Analysis of Cholangitis Rates with Extended Perioperative Antibiotics and Adjuvant Corticosteroids in Biliary Atresia / 대한소아소화기영양학회지

Purpose@#There is no consensus regarding adjuvant therapies following Kasai portoenterostomy (KP) for biliary atresia (BA). This study aimed to analyze the effect of extended perioperative intravenous antibiotics (PI-Abx) and adjuvant corticosteroid on cholangitis and jaundice clearance rates in the 3 years post-KP in children with BA. @*Methods@#Data of patients who underwent KP between 1999-2018 at a single center were retrospectively analyzed. Group A (1999–2010) received PI-Abx for 5 days, Group B (2010–2012) received PI-Abx for 5 days plus low-dose prednisolone (2 mg/kg), and Group C (2012–2017) received PI-Abx for 14 days plus high-dose prednisolone (5 mg/kg). @*Results@#Fifty-four patients were included with groups A, B, and C comprising 25, 9, and 20 patients, respectively. The number of episodes of cholangitis was 1.0, 1.6, and 1.3 per patient (p=NS) within the first year and 1.8, 2.3, and 1.7 (p=NS) over 3 years in Groups A, B, and C, respectively. The jaundice clearance rate at 6 months was 52%, 78%, and 50% (p=NS), and the 3-year native liver survival (NLS) rate was 76%, 100%, and 80% (p=NS) in Groups A, B, and C, respectively. A near-significant association was observed between the incidence of cholangitis within the first year and decompensated liver cirrhosis/death at 3 years post KP (p=0.09). Persistence of jaundice at 6 months was significantly associated with decompensated cirrhosis/death at 3 years (p<0.001). @*Conclusion@#The extended duration of PI-Abx and adjuvant corticosteroids was not associated with improved rates of cholangitis, jaundice clearance, or NLS in patients with BA.

Analysis of Cholangitis Rates with Extended Perioperative Antibiotics and Adjuvant Corticosteroids in Biliary Atresia / 대한소아소화기영양학회지

Purpose@#There is no consensus regarding adjuvant therapies following Kasai portoenterostomy (KP) for biliary atresia (BA). This study aimed to analyze the effect of extended perioperative intravenous antibiotics (PI-Abx) and adjuvant corticosteroid on cholangitis and jaundice clearance rates in the 3 years post-KP in children with BA. @*Methods@#Data of patients who underwent KP between 1999-2018 at a single center were retrospectively analyzed. Group A (1999–2010) received PI-Abx for 5 days, Group B (2010–2012) received PI-Abx for 5 days plus low-dose prednisolone (2 mg/kg), and Group C (2012–2017) received PI-Abx for 14 days plus high-dose prednisolone (5 mg/kg). @*Results@#Fifty-four patients were included with groups A, B, and C comprising 25, 9, and 20 patients, respectively. The number of episodes of cholangitis was 1.0, 1.6, and 1.3 per patient (p=NS) within the first year and 1.8, 2.3, and 1.7 (p=NS) over 3 years in Groups A, B, and C, respectively. The jaundice clearance rate at 6 months was 52%, 78%, and 50% (p=NS), and the 3-year native liver survival (NLS) rate was 76%, 100%, and 80% (p=NS) in Groups A, B, and C, respectively. A near-significant association was observed between the incidence of cholangitis within the first year and decompensated liver cirrhosis/death at 3 years post KP (p=0.09). Persistence of jaundice at 6 months was significantly associated with decompensated cirrhosis/death at 3 years (p<0.001). @*Conclusion@#The extended duration of PI-Abx and adjuvant corticosteroids was not associated with improved rates of cholangitis, jaundice clearance, or NLS in patients with BA.

Prevention of diabetic foot complications

This paper discussed the importance of prevention of diabetic foot ulcers and our institution's protocol for prevention, reviewing the existing evidence in the literature regarding the effectiveness of the preventive approach. Diabetes mellitus is the second most significant cause of disease in Singapore after ischaemic heart disease. National University Hospital, Singapore, adopts a two-pronged strategy for the management of diabetic foot ulcers. The most important strategy is prevention, and education is key. Education should mainly be directed at patients and caregivers, but also professionals (general practitioners, allied health professionals and nurses) so that they can effectively educate patients and caregivers. Patient education includes care of diabetes mellitus, care of the foot and use of appropriate footwear. Patients also tend to have poor foot hygiene. Annual foot screening for diagnosed diabetics plays an important role. However, prolonged and sustained government intervention is necessary to provide education and screening on a national scale.

Isolated fallopian tube torsion in prepubertal females – A report of 2 cases

Isolated fallopian tube torsion is an uncommon diagnosis. It is particularly rare in the paediatric and post-menopausal age groups. It lacks pathognomonic symptoms, signs and imaging findings, yet each of these diagnostic steps plays a crucial role in early diagnosis. We describe two cases of isolated fallopian tube torsion in prepubertal females.

Achalasia and Down syndrome: a unique association not to be missed

Achalasia is a rare primary oesophageal motility disorder that presents as a functional obstruction at the oesophago-gastric junction. The prevalence of achalasia in Down syndrome is much higher, which implies a unique association between these two uncommon conditions. Although the exact aetiology of achalasia is unknown, studies have proposed that its pathogenesis is related to autoimmune, infectious or genetic factors, leading to the intrinsic loss of inhibitory myenteric neurons in both the oesophagus and lower oesophageal sphincter. We herein report the case of a 16-month-old girl with Down syndrome and achalasia who was initially treated for gastro-oesophageal reflux disease. The diagnosis of achalasia was made only when her condition deteriorated, with subsequent failure to thrive, and upon further investigations, including barium swallow study and upper endoscopy. We also review the various mechanisms postulated in the development of achalasia in Down syndrome, as well as the various treatment modalities available for this rare disorder.

Mid-term outcomes of laparoscopic versus open choledochal cyst excision in a tertiary paediatric hospital

<p><b>INTRODUCTION</b>Paediatric laparoscopic choledochal cyst excision has increasingly gained acceptance as an alternative to open excision. Laparoscopic excision is feasible and safe in the short term, but long-term outcomes are not as well established. KK Women's and Children's Hospital started performing laparoscopic choledochal cyst excision in children since 2007. In this paper, we report our experience with the laparoscopic approach, and the early and mid-term outcomes in comparison with the conventional open approach.</p><p><b>MATERIALS AND METHODS</b>Thirty-five consecutive cases by a single surgeon between May 2006 and April 2012 were retrospectively reviewed. Patient characteristics and surgical outcomes were analysed.</p><p><b>RESULTS</b>There were 13 laparoscopic and 22 open cases. Baseline patient characteristics were similar. Operative time was longer in the laparoscopic group. Three cases in the laparoscopic group were converted to open in our early experience. There were no differences in time to feeds or length of hospitalisation. One laparoscopic case developed minor bile leak that resolved on conservative management. There were no complications in the laparoscopic group on median follow-up of 35 months. In the open group, there was 1 case of pancreatitis, cholangitis, and hypertrophic scarring respectively. There were 3 cases of suspected adhesive colic that resolved without surgery.</p><p><b>CONCLUSION</b>Laparoscopic choledochal cyst excision enjoys excellent early and mid-term outcomes compared to open excision, even in centres with smaller patient volume. It should be the approach of choice where technical expertise is available.</p>

Low-lying spinal cord and tethered cord syndrome in children with anorectal malformations

<p><b>INTRODUCTION</b>Anorectal malformations (ARMs) and low-lying spinal cord (LLC) are commonly associated owing to their common embryonic origin. LLC may lead to tethered cord syndromes (TCS), requiring surgery. This study aimed to review the incidence of LLC in children with ARMs using ultrasonography (US) and magnetic resonance (MR) imaging, the incidence of TCS and the surgical outcomes of these patients after detethering.</p><p><b>METHODS</b>We conducted a retrospective study of children who underwent surgery for ARMs in 2002-2009 at KK Women's and Children's Hospital, Singapore.</p><p><b>RESULTS</b>Out of 101 (16.8%) ARM patients, 17 had LLC, of which 12 (70.6%) were high ARMs. 12 of the 17 (70.6%) patients had abnormal US and MR imaging findings. Five (29.4%) had normal US but abnormal MR imaging results; in these five patients, MR imaging was performed due to new symptoms and equivocal US findings. These 17 patients subsequently underwent surgical detethering. Three out of seven patients with TCS improved after surgery. None of the 17 patients had any complications.</p><p><b>CONCLUSION</b>LLC appeared to be associated with high ARMs, although this was not statistically significant. LLC should be investigated for whenever ARM is diagnosed, regardless of its type. Lumbar US is useful for first-line screening for LLC. Abnormal US or onset of new symptoms should subsequently be investigated with MR imaging. Equivocal US findings are also likely to benefit from further MR imaging. Surgery to detether LLC can improve outcome in TCS, while prophylactic detethering for asymptomatic patients with lipoma of the filum terminale has very low surgical risk.</p>

Perforated appendicitis in children: benefits of early laparoscopic surgery

<p><b>INTRODUCTION</b>The aim of this study was to analyse the feasibility, safety and benefits of laparoscopic appendicectomy (LA) in comparison with open appendicectomy (OA) for perforated appendicitis (PA) in children.</p><p><b>MATERIALS AND METHODS</b>A retrospective analysis of all consecutive cases of PA who underwent OA or LA between July 2001 and April 2004 was done. The patient demographics, duration of symptoms and operative findings were noted and the feasibility, safety and benefits of LA were analysed with respect to postoperative recovery and complications.</p><p><b>RESULTS</b>One hundred and thirty-seven consecutive patients with PA underwent either OA (n = 46) or LA (n = 91). Both groups were comparable with respect to patient demographics, duration of symptoms and operative findings. The mean operative time was 106.5 min (95% CI, 100.2 - 112.8) in the LA group and 92.8 min (95% CI, 82.9-102.7) in the OA group (P = 0.02). The return to afebrile status after surgery was significantly faster in the LA group [mean, 45.4 hours (95% CI, 36.8-54)] than the OA group [mean, 77 hours (95% CI 56.7-97.3)] (P = 0.007). The mean duration for postoperative opioid analgesia was 2.5 days (95% CI, 2.2-2.7) for LA and 3.2 days (95% CI, 2.9- 3.6) for OA (P = 0.001). The resumption of oral feeds after surgery was at 3.1 days (95% CI, 2.8-3.3) for LA and 3.7 days (3.4-4.1) for OA (P = 0.005). The length of the hospital stay was shorter in the LA group [mean, 6.5 days (95% CI, 6.1-6.8)] as compared to that of the OA group [mean, 8.2 days (95% CI, 7.1-9.3)] (P = 0.006). Postoperative complications included wound infection, adhesive intestinal obstruction and pelvic abscess formation. The incidence of these complications was 5.6% in the LA group and 19.6% in the OA group (P = 0.01). Nine patients (9.8%) needed conversion to open surgery in the LA group. None of the LA patients had wound infection.</p><p><b>CONCLUSION</b>LA is feasible, safe and beneficial in children with PA.</p>

Bile duct perforation in children: is it truly spontaneous?

<p><b>INTRODUCTION</b>Bile duct perforation (BDP) with resultant biliary ascites in children is a rare clinical condition. The aetiopathogenesis is still an enigma, with increasing evidence suggesting anomalous union of pancreaticobiliary ductal (AUPBD) system as the prime causative factor.</p><p><b>CLINICAL PICTURE</b>We report 2 cases of spontaneous perforation of the bile duct confirmed on histopathological examination as choledochal cyst, in a 6-month-old female child and a 4-year-old boy who presented with subtle clinical symptoms.</p><p><b>TREATMENT AND OUTCOME</b>Both patients were successfully managed by excision of the gall bladder and common bile duct and Roux-en- Y hepaticojejunostomy. This procedure was performed following initial cholecystostomy drainage in the second case.</p><p><b>CONCLUSIONS</b>From the available literature and experience with our patients, BDP is not merely spontaneous but may be related to AUPBD and choledochal cyst.</p>