Single-incision laparoscopic surgery (SILS) for children with Crohn’s disease

Purpose

Single-incision laparoscopic surgery (SILS) has been described in adults with Crohn’s disease, but its use in pediatric Crohn’s patients has been limited. The purpose of this study was to review our experience with SILS in pediatric patients with Crohn’s disease.

Methods

A retrospective review was performed for patients diagnosed with Crohn’s disease who underwent small bowel resection or ileocecectomy at a freestanding children’s hospital from 2006 to 2014. Data collected included demographic data, interval from diagnosis to surgery, operative time, length of stay, and postoperative outcomes.

Results

Analysis identified 19 patients who underwent open surgery (OS) and 41 patients who underwent SILS. One patient (2.4 %) within the SILS group required conversion to OS. Demographic characteristics were similar between the 2 cohorts. The most common indication for surgery was stricture/obstruction (SILS 70.7 % vs. OS 68.4 %, p = 0.86), and ileocecectomy was the most common primary procedure performed (SILS 90.2 % vs. OS 100 % OS). Operative times were longer for SILS (135 ± 50 vs. 105 ± 37 min, p = 0.02). However, when the last 20 SILS cases were compared to all OS cases, the difference was no longer statistically significant (SILS 123.3 ± 34.2 vs. OS 105 ± 36.5, p = 0.12). No difference was noted in postoperative length of stay (SILS 6.5 ± 2.2 days vs. OS 7.4 ± 2.2 days, p = 0.16) or overall complication rate (SILS 24.4 % vs. OS 26.3 %, p = 0.16).

Conclusion

SILS ileocecectomy is feasible in pediatric patients with Crohn’s disease, achieving outcomes similar to OS. As experience increased, operative times also became comparable.

     

Hypospadias repair and outcome in Abuja,Nigeria: A 5-year single-centre experience

Background:

To determine the outcome of hypospadias repair in children.

Patients and Methods:

This was a retrospective study of all patients with hypospadias managed at the University of Abuja Teaching Hospital, Abuja, Nigeria from January 2009 to December 2013.

Results:

Twenty-four cases of hypospadias had corrective surgery during the 5-year period under review. Seventy-five percent of the patients (n = 18) were seen after the 1^st year of life. There were two peaks of ages at corrective repair; 45.8% between age 1 and 3 years and 29.1% between age 5 and 10 years. The average age at time of surgery was 44.9 months. Distal hypospadias were more common (58.4%), followed by glanular (20.8%) and proximal (20.8%) hypospadias. Associated anomalies included chordee, maldescended testicles and inguinal hernia in 20.8%, 4.1% and 8.3% cases, respectively. Operative techniques were single-stage procedures in 79.1% of patients consisting of simple circumcision in two cases (10.5%), Mathieu''s peri-meatal based flap in four cases (21%), meatal advancement and glanuloplasty incorporated in three cases (16%) and Snodgrass tubularised incised urethral plate tubularised incised plate in 10 cases (52.5%). The remaining 20.9% (n = 5) had multi-staged procedures. The most common post-operative complications were urethrocutenous fistula in nine patients (33.3%) and metal stenosis in 3 patients (12.5%).

Conclusions:

Our results show that hypospadia repair is froth with attendant high complications in our setting.     

Work-related upper limb musculoskeletal disorders in pediatric minimally invasive surgery: a multicentric survey comparing laparoscopic and sils ergonomy

Purpose

Surgeons are at risk for developing work-related musculoskeletal symptoms (WMS). The present study aims to compare laparoscopy and SILS ergonomy among pediatric surgeons.

Methods

A questionnaire formed by 17 questions was mailed to 14 pediatric surgeons, seven with a large experience in laparoscopy and seven in SILS. All surgeons completed the survey. The questionnaires were focused on the type of laparoscopic or SILS activity, location and type of pain, need for drugs and its physical consequences. Results were analyzed using χ ² test.

Results

Results indicated a similar incidence of WMS with shoulder symptoms (>75 %) in both groups. In laparoscopic group this pain is evident only after a long lasting procedure, while in SILS group the pain is present after each procedure performed. SILS surgeons used painkillers and other therapies statistically more frequently than laparoscopic group (χ ² = 0.001).

Conclusions

This study confirms there is a strong association between WMS and MIS surgery. The incidence of pain is similar in both groups. Pain was present only after long lasting procedures in laparoscopic group, while SILS surgeons have pain after each procedure performed. In addition SILS surgeons use more frequently painkillers and other therapies compared to laparoscopic surgeons. In conclusion, it seems that SILS has a worse ergonomy compared to laparoscopy.     

Subtotal colectomy with a single-incision laparoscopic surgery technique in children with long-segment Hirschsprung disease and allied disorders

Background

Over the last 15 years, the laparoscopic-assisted endorectal pull-through procedure has become the standard treatment for Hirschsprung disease in many centers around the world. Recently, single-incision laparoscopic techniques have drawn more attention. We describe a single-incision laparoscopic surgery (SILS) subtotal colectomy to treat long-segment Hirschsprung disease (LSHD) and Hirschsprung disease allied disorder (HAD) in children.

Methods

A total of 22 patients who underwent SILS subtotal colectomy, including three patients with a failed first surgery, were included in this retrospective study. For SILS, a 1-cm skin incision was first made below the umbilical margin and a 5-mm trocar was placed into the abdomen after incising the peritoneum. Two 5-mm trocars were then placed on both sides of the umbilicus. Subsequently, based upon preoperative examination and biopsy results, we performed subtotal colectomy. The affected colon was mobilized successively beyond the peritoneum using high-frequency cutting and sealing devices, followed by a pull-through procedure and colon-anal anastomosis.

Results

The average operative time was 206.39 min. No case needed conversion from SILS to either conventional laparoscopy or open surgery. Of the 22 patients, 15 were diagnosed as LSHD, while 6 cases were diagnosed with intestinal neuronal dysplasia and one was diagnosed with hypoganglionosis. There were no intra-operative complications. One child had incision dehiscence on postoperative day three. During the follow-up over 12 months, all patients were noted to have excellent cosmetic outcomes, and enterocolitis was observed in four children.

Conclusions

Subtotal colectomy with the SILS technique can be safely performed in LSHD or HAD patients in the pediatric population without major complications.     

Herniotomy in resource-scarce environment: Comparison of incisions and techniques

Background:

There are various methods for surgical treatment of hernia and hydrocele in children with variable cost-effectiveness, recovery and cosmetic outcomes. This study analyses our experience with mini-incision/invasive herniotomy in children in resource-limited centre.

Materials and Methods:

Seven hundred and eighty-four n = 784 patients underwent herniotomy via conventional and mini-invasive methods were assigned into Group A and Group B. Three hundred and seventy-six n = 376 (47.95%) in Group A while four hundred and eight n = 408 (52.04%) in Group B. Eight hundred and seventeen (817) herniotomy was performed. Demographic data, hernia/hydrocele sides, volume of surgical suture used, surgery duration, and complications analysed.

Results:

Right side hernia and/or hydrocele were 464 (59.18%). 287 (36.60%) had left sided while 33 (4.21%) had bilateral hernia and/or hydrocele. There were 14 bilateral hernia repair in Group A and 19 in Group B. The lengths of operation time for unilateral repair ranged from 14 to 54 min in Group A (median, 23 min) and 7-44 min in Group B (median, 15 min) with a mean surgical duration of 15.48 ± 4.16 min in Group B versus 23.41 ± 5.94 min in Group A (P < 0.001) while the range of the lengths of operation time for bilateral repair in Group A was 20-54 min (median, 36) and 12-30 min (median, 21) in Group B with a mean duration of 36.35 ± 9.89 min in Group A versus 20.42 ± 4.83 min in Group B P = 0.00563. 376 sachets of 45 cm suture material were used in Group A versus 137 in Group B. There were total of 87 (23.13%) complications in Group A versus 3 (1.47%) in Group B P = 0.000513. Superficial wound infection and abscess were 9 (2.36%) and 16 (4.25%) in Group A versus none (0) in Group B.

Conclusion:

Mini-incision/invasive herniotomy in children and adolescents is fast, cost-effective with satisfactory cosmetic outcome and limited complications     

Epidemiology,management and outcome of gastroschisis in Sub-Saharan Africa: Results of an international survey

Background:

The aim was to compare gastroschisis (GS) epidemiology, management and outcome in low-income countries (LIC) in Sub-Saharan Africa (SSA) with middle- (MIC) and high-income countries (HIC).

Materials and Methods:

A 10-question survey was administered at the 2012 Pan-African Paediatric Surgery Association Congress. Results are presented as median (range); differences were analysed using contingency tests.

Results:

A total of 82 delegates (28 countries [66 institutions]) were divided into LIC (n = 11), MIC (n = 6) and HIC (n = 11). In LIC, there were fewer surgeons and more patients. LIC reported 22 cases (1-184) GS/institution/year, compared to 12 cases (3-23)/institution/year in MICs and 15 cases (1-100)/institution/year in HICs. Antenatal screening was less readily available in LIC. Access to parenteral nutrition and neonatal intensive care in LIC was 36% and 19%, compared to 100% in HIC. Primary closure rates were similar in LIC and HIC at 58% and 54%, respectively; however, the majority of staged closure utilised custom silos in LIC and preformed silos in HIC. In LIC, mortality was reported as >75% by 61% delegates and 50-75% by 33%, compared to <25% by 100% of HIC delegates (P < 0.0001).

Conclusions:

Gastroschisis is a problem encountered by surgeons in SSA. Mortality is high and resources in many centres inadequate. We propose the implementation of a combined epidemiological research, service delivery training and resource provision programme to help improve our understanding of GS in SSA whilst attempting to improve outcome.     

The success rate and complications of awake caudal epidural bupivacaine alone or in combination with intravenous midazolam and ketamine in pre-term infants

Background:

The aim of the present study is to compare the success rate and complications of caudal epidural bupivacaine alone or in combination with intravenous (IV) midazolam and ketamine in awake infants undergoing lower abdominal surgery.

Materials and Methods:

In this double-blind, clinical trial study, 90 infants (aged below 3 months and weight below 5 kg) with American Society of Anaesthesiologists I-II, were divided into three groups of each 30: Group 1 received bupivacaine 0.25%, 1 mL/kg for caudal epidural block; Groups 2 and 3 received caudal block with same dose bupivacaine along with IV pre-treatment with midazolam 0.1 mg/kg or IV midazolam 0.1 mg/kg and ketamine 0.3 mg/kg, respectively.

Results:

The success rates in Groups 2 and 3 were 93.3% and 93.1%, respectively, compared with a caudal block with bupivacaine alone 80%; P = 0.015). There was no significant difference among the three groups in terms of mean systolic and diastolic blood pressures and mean heart rate at intervals of 0, 20, 40 and 60 min (P < 0.05). There were no significant differences in the pain scores >3 on the Neonatal Infant Pain Scale at three intervals (30, 60 and 120 min) after surgery among the three groups. The complications such as apnoea or desaturation were not found in any of the studied groups.

Conclusions:

Adding IV ketamine and/or midazolam to bupivacaine caudal epidural block in the conscious infants can positively affect block success rate.Key words: Awake caudal epidural block, bupivacaine, children, ketamine, midazolam     

Laparoscopic upper pole heminephroureterectomy in children: Seven-year experience

Background:

Minimally invasive surgery is the current approach to perform heminephroureterectomy (HN) in children. This can be obtained through a transperitoneal (TP) or a retroperitoneal approach. Here, we report our experience using a TP approach.

Materials and Methods:

From 2005 to 2014, 22 TP laparoscopic upper poles HN were performed at our institution. There were nine girls and 13 boys aged between 20 months and 6 years (mean age 3.9). Eight patients were diagnosed prenatally, 17 patients presented with urinary tract infection (UTI) and three with vomiting and failure to thrive. The indication for HN was reflux nephropathy and UTI in non-functioning upper pole in 19 patients and cystic dysplasia in 1 patient. The surgical technique involved the following steps: Cystoscopic recognition; positioning of 3-4 trocar (right HN); identification of the kidney (detachment of the colon); isolation and low ligation of the dilated ureter; decrossing from renal vessels; section of the parenchyma by LigaSure; haemostasis with clips and LigaSure; drain.

Results:

The mean operative time was 154 min (range: 81-220 min). All patients were discharged from the 2^nd to 4^th day. Neither major complication nor conversion was recorded. 1 patient presented leakage of urine for 7 days from the drainage which resolved spontaneously. At ultrasound follow-up, 5 patients showed a secondary perirenal cyst, 2-5 cm diameter that resolved spontaneously.

Conclusion:

The results indicate that laparoscopic upper pole heminephrectomy is the treatment of choice in cases of non-functioning dilated lower segments of duplicated kidneys. The use of laparoscopic approach offers a good working space, a good visual control of the vessels and allows a very low isolation of the ureteral stump which counterbalance the peritoneal violation.Key words: Duplex kidney, heminephrectomy, infants, laparoscopy     

Laparoscopic <Emphasis Type="Italic">versus</Emphasis> open appendectomy for acute appendicitis in children

Objective

To compare the efficacy and safety of laparoscopic appendectomy and open appendectomy for acute appendicitis in children.

Methods

This study was conducted as a retrospective comparison of hospital records for postoperative complications, duration of operation, and postoperative length of stay between children (aged <18y) who underwent laparoscopic (n=190) or open (n=199) appendectomy over a six-year period. Quality of life was evaluated immediately and 1 month postoperatively.

Results

The major complication rate after surgery in laparoscopic group was significantly lower than that of open appendectomy group (13% vs 27%, P<0.05). The mean (SD) postoperative hospital stay was also shorter in laparoscopic group (2.4 (0.6) days vs 3.7 (1.1) days, P<0.05). The postoperative minor complication rate and hospital expenses were not significantly different between the two groups. The duration of surgery was longer in laparoscopic group (P<0.05). Children in laparoscopic group had less postoperative pain and higher quality of life after one month than those in open appendectomy group.

Conclusions

Laparoscopic technique seems to be safer than open appendectomy for acute appendicitis in children.

     

The Role of Zinc Sulfate in Acute Bronchiolitis in Patients Aged 2 to 23 Months

Objective

Evaluating the effect of zinc sulfate in improving the clinical manifestations of acute bronchiolitis in children younger than 2 years.

Methods

This was a double blind pilot trial on 50 patients aged 2 to 23 months at Ghaem and Dr. Sheikh Hospitals in Mashhad from January 2008 to March 2009. Patients were randomly divided into two groups: a case group received oral zinc sulfate and to the control group was given placebo.

Findings

Mean age of case group was 168.0±108.6 days and control group 169.2±90.4 days (P=0.98) with male predominance in both groups. At first there was no statistically significant difference between the two groups in reducing the symptoms. But 24 hours after treating, improvement of some important manifestations including tachypnea, subcostal and intercostal retraction, wheezing and cyanosis revealed statistically significant difference in control group in comparison with case group (P=0.04).

Conclusion

Zinc sulfate has no benefit in improving clinical manifestations of acute bronchiolitis.     

Oesophageal atresia: Diagnosis and prognosis in Dakar,Senegal

Background:

Oesophageal atresia is a neonatal emergency surgery whose prognosis has improved significantly in industrialised countries in recent decades. In sub-Saharan Africa, this malformation is still responsible for a high morbidity and mortality. The objective of this study was to analyse the diagnostic difficulties and its impact on the prognosis of this malformation in our work environment.

Patients and Methods:

We conducted a retrospective study over 4 years on 49 patients diagnosed with esophageal atresia in the 2 Paediatric Surgery Departments in Dakar.

Results:

The average age was 4 days (0-10 days), 50% of them had a severe pneumonopathy. The average time of surgical management was 27 h (6-96 h). In the series, we noted 10 preoperative deaths. The average age at surgery was 5.7 days with a range of 1-18 days. The surgery mortality rate is 28 patients (72%) including 4 late deaths.

Conclusion:

The causes of death were mainly sepsis, cardiac decompensation and anastomotic leaks.Key words: Esophageal atresia, Diagnosis, Prognosis, Sub-Saharan Africa     

Laparoscopic Mitrofanoff continent catheterisable stoma in children with spina bifida

Background:

In 1980, Mitrofanoff described the creation of an appendicovesicostomy for continent urinary diversion. This procedure greatly facilitates clean intermittent catheterisation in patients with neurogenic bladder. The purpose of our study was to determine the clinical efficacy of the laparoscopic Mitrofanoff catheterisable stoma for children and adolescents with spina bifida.

Materials and Methods:

Review of hospital records revealed that 11 children with spina bifida underwent a laparoscopic Mitrofanoff procedure with at least 1-year of follow-up. A four-port transperitoneal laparoscopic approach was used to create a Mitrofanoff appendicovesicostomy. The child was followed-up in the urology clinic at 6 weeks, 3 months, 6 months, 1-year, and then semiannually after that. Questionnaires were administered to determine, from the children''s perspective, the level of satisfaction with catheterisation and the psychosocial implications of catheterisation before and after the creation of the Mitrofanoff continent catheterisable stoma.

Results:

Of the 11 children, six were female, and five were male. The mean age at presentation to Paediatric urological services was 11 ± 3.22 years. Overall the mean operative time was 144.09 ± 17.00 min. Mean estimated blood loss was 37.36 ± 11.44 cc. None of the cases needed conversion to open. Patient satisfaction with their catheterisation was measured at 2.18 ± 0.98 preoperatively, Post-operatively, this improved to 4.27 ± 0.46. Statistical analysis using paired t-test showed significance with P < 001.

Conclusions:

Laparoscopic Mitrofanoff catheterisable stoma is feasible in children with spina bifida and is associated with reasonable outcome with early recovery, resumption of normal activities and excellent cosmesis.Key words: Clean intermittent catheterisation, Mitrofanoff, neurogenic bladder, spina bifida, urinary incontinence     

Congenital cystic lesions of lung in the paediatric population: A 5-year single institutional study with review of literature

Background:

The aim was to evaluate the clinical presentation, investigation modalities, operative management, pathology, outcome (morbidity and mortality) and short term follow-up of congenital cystic lesions of the lung.

Materials and Methods:

This is a retrospective study. Study period was 5 years (December 2008-November 2013) in the Department of paediatric surgery, Nil Ratan Sircar Medical College. Study population: Total number = 10 patients. Age range: 2 days-7 years. (Neonate-4). Male and female ratio = 1:1.

Result:

Among 10 cases of lung cyst four having congenital lobar emphysema, four having congenital pulmonary airway malformation, one sequestration and one teratoma. All patients have undergone surgical excision in terms of lobectomy or excision of the lesion. Post-operative histopathology confirmed the diagnosis. Recovery was uneventful.

Conclusion:

Although our experience is limited, operative management of lung cysts seems to be safe with rewarding results. However we are yet to encounter many of the other varieties of the cysts found in the lung, which may be associated with other congenital anomalies and have an impact on prognosis.     

Wilms’ tumour: Determinants of prognosis in an African setting

Background:

The few studies available in the literature on Wilms’ tumour (WT) from sub-Saharan Africa have reported a dismal outcome for children with the tumour. This study evaluated the risk factors that have been correlated with outcome in the literature and compare these with outcome among our patients.

Materials and Methods:

Cases of histologically confirmed WT between 2009 and 2013 in a tertiary hospital in Northwestern Nigeria were evaluated for gender, age, laterality, symptoms, duration before presentation, stage at presentation, histologic subtype and p53 mutation. These were then correlated with outcome.

Results:

Totally, 30 cases of WT were diagnosed with mean age of 4.8 ± 1.9 years; and male:female ratio of 2:1. No statistically significant relationship with outcome was found for gender (P = 0.138) or histologic subtype (P = 0.671). The most significant variables which positively influenced the outcome were presentation at earlier stages (P = 0.007) and completion of therapy (P = 0.0007). p53 mutation was seen in 3 (16.7%) of 18 cases and was not associated with a poor outcome (P = 0.089). However, 2 of the 3 cases presented in Stage IV and none of them survived the 1^st year.

Conclusion:

This study shows that even though p53 mutation was associated with a more aggressive phenotype, the most significant determinants of a good outcome among patients in a developing country like ours is non-blastemal dominant histologic subtype, early stage at presentation and completion of therapy.Key words: Blastema, outcome, p53, Wilms’ tumour     

New Single Nucleotide Deletion In the SMPD1 Gene Causes Niemann Pick Disease Type A in a Child from Southwest Iran: A Case Report

Objective

Niemann Pick disease (NPD) type A (NPA: MIM #257200) is a lipid storage disorder with an autosomal recessive inheritance and occurrs by defect of the SMPD1 gene encoding sphingomyelinase. Disruption of this enzyme leads to the accumulation of sphingomyelin in brain and liver, which in turn causes dysfunction or damage of tissue.

Methods

We report firstly a 2.5 year old boy with NPA in southwest Iran. Initially, the diagnosis was resulted on the basis of clinical symptoms. The genomic DNA of the suspected individual was subjected to exon sequencing of the SMPD1 gene. According to the human reference sequence {"type":"entrez-nucleotide","attrs":{"text":"NM_000543.4","term_id":"300795568","term_text":"NM_000543.4"}}NM_000543.4, a novel single guanine deletion resulting in a frameshift mutation (p.Gly247Alafs*9) was observed in the SMPD1 gene that might be causative for the outcome of the disease.

Findings

The present report is the first molecular genetics diagnosis of the NPA in southwest Iran. The detected deletion in the SMPD1 gene is remarkable because of its novelty.

Conclusion

Despite similar morbidity SGA infants exhibited higher lethal complication rates following delayed meconium passage compared to AGA infants.     

The Effect of Performing Preoperative Preparation Program on School Age Children's Anxiety

Objective

The purpose of this study was to examine effects of performing preoperative preparation program on children''s anxiety.

Methods

This study was performed in Amirkola Pediatrics Hospital, Mazandaran. A randomized controlled trail was performed on 122 children (7–12 years of age) admitted for elective surgery during 15 months. The researcher randomly assigned eligible participants in to the experimental and control groups, after pre-test baseline measurement had been taken. Analyzing was performed through independent t-test and χ² test. P<0.005 was considered statistically significant. The experimental group received therapeutic play and the control group received routine preoperative information preparation.

Findings

The mean and standard deviation of the state anxiety scores of children in experimental and control groups before intervention were 35.52±6.99 and 34.98±6.78, after intervention 31.44±5.87 and 38.31±7.44 respectively. The state anxiety score was lower significantly in the experimental group prior to preoperative surgery than in the control group (P=0.000).

Conclusion

Performing preoperative program with using therapeutic play intervention is effective for preparing children before surgery and decreases their anxiety.     

Reliability and Validity of HeartSmartKids: A Survey of Cardiovascular Risk Factors in Children

Introduction

Reliable and valid instruments to measure counseling effectiveness related to eating, activity, and inactivity are lacking. HeartSmartKids (HSK; HeartSmartKids, LLC, Boulder, Colorado) is a bilingual decision-support technology that can be used to assess and counsel families on cardiovascular risk factors in children. The purpose of this study was to establish preliminary test–retest reliability and convergent validity of HSK questions relative to a previously validated questionnaire, HABITS.

T-Peak to T-End Abnormality in Pediatric Patients with Syncope

Objective

The purpose of this study was to examine the relationship between T-peak-to-T-end interval and its dispersion in children with syncope to detect possible repolarization abnormalities in these patients.

Methods

We enrolled 19 patients with a positive tilt test for syncope (7 boys, 12 girls) and 35 participants with normal results on the test.

Findings

Mean age was 11.4±3.1 years in patients and 10.0±5.1 years in controls (P =0.27). The T-peak-to-T-end interval in lead V1 was significantly longer in patients with a positive tilt test (0.36±0.062 vs. 0.32±0.071, P=0.007). T-peak-to-T-end interval dispersion was significantly greater in the group of patients (0.15±0.07 vs. 0.11±0.04, P±0.003).

Conclusion

The T-peak-to-T-end interval in lead V1 and T-peak-to-T-end dispersion were significantly larger in patients with a positive tilt test. Our findings suggest a depolarization abnormality in children with syncope.