Sclerotherapy for rectal prolapse in children: A systematic review and meta-analysis

BackgroundSclerotherapy is a commonly utilized treatment for rectal prolapse in children. This study systematically evaluates the effectiveness and complications of various sclerosing agents in treating pediatric rectal prolapse.MethodsAfter protocol registration (CRD-42018088980), multiple databases were searched. Studies describing injection sclerotherapy for treatment of pediatric rectal prolapse were included, with screening and data abstraction duplicated. The methodological quality of included papers was assessed using the Methodological Index for Non-Randomized Studies (MINORS) score.ResultsNineteen studies were identified, published between 1970 and 2017. Most studies were single institution case series, with median “N” 57 +/?88.9 and mean MINORS score of 0.51 +/?0.17 (perfect score = 1). 1510 patients with a mean age of 4.5 years were accounted for: 36.2% female, most without comorbidities. Mean follow up length was 30 months. The most common sclerosing agent described was ethanol (45%), followed by phenol (33%). The mean number of treatments per patient was 1.1 +/?0.34. The overall success rate after a single sclerotherapy treatment was 76.9%+/?8.8%. The overall complication rate was 14.4%+/?2%.ConclusionsInjection sclerotherapy appears effective and low-risk in the treatment of pediatric rectal prolapse and should be considered before more invasive surgical options. The available evidence is of relatively poor quality, and prospective comparative investigations are warranted.Level of evidence3 (meta-analysis of level 3 studies).     

Breast cancer in association with lobular carcinoma in situ. Clinicopathologic review and treatment recommendation

A 6 year follow-up study of 80 women with coexisting lobular carcinoma in situ and infiltrating breast cancer has been conducted to emphasize the natural history and management of these cancers. Treatment of the contralateral breast is of utmost importance as lobular carcinoma in situ is a multicentric neoplasm associated with a subsequent high occurrence of invasive cancer. This series has documented a high incidence of bilateral cancer. Six patients (7.5 percent) had simultaneous bilateral tumors and eight patients (10 percent) had the subsequent development of a second primary tumor, representing approximately four times the expected rate. Despite a well structured out-patient department, follow-up was suboptimal. Six of eight metachronous tumors were detected at a late stage (T2 and greater).     

Open abdomen in liver transplantation

Introduction

Damage control laparotomy with vacuum assisted closure (VAC) is used for selective cases in trauma. In liver transplantation, VAC has also been applied for management of intra-operative hemorrhage. The primary objective was to evaluate peri-operative blood loss and blood product utilization in VAC compared to primary abdominal closure (PAC) at the index transplant operation.

Prospective comparison of silver sulfadiazine 1 per cent plus chlorhexidine digluconate 0·2 per cent (Silvazine) and silver sulfadiazine 1 per cent (Flamazine) as prophylaxis against burn wound infection

Patients with fresh full-thickness burn wounds were randomly assigned to receive wound treatment with daily applications of either I per cent silver sulfadiazine plus 0·2 per cent chlorhexidine digluconate cream (Silvazine) or 1 per cent silver sulfadiazine (Flamazine). Fifty-four patients treated with Silvazine were comparable to 67 treated with Flamazine with respect to extent and distribution of burn, age and all aspects of wound and associated treatment. Overall incidence of wound bacterial colonization was less in the Silvazine treated patients (65 per cent versus 88 per cent; P = 0·002). With Silvazine, wound colonization by Staphylococcus aureus was less (41 per cent versus 64 per cent; P = 0·01). Clinical wound infection with Staph. aureus developed in one Silvazine treated patient and five Flamazine treated patients (P = 0·16). Colonization by and infection due to all other organisms did not differ in the two groups. The incidence of graft failure was similar with both agents. In future increasing the concentration of chlorhexidine digluconate above 0·2 per cent might produce an improved prophylactic effect against Gram negative bacteria reported by other authors using the combined agent in in vitro and clinical trials. Silvazine was effective in reducing the incidence of Staph. aureus burn wound colonization without fostering supervening opportunistic infection.     

Deriving literature-based benchmarks for pediatric appendectomy and cholecystectomy complications from national databases in high-income countries: A systematic review and meta-analysis

BackgroundHealth systems must identify preventable adverse outcomes to improve surgical safety. We conducted a systematic review to determine national rates of postoperative complications associated with two common pediatric surgery operations in High-Income Countries (HICs).MethodsNational database studies of complication rates associated with pediatric appendectomies and cholecystectomies (2000–2016) in Canada, the US, and the UK were included. Outcomes included mortality, length of hospital stay (LOS), and other surgical complications. Outcome data were extracted and comparisons made between countries and databases.ResultsThirty-three papers met inclusion criteria (1 Canadian, 1 UK, and 4 US Databases). Mean LOS was 3.00 (± 1.42) days and 3.44 (± 1.55) days for appendectomy and cholecystectomy, respectively. Mortality was 0.06% after appendectomy and 0.24% after cholecystectomy. Readmission and reoperation rates were 6.79% and 0.32% for appendectomy, and 1.37% and 0.71% for cholecystectomy. For appendectomies, LOS was shorter in Canadian and UK studies compared to US studies, and mortality and readmission rates were lower (OR 0.46 95%CI 0.23 to 0.93, OR 3.63 to 3.77 95%CI) in UK studies compared to US studies.ConclusionsOutcomes after pediatric appendectomy and cholecystectomy are good but vary between HICs. Understanding national outcomes and intercountry differences is essential in developing health system approaches to pediatric surgical safety.Level of evidenceII     

Carcinoma of the lung in patients under 40 years of age

Bronchogenic carcinoma in the young population (40 years of age or less) is reported to present in an advanced stage and to have a virulent course. Between 1969 and 1979, 101 patients (65 men and 36 women) presented with cancer of the lung. Their mean age was 36.2 +/- 3.9 years (range 18 to 40 years). Eighty-seven percent had a history of cigarette smoking. Fifty percent of the patients had a strong familial history of malignancy of several organs. The interval between onset of symptoms and diagnosis was 4.01 +/- 3.48 months (3.56 +/- 3.34 for the surgically treated group and 4.16 +/- 3.53 for the nonoperated or unresectable group). Diagnosis was made at bronchoscopy in 32 patients, during thoracotomy in 30 patients, during nodal biopsy in 28 patients, and on cytologic examination of the sputum in 9 patients. The most common cell types were adenocarcinoma in 39 patients, squamous carcinoma in 29 patients, and oat cell carcinoma in 18 patients. Eighty-six patients (the majority) presented in stage III, whereas 9 were in stage I and 6 were in stage II. Twenty-seven patients (26.7 percent) underwent resection for cure, whereas 18 patients were inoperable at surgery. Eighteen of the surgical patients had adjuvant radiotherapy, and chemotherapy, immunotherapy, or both. The average length of survival for the nonresected patients was 7.12 +/- 5.9 months (range 1 to 36 months) and the actuarial survival was 1.5 percent at 36 months. The survival for the surgically managed patients was 56.1 +/- 52.6 months (range 3 to 168 months) or 48 percent at 36 months. At 46 to 168 months after treatment, the only survivors were 13 patients who were surgically managed. Stage III patients had longer survival after surgery (24.1 +/- 24.6 months to 7.09 +/- 5.90 months; range 3 to 74 months and 1 to 36 months, respectively). The survival at 5 years for patients with stage I disease was 78.8 percent, stage II disease 66.6 percent, and stage III disease, 3.6 percent. Early diagnosis and aggressive surgical management are necessary to improve the survival of patients with bronchogenic carcinoma under 40 years of age.