliteration (FGO) show promising results in adults. We present our experience of its use in children.MethodsReview of all pediatric patients receiving FGO of pilonidal sinus performed by a single surgeon from September 2014 to February 2018.ResultsEighteen patients were identified. Median age was 16 (range 15–17), 55.6% were male. All procedures were completed as day cases. Median operative duration was 14 .1 (6–29) min. Twelve patients required only 1 procedure, 4 required 2 procedures, 1 required 5 procedures and 1 elected for formal excision after 2 FGO treatments. Median return to normal activities was 3 days, with 1 day school absence. Two patients developed minor surgical site infections. Median follow-up was 52 weeks (17–102), during which time there was 1 recurrence (5.6%).ConclusionThis study demonstrates FGO is a safe, effective procedure for pediatric PNS, with results comparable to off-midline flap techniques and without the need for extensive tissue excision and the associated morbidity.Level of evidenceIV     

Crystallized phenol treatment vs excision and primary closure in pilonidal sinus disease: A randomized clinical trial in adolescent patients

IntroductionPilonidal sinus is a chronic inflammatory disease seen in the intergluteal sulcus. A wide variety of treatment modalities have been described for the management of this disease, however optimal therapy remains controversial. The study aims to compare phenol treatment, a minimally invasive method used in the treatment of pilonidal sinus disease, with the commonly practiced surgical methods of excision and primary closure in the adolescent age group.Patients and MethodsAdolescent patients who presented with pilonidal sinus disease between January 2018 and December 2018 were randomized into 2 groups as phenol treatment and surgical treatment (after obtaining consent for the study). Early complications and recurrence rates after 24 months of follow-up were the two main endpoints of the study.ResultsA total of 100 patients (phenol group n = 50, surgery group n = 50) were included in the study. Both groups were similar in terms of age, gender, and BMI. The mean duration of the procedure was 12.4 ± 2.84 min in the phenol group and 42.3 ± 7.22 min in the surgery group (p = 0.00). There was no difference in postoperative complications between the groups (p = 0.22). After 24 months of follow-up, recurrence was found in 8% (n = 4) of the cases in the phenol group and 10% (n = 5) of the cases in the surgery group (p = 0.5).ConclusionIn our study, phenol treatment and excision/primary closure methods for pilonidal sinus disease have similar complication and recurrence rates. However, phenol treatment seems to be the method of choice in the adolescent age group as it has the advantage of being a minimally invasive method and it does not affect subsequent surgical treatments.Level of evidence: Level II treatment study     

Sinus laser closure (SiLaC) versus Limberg flap in management of pilonidal disease: A short-term non-randomized comparative prospective study

IntroductionFistula Laser Closure (FiLAC) is a method that was originally applied in the treatment of perianal fistulas. Because of promising results, diode lasers were later on used to treat pilonidal sinus disease in a method called sinus Laser Closure (SiLaC).The aim of this study is to compare between SiLaC and Limberg flap in management of pilonidal disease.MethodsA prospective, nonrandomized comparative study. A short-term follow-up of 71 patients with pilonidal disease was analyzed (24 operated on using the SiLaC technique and 47 using the Limberg technique). With a primary outcome is healing rate and recurrence and a secondary outcome is other measures i.e. complications, hospital stay and postoperative pain.ResultsThe median operative time in the SiLaC group was 26.45 ± 5.41 min (20–35 min) and in the Limberg group 58.63 ± 7.42 min (50–75 min). In the SiLaC group, the primary healing was achieved in 23 out of 24 patients (95.8%) with a total complication rate of 20.83%. There were two cases of recurrence after initial healing in each group.ConclusionSinus laser Closure (SiLaC) is comparable to Limberg flap technique in the terms of healing rate and recurrence with better outcome regarding operative time, hospital stay and post-operative pain.     

Excision and Primary Closure Using the Karydakis Flap for the Treatment of Pilonidal Disease: Outcomes from a Single Institution

Background  

Chronic pilonidal disease is a debilitating condition that typically affects young adults. There is a wide variety of available therapeutic strategies reflecting the inconsistent outcomes attributed to the various operative approaches. The majority involve excision of the sinus tract followed by either primary closure or healing by secondary intention. A variety of closure approaches exist. There remains uncertainty as to which is more effective. The aim of the current study was to determine subjective and objective outcomes following excision and Karydakis flap closure in a unit where this technique is the standard of care in the management of chronic pilonidal disease.     

Patience is a virtue: Multiple preoperative visits are associated with decreased recurrence in pediatric pilonidal disease

Background/PurposeThis study aimed to compare preoperative management strategies for patients undergoing trephination for pilonidal disease and evaluate risk factors for recurrence.MethodsA retrospective review was performed of children undergoing index surgical treatment with trephination for pilonidal disease between September 2017 and April 2019. Intraoperative and postoperative management were standardized. Demographic and perioperative data were collected and analyzed.ResultsOne-hundred twenty patients were identified with a median follow-up time of 7.5 months (interquartile range 4.1–13.2 months). Overall, 24 (20%) patients had a postoperative recurrence of pilonidal disease. Patients with multiple preoperative surgery clinic visits were less likely to have recurrent disease compared to those seen only once preoperatively (11% vs 26%, p = 0.040). Compared to patients without recurrence, those who recurred went to the operating room sooner from the time of initial surgical consultation (32 days vs 54 days, p < 0.001). Perioperative antibiotics, history of acute infection, and prior drainage procedures were not risk factors for recurrence.ConclusionsMultiple preoperative clinic visits are associated with a lower recurrence rate in children undergoing trephination for pilonidal disease. An increased duration of preoperative medical management may be responsible for this finding. Prospective study is needed to confirm these findings and identify additional factors that influence recurrence.Type of StudyTreatment Study.Level of EvidenceIII (Retrospective Comparative).     

Erhöhtes Rezidivrisiko nach primärem medianem Wundverschluss bei Patienten mit Pilonidalsinus

BACKGROUND: There is a high incidence of postoperative complications and late recurrences after operative therapy of a pilonidal sinus.The optimal treatment strategy is still matter of discussion.We studied the long-term results after excision of a pilonidal sinus and primary midline closure compared with the open surgical procedure. MATERIALS AND METHODS: A total of 73 patients (62 male and 11 female, mean age 26.6 years) underwent a total of 79 operations between 1992 and 2001.Thirty patients (38%) were previously operated on because of a pilonidal sinus.Twenty-four were treated in our institution by an open procedure (five after simple abscess incision, 19 after sinus excision) and 52 by primary midline closure. Another three patients received skin flap procedures. RESULTS: Follow-up was possible for 65 patients (82%) for a median of 50 months.Recurrent pilonidal sinus occurred in 22 cases: 18 after primary midline closure (42%) and four after open procedure (21%, P=0.4).We found no relapse following the three skin flap procedures. There was a significantly higher relapse rate in patients operated with recurrent disease (12/25 vs 10/40; P<0.05). CONCLUSIONS: Despite of numerous previously operated patients (38%), there was a high recurrence rate (42%) after excision of a pilonidal sinus and primary midline closure. Alternative operative techniques creating a lateral wound or the various skin flap procedures may be promising alternatives.We are in the process of changing our treatment strategy for patients suffering from a pilonidal sinus.     

Adoption of a standardized treatment protocol for pilonidal disease leads to low recurrence

BackgroundPilonidal disease may present as acute abscesses or chronic draining sinuses. There is no standardized treatment and recurrence rates can be as high as 30%. Within our five-hospital network we have established a standardized treatment protocol including minimally invasive surgical trephination and aggressive epilation. We hypothesize that such a treatment protocol can be established across different hospital settings and lead to low overall recurrence.MethodsPatients with pilonidal disease were enrolled in the study on presentation to our hospital network. Those that underwent initial surgery outside our hospital system or were noncompliant with our treatment protocol were excluded. Patients were grouped based on surgeon and treating facility. Frequency of recurrence per surgeon and per hospital was calculated and compared.ResultsOut of 132 patients, 80 patients were included (45 female, 35 male) while 52 were excluded because of initial surgery at a non-network hospital or for protocol noncompliance. Median age was 17 (16–19) years and median length of follow-up was 352 (261–496) days. There were 6 patients who experienced at least one recurrence. There was an overall 8% recurrence rate with no significant difference noted between surgeons or hospitals (p = 0.15, p = 0.64, respectively).ConclusionsWe have successfully implemented a standardized treatment protocol for pilonidal disease across different hospital settings and by different surgeons, with an overall low recurrence rate. Our findings suggest that adoption of a standardized protocol for treatment of pilonidal disease can lead to low recurrence.Level of evidenceLevel IV.     

Three dimensional (3D) modelling and surgical planning in trauma and orthopaedics

IntroductionThree dimensional (3D) modelling facilitates visualization, manipulation, and analysis of image data, the three dimensional format of such image, allows a better appreciation of the geometry, size, and exact relationship between diseased and normal tissue. The role in orthopaedic surgical planning is highlighted.DiscussionSurgical procedures in orthopaedics and trauma rely on imaging, which in addition to making the diagnosis also assist in planning the elected surgical procedure through to a successful execution.In the area of trauma management, the use of 3D modelling eases the execution of fracture operative approach, reduction and appropriate fixation, especially in complex fractures, like in the acetabulum. Post trauma correction of deformities is made easier using 3D modelling in the preoperative surgical planning.For the purposes of tumour excision, a more acceptable margin of excision can be planned and successfully implemented.There is an increasing role for computer assisted procedures in arthroplasty, the use of a 3D image for preoperative planning promises to deliver patient specific bone cut in dimensions that will allow less of inappropriate loading thereby promoting longevity of the implant especially in younger patients.ConclusionThe processes for acquiring 3D images need to be made simpler and easier to gain more widespread use in orthopaedics and trauma.     

Limberg Flap Versus Primary Closure in the Treatment of Primary Sacrococcygeal Pilonidal Disease; A Randomized Clinical Trial

Pilonidal sinus is a chronic intermittent disease, usually involving the sacrococcygeal area. This study was undertaken to compare the results of rhomboid excision followed by Limberg flap with that of excision and primary closure in patients with primary pilonidal sinus. A total of 120 patients with pilonidal disease were randomly divided into group A who underwent excision and primary closure (n = 60) and group B who underwent the rhomboid transposition flap procedure (n = 60). Length of hospital stay and postoperative complications in two groups were compared. Duration of hospital stay (P < 0.001) and time to resumption of work (P < 0.001) was less for group B, and postoperative complications were fewer in group B (P < 0.05). During follow-up of 2 years, no recurrence was detected in patients in group B, whereas five patients developed recurrence in group A (P = 0.02). Limberg flap procedure is better than the simple excision and primary closure for the management of sacrococcygeal pilonidal disease.     

Persistent pilonidal disease: What to do when your initial surgery fails?

The crude rate of persistent or recurrent disease following surgical interventions for pilonidal disease correlates with the duration of follow-up. Furthermore, patient and disease related factors, body habitus, and the choice of surgical technique impact both short and long-term outcomes. Despite modern advances in surgical care, persistent and recurrent disease remain a challenge to the surgeon and the patient. Currently there is no standard of care or consensus as to the choice of operation for either primary, persistent, or recurrent disease. The selection of an operation for an individual patient is often determined by the surgeon's training background, personal experience, and own biases. A variety of techniques have been described to treat pilonidal disease ranging from simple minimally invasive procedures to operations entailing wide excision with primary closure, flap reconstruction, or wound management by secondary healing. In this article we share our perspective and approach to patients with persistent disease following failed intervention.     

Updated APSA Guidelines for the Management of Blunt Liver and Spleen Injuries

BackgroundNon-operative management of blunt liver and spleen injuries was championed initially in children with the first management guideline published in 2000 by the American Pediatric Surgical Association (APSA). Multiple articles have expanded on the original guidelines and additional therapy has been investigated to improve care for these patients. Based on a literature review and current consensus, the management guidelines for the treatment of blunt liver and spleen injuries are presented.MethodsA recent literature review by the APSA Outcomes committee [2] was utilized as the basis for the guideline recommendations. A task force was assembled from the APSA Committee on Trauma to review the original guidelines, the literature reported by the Outcomes Committee and then to develop an easy to implement guideline.ResultsThe updated guidelines for the management of blunt liver and spleen injuries are divided into 4 sections: Admission, Procedures, Set Free and Aftercare. Admission to the intensive care unit is based on abnormal vital signs after resuscitation with stable patients admitted to the ward with minimal restrictions. Procedure recommendations include transfusions for low hemoglobin (<7 mg/dL) or signs of ongoing bleeding. Angioembolization and operative exploration is limited to those patients with clinical signs of continued bleeding after resuscitation. Discharge is based on clinical condition and not grade of injury. Activity restrictions remain the same while follow-up imaging is only indicated for symptomatic patients.ConclusionThe updated APSA guidelines for the management of blunt liver and spleen injuries present an easy-to-follow management strategy for children.Level of EvidenceLevel 5.     

Management and radiographic outcomes of femoral head fractures

Background

Femoral head fractures are uncommon injuries. Small series constitute the majority of the available literature. Surgical approach and fracture management is variable. The purpose of this study was to evaluate the incidence, method of treatment, and outcomes of consecutive femoral head fractures at a regional academic Level I trauma center.

Materials and methods

A retrospective review of a prospective database was performed over a 13-year period. All AO/OTA 31C femoral head fractures were identified. A surgical approach and fixation method was recorded. Clinical and radiographic evaluation was performed for patients with 6 months or greater follow-up. Radiographs were evaluated for fixation failure, heterotopic ossification (HO), avascular necrosis (AVN) and post-traumatic arthritis.

Results

We identified 164 fractures in 163 patients; 147 fractures were available for review. Treatment was operative reduction and internal fixation (ORIF) in 78 (53.1%), fragment excision in 37 (25.1%) and non-operative in 28 (19%). An anterior approach and mini-fragment screws were used in the majority of patients treated with fixation. Sixty-nine fractures had follow-up greater than 6 months. Sixty-two fractures (89.9%) proceeded to uneventful union. All Pipkin III fractures failed operative fixation. Six patients developed AVN, seven patients had a known conversion to hip arthroplasty; HO developed in 28 (40.6%) patients and rarely required excision.

Conclusions

Fractures of the femoral head are rare. An anterior approach can be used for fragment excision or fixation using mini-fragment screws. Pipkin III fractures represent catastrophic injuries. Non-bridging, asymptomatic HO is common. AVN and posttraumatic degenerative disease of the hip occur but are uncommon.

Level of evidence

IV—prognostic.

     

Modified Zadek osteotomy without excision of the intratendinous calcific deposit is effective for the surgical treatment of calcific insertional Achilles tendinopathy

IntroductionNonoperative management of calcific insertional Achilles tendinopathy (CIAT) may fail in 10–30% of patients, and various operative procedures have been described to manage those.MethodsA modified Zadek (dorsal closing wedge) calcaneal osteotomy, without removing the calcific deposits and without detaching the insertion of the Achilles tendon, was performed between November 2016 and December 2017 in 25 consecutive patients (mean age 53.5 years), who were followed for at least 2 years.ResultsThe osteotomies had united at an average of 5 weeks. Two superficial wound infections (8%) were documented. Patients had returned to their normal activities at an average time of 23 ± 7.7 weeks. Three out of four patients, who practised recreational sport activity, returned to their pre-injury level. VAS and VISA-A scores had significantly improved at 3 months postoperatively (p < .001) and continued to improve for 24 months.ConclusionThe modified Zadek osteotomy, without excision of the intra-tendinous calcification, was safe, and significantly improved clinical outcome in patients with CIAT at 2 years after surgery.Level of evidence IV.     

Skin Glue Improves Outcome after Excision and Primary Closure of Sacrococcygeal Pilonidal Disease

Evaluating the effect of Histoacryl on the outcome and recurrence rate after excision and primary closure of sacrococcygeal pilonidal disease. Forty patients with sacrococcygeal pilonidal sinus were randomly divided into 2 equal groups through computer randomization program. Group I was operated by complete excision of sinus with wound closure using Histoacryl. Group II was operated with primary wound closure by interrupted inverting sutures. Mean operative time was 31.5 ± 5.6 minutes in group I and 35.9 ± 5.1 minutes in group II. Mean healing time was 13.4 ± 2.7 days in group I and 18.0 ± 8.9 days in group II. Wound infection occurred in 2 patients (10%) in Group II. Delayed wound healing occurred in 3 patients (15%) in group I and 4 patients (20%) in group II. Recurrence occurred in 1 patient (5%) in group I and 3 patients (15%) in group II. Histoacryl improves outcome (significantly decreases operative and healing times and increases patient satisfaction score, insignificantly decreases rates of complications and recurrence) after excision and primary closure of sacrococcygeal pilonidal disease.     

Operative treatment options for Morton’s neuroma other than neurectomy − a systematic review

BackgroundThe effectiveness of operative treatments other than neurectomy for Morton’s neuroma remains debatable despite several reported studies. This review aimed to evaluate the effects of operative treatments for Morton’s neuroma other than neurectomy using an algorithmic approach and a structured critical framework to assess the methodological quality of reported studies.MethodsSeveral electronic databases were searched for articles published until August 2021 that evaluated the outcomes of operative treatments other than neurectomy in patients diagnosed with Morton’s neuroma. Data searches, extraction, analysis, and quality assessments were performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and the clinical outcomes were evaluated using objective, subjective, and negative outcomes; complications; and reoperation rate and type.ResultsAfter reviewing 11,213 studies, 22 studies were finally included. Although a number of studies with high level of evidence are limited, we divided them according to four categories: (1) neurolysis with or without nerve transposition, (2) minimally invasive nerve decompression, (3) metatarsal osteotomy, and (4) additional procedures after nerve transection or neurectomy. All categories showed reliable outcomes except minimally invasive nerve decompression. The proportion of postoperative neurogenic symptoms was lower with neurolysis than with neurectomy.ConclusionWhether the alternative procedures were superior to neurectomy remains unclear as the number of good quality studies was limited. The proportion of postoperative neurogenic symptoms was lower with neurolysis than with neurectomy. Furthermore, performing simultaneous dorsal transposition of the nerve along with neurolysis is more recommended than neurolysis alone. Surgeons should be more careful with minimally invasive deep transverse intermetatarsal ligament release and metatarsal shortening osteotomy as their effectiveness remains inconclusive. Finally, we strongly recommend performing intramuscular embedding or intermuscular transposition of the nerve cutting end if neurectomy or nerve transection is inevitable.Level of evidenceLevel III, systematic review     

Oblique excision with primary closure for the treatment of pilonidal sinus

Although pilonidal disease of the sacrococcygeal region is common, controversy still exists regarding its treatment. The goal of treatment should be to prevent recurrence while minimizing the patient's postoperative pain and disability. During a two-year period, 32 consecutive patients (Group A) were treated for chronic pilonidal disease by oblique excision and primary closure. The results were compared with 45 patients (Group B) who had been treated by vertical excision and primary closure. Patients with acute pilonidal abscess or recurrent pilonidal disease were excluded from the study. The mean follow-up was 15.9 months for Group A and 19.6 months for Group B. The average length of hospital stay and time for return to daily activities were 3.18±1.31 vs. 5.53±4.11 days and 10.4±14.37 vs. 12.91±39.17 days in Groups A and B, respectively (p<0.001 and p<0.01). The overall recurrence rate was 35.5% in Group B whereas there were no recurrences in Group A. On the basis of our current experience, oblique excision with primary closure achieves the most promising treatment of this condition.     

Should we look for Hirschsprung disease in all children with meconium plug syndrome?

BackgroundMeconium plug syndrome (MPS) is associated with Hirschsprung disease (HD) in 13–38% of cases. This study sought to assess institutional variation in utilization of rectal biopsy in children with MPS and the likelihood of diagnosing HD in this population.MethodsPatients with MPS on contrast enema in the first 30 days of life from the Pediatric Health Information System database in 2016–2017 were included. Institutional rates of rectal biopsies performed during the initial admission were calculated and then used to predict institutional rates of early HD diagnoses using Poisson regression.ResultsOf 373 newborns with MPS, 106 (28.4%) underwent early rectal biopsy, of whom 43 (40.5%) had HD. Fifty-seven (15.3%) were ultimately diagnosed with HD. Eight (14%) of these patients had a delayed diagnosis. HD rates between institutions did not differ significantly (range 0–50%, p = 0.52), but usage of early rectal biopsy did (range 0–80%, p = 0.03). Each additional early biopsy increased the early HD diagnosis rate by 35% (β = 0.30, 95% CI 0.15–0.45, p < 0.0001).ConclusionThe incidence of HD is increased in children with MPS. There is significant hospital variability in the utilization of early rectal biopsy, and opportunity exists to standardize practice.Type of Study: Study of Diagnostic testLevel of Evidence: Level III     

Operative outcome of mucous cyst of lesser toes: A comparison between cyst excision with osteophytectomy and distal interphalangeal fusion

BackgroundTo date, the optimal operative treatment for mucous cysts of the lesser toes (MCLT) has not been discussed in detail, although many previous studies have focused on treating finger lesions. Therefore, we evaluated the operative outcomes of two different procedures for MCLT: cyst excision with osteophytectomy and cyst excision with distal interphalangeal (DIP) fusion.MethodsWe retrospectively reviewed and compared the clinico-radiographic outcomes of patients who underwent cyst excision with osteophytectomy (group 1, 22 cases) or cyst excision with DIP fusion (group 2, 16 cases) for MCLT between January 2010 and August 2021. The minimum follow-up duration for inclusion in the study was 12 months. Clinical outcomes were evaluated using the American Orthopedic Foot and Ankle Society (AOFAS) lesser toes metatarsophalangeal-interphalangeal scale and the Foot and Ankle Ability Measure (FAAM) Activities of Daily Living (ADL) subscale. We also collected information on postoperative recurrence and operation-related complications.ResultsThe preoperative and postoperative AOFAS and FAAM-ADL scores were not significantly different between the two groups (P > 0.05, each). However, the postoperative recurrence rate was 31.8 % in group 1 (7 of 22 cases), whereas no recurrence was observed in group 2. Every recurrence occurred within 8 postoperative weeks (mean, 4.8 weeks; range, 3–8 weeks). Nonunion of the fusion site was observed in one patient (6.3 %).ConclusionWe confirmed that postoperative recurrence was significantly lower in the case of cyst excision with DIP fusion than in cyst excision with osteophytectomy for the treatment of MCLT. Clinical outcomes were not significantly different between the two procedures.Level of evidenceLevel III, retrospective comparative study.