Laparoscopic inguinal hernia repair by the hook method in emergency setting in children presenting with incarcerated inguinal hernia.

BACKGROUND: The development of laparoscopic hernia repair has provided an alternative approach to the management of incarcerated inguinal hernia in children. Different laparoscopic techniques for hernia repair have been described. However, we hereby review the role of laparoscopic hernia repair using the hook method in the emergency setting for incarcerated inguinal hernias in children. METHODS: A retrospective review was conducted of all children who presented with incarcerated inguinal hernia and underwent laparoscopic hernia repair using the hook method in emergency setting between 2004 and 2010. RESULTS: There were a total of 15 boys and 1 girl with a mean age of 30 ± 36 months (range, 4 months to 12 years). The hernia was successfully reduced after sedation in 7 children and after general anesthesia in 4 children. In 5 children, the hernia was reduced by a combined manual and laparoscopic-assisted approach. Emergency laparoscopic inguinal hernia repair using the hook method was performed after reduction of the hernia. The presence of preperitoneal fluid secondary to recent incarceration facilitated the dissection of the preperitoneal space by the hernia hook. All children underwent successful reduction and hernia repair. The median operative time was 37 minutes. There was no postoperative complication. The median hospital stay was 3 days. At a median follow-up of 40 months, there was no recurrence of the hernia or testicular atrophy. CONCLUSIONS: Emergency laparoscopic inguinal hernia repair by the hook method is safe and feasible. Easier preperitoneal dissection was experienced, and repair of the contralateral patent processus vaginalis can be performed in the same setting.

Impact of pediatric Rome III criteria of functional dyspepsia on the diagnostic yield of upper endoscopy and predictors for a positive endoscopic finding.

OBJECTIVE: Pediatric Rome III criteria of functional dyspepsia (FD) has eliminated the mandatory use of upper endoscopy and recommended a symptom-based approach. In the absence of alarm symptoms, FD can be positively diagnosed in children having normal physical findings without exclusionary investigations. We aimed to investigate the effectiveness of Rome III guidelines to discriminate organic diseases from FD and to identify the predictors for positive endoscopic findings. PATIENTS AND METHODS: A prospective study was conducted on consecutive children fulfilling Rome III criteria of FD. Upper endoscopy was performed in all subjects, both with and without alarm features. RESULTS: Eighty consecutive children ages 7 to 15 were recruited. Nine (11.3%) had experienced alarm features. Five (6.3%) had organic diseases confirmed in upper endoscopy: duodenal ulcer (n = 2), duodenitis with erosion (n = 2), and gastritis with erosion (n = 1), 33.3% of children having alarm features had organic pathology, compared with 2.8% of those without (P < 0.01). A male predominance (80% vs 25.3%, P < 0.01), higher prevalence of alarm features (60% vs 8%, P < 0.01), and higher prevalence of Helicobacter pylori infection (80% vs 5.3%, P < 0.01) were found in children with organic diseases, compared with FD. Multivariate analysis identified H pylori infection (odds ratio 23.2; 95% confidence interval 1.5-333) and nocturnal pain (odds ratio 26.3; 95% confidence interval 1.2-500) to be independent predictors for positive endoscopic findings. CONCLUSIONS: Rome III recommendations of screening dyspeptic children for alarm features and investigation for H pylori are effective to identify children who have a higher likelihood of organic diseases and require upper endoscopy before making a diagnosis of FD.

The outcome of laparoscopic portoenterostomy for biliary atresia in children.

AIM: There were only a few reports on laparoscopic portoenterostomy for biliary atresia in children. We report our experience on laparoscopic Kasai operation for biliary atresia. MATERIAL AND METHODS: A retrospective review of all children who had biliary atresia underwent laparoscopic portoenterostomy from January 2002 to September 2006 were included and analyzed. RESULTS: Sixteen children (five boys and eleven girls) with a mean age of 66 days (range 47-106 days) at operation were included in this study. All patients had type III biliary atresia. There was no conversion to open procedure. The operative time ranged from 193 to 435 min (mean 292 min). At a median follow-up of 72 months (range 33-89 months), eight patients were free of jaundice with bilirubin level <20 µmol/L and did not require liver transplantation. Seven patients underwent liver transplantation. One patient who had persistent elevated bilirubin defaulted follow-up. One patient complicated with volvulus of intestine post-operatively. All patients survived except one patient who had combined liver and intestine transplantation. CONCLUSION: Laparoscopic portoenterostomy in children with biliary atresia is technically feasible. 50% of children who had type III biliary atresia were free of jaundice and did not require liver transplantation. A longer follow-up is required to assess the long-term outcome.

Single-incision laparoscopic nephrectomy and heminephroureterectomy in young children using conventional instruments: first report of initial experience.

OBJECTIVES: To report the surgical technique and the early outcomes of nephrectomy and heminephroureterectomy by single-incision laparoscopic surgery (SILS) in children using conventional laparoscopic instruments only. METHODS: Three consecutive children (aged 3, 4 and 7 years) who underwent nephrectomy for multicystic dysplastic kidney (n = 2) and upper moiety heminephroureterectomy for duplex kidney (n = 1) by SILS were retrospectively reviewed. A standardized infraumbilical incision was used for the insertion of 3 reusable ports of 3 and 5 mm. The SILS procedure was performed by the technique of crossing 2 straight instruments. RESULTS: All 3 procedures were successfully performed by SILS without any intraoperative complications or need for conversion. The 2 nephrectomies were each completed in 120 minutes, whereas the heminephroureterectomy took 400 minutes. Only 1 dose of narcotic analgesic was required by 1 patient, and 2-6 doses of oral acetaminophen were taken for postoperative pain control. All 3 children recovered smoothly from surgery without complications. CONCLUSIONS: Nephrectomy and heminephroureterectomy by SILS using conventional instruments are technically feasible in young children. Further studies are required to investigate whether the SILS approach can become a sound alternative to standard laparoscopy.

Initial experience in children using conventional laparoscopic instruments in single-incision laparoscopic surgery.

BACKGROUND: Single-incision laparoscopic surgery (SILS) has been successfully performed in children using 5-mm reticulating instruments. There are, however, few reports investigating the use of conventional instruments in SILS in the pediatric population. METHODS: We conducted a retrospective review of all consecutive children who underwent SILS from October 2009 to January 2010, with the procedure being solely performed by conventional 3- and 5-mm instruments through a standard access technique. RESULTS: A total of 19 SILS procedures were successfully performed in children aged 3 to 15 years. They included appendectomy (n = 10), nephrectomy (n = 1), combined cholecystectomy and splenectomy (n = 2), cholecystectomy (n = 1), high ligation for varicocele (n = 2), excision of Meckel diverticulum (n = 1), and staged orchidopexy and exploration for impalpable testis (n = 2). There was one conversion to conventional laparoscopic surgery, and that occurred in our first case of splenectomy. All the patients had smooth recovery from surgery without complications. CONCLUSIONS: Using conventional instruments in SILS is technically feasible in children from simple to complex procedures and may have the potential to popularize this approach by eliminating the mandatory demand for specially designed instruments.

Technical report on the initial cases of single-incision laparoscopic combined cholecystectomy and splenectomy in children, using conventional instruments.

AIM: The authors report a technique to perform single-incision laparoscopic combined cholecystectomy and splenectomy in 3 children using conventional instruments. METHODS: Three ports, including 5-mm and 3-mm ports, were placed through an infraumbilical incision for the procedure. Splenectomy was completed in most parts by crossing the 2 straight instruments. RESULTS: The 3 patients, aged 11 to 13 years, with body weight 29 kg to 32 kg, underwent the procedure. In the first patient, 2 additional extraumbilical 5-mm ports were required to complete the splenectomy. After modification of the technique, combined cholecystectomy and splenectomy by SILS were successfully performed in the other 2 patients without complications, and postoperative courses were uneventful. CONCLUSIONS: Combined cholecystectomy and splenectomy in children by SILS is technically feasible using conventional instruments. Further studies are required to investigate its safety, benefits over conventional laparoscopic surgery, and refinements in the technique.

Colonoscopy in Hong Kong Chinese children.

AIM: To investigate the safety and diagnostic yield of colonoscopy in Chinese children in whom the procedure is not often done. METHODS: We conducted a retrospective review of all colonoscopies in consecutive children who underwent their first diagnostic colonoscopy from Jan 2003 to 2008. RESULTS: Seventy-nine children (48 boys, 31 girls; mean age 9.2 +/- 4.2 years) were identified and reviewed with a total of 82 colonoscopies performed. Successful caecal and ileal intubation rates were 97.6% and 75.6% respectively. Forty patients (50.6%) had a positive diagnosis made in colonoscopy and that included colonic polyps (23), Crohn's disease (12), ulcerative colitis (1), and miscellaneous causes (4). 80% of polyps were in the rectosigmoid colon. All but one were juvenile hamartomatous polyps. The exception was an adenomatous polyp. The mean ages for children with inflammatory bowel disease (IBD) and polyps were 11.3 and 4.3 years respectively. There was no procedure-related complication. CONCLUSION: Colonoscopy is a safe procedure in our Chinese children. The increasing diagnosis of IBD in recent decades may reflect a rising incidence of the disease in our children.

Evidence-based adjustment of antibiotic in pediatric complicated appendicitis in the era of antibiotic resistance.

INTRODUCTION: Antibiotic resistance is a global issue especially in developed areas. With the emergence of antibiotic resistant-bacteria, the traditional choice of broad spectrum antibiotics may not be effective in complicated appendicitis. We herein report the bacteriology and antibiotic susceptibility of intra-operative peritoneal culture in children with acute appendicitis in Hong Kong. This may guide us to adjust the choice of antibiotics with evidence. METHODS: A retrospective review of all cases of children who underwent laparoscopic appendicectomy from 2003 to 2007 was performed. Data including histology of appendixes, the choice of antibiotics, bacteriology, and antibiotic susceptibility of the intra-operative peritoneal cultures were analyzed. RESULTS: Over a 5-year period, 250 children were included in this study. 41 children had gangrenous- and 77 had ruptured appendicitis, respectively. Peritoneal swab was taken in 158 children. Common bacteria isolated including E. coli, Streptococcus, and Bacteroides. Ampicillin, cefuroxime, and metronidazole were our choice of antibiotics. 26% of children with gangrenous and 25% with ruptured appendicitis were insensitive to the current regime. Using 3 antibiotics regime by switching cefuroxime to ceftazidime, it covered 77% resistant bacteria. Using 4 antibiotics regime by adding gentamycin, it covered 96% resistant bacteria. CONCLUSIONS: One-fourth of children with gangrenous or ruptured appendicitis were insensitive to the current regime. This study provides evidence-based information on the choice of antibiotics.

An 18-year experience in total colonic aganglionosis: from staged operations to primary laparoscopic endorectal pull-through.

BACKGROUND: Traditionally, total colonic aganglionosis (TCA) was managed with enterostomy +/- pull-through. Since 1998, primary laparoscopic endorectal pull-through (PLEP) was offered to patients with TCA in our unit. A retrospective study was conducted and early results reviewed. METHOD: Patient data were collected retrospectively. Before 1998, enterostomy followed by open Duhamel pull-through was performed. From 1998, patients were assessed to receive staged operation or PLEP. RESULTS: From June 1990 to May 2007, 10 patients (6 males) were treated. All presented in the neonatal period. Seven patients, with transition zone within proximal 15 cm of terminal ileum, had pull-through performed. Three had staged pull-through, whereas 4 had PLEP. Two had extensive small bowel involvement with high output stoma pending reconstruction. One had total intestinal aganglionosis and died. The 3 patients with staged pull-through had normal bowel habit without soiling (mean follow-up, 13 years). For PLEP, all procedures were accomplished laparoscopically without intraoperative complication (mean operative time, 6 hours 50 minutes). The mean bowel motion is 5x per day, but most were too young to evaluate continence (mean follow-up, 3.5 years). CONCLUSION: Primary laparoscopic endorectal pull-through is feasible in TCA with limited small bowel involvement and has the advantage of a single-stage operation, avoiding a stoma and its related complications.

Laparoscopic hernia repair in children by the hook method: a single-center series of 433 consecutive patients.

BACKGROUND: The relatively high recurrence rate reported in laparoscopic hernia repair in children using intracorporeal suturing technique remains a concern. We aimed to investigate the effectiveness of the hook method during hernia repair that allows extraperitoneal passage of suture to close the hernia sac without creating any tension or skip areas and does not require laparoscopic suturing skills. METHODS: A retrospective review was conducted on 433 consecutive children who underwent laparoscopic hernia repair using the hook method by 1 of 4 surgeons from July 2004 to June 2007. RESULTS: A total of 572 successful laparoscopic hernia repairs were performed among the 433 children with an age range of 1 week to 15 years (mean = 56 months). Conversion rate was 1.04%. Contralateral patent processus vaginalis was found in 26.8%. Mean operating time was 23.8 and 40.2 minutes for unilateral and bilateral repair, respectively. At a median follow-up of 20 months, there were 2 recurrences (0.35%), 2 hydroceles, 1 ascending testis, and 1 instance of testicular atrophy. No serious complications were associated with the procedure. CONCLUSIONS: Medium-term results suggest that laparoscopic hernia repair with the hook method is a sound alternative to open herniotomy in children.

Helicobacter pylori-positive versus Helicobacter pylori-negative idiopathic peptic ulcers in children with their long-term outcomes.

OBJECTIVES: The aim of this study is to investigate the differences in the characteristics between Helicobacter pylori-positive and H pylori-negative primary ulcers in Chinese children. PATIENTS AND METHODS: We conducted a retrospective review of children with primary peptic ulcers. Demographic data, clinical presentations, endoscopic features, histological findings, H pylori prevalence, and ulcer recurrences were studied. RESULTS: Forty-three Chinese children with primary peptic ulcers were diagnosed over 8 years and were reviewed. There were 31 boys and 12 girls (median age 12 years, range 3-16 years). Thirty children (70%) presented with acute gastrointestinal bleeding, whereas only 19 had a history of epigastric pain. Twenty-three patients (53.5%) were H pylori positive. H pylori-positive ulcers developed in older children (median age 12 vs 10 years, P<0.05) and affected more males (91.3% vs 50%, P<0.01) than the H pylori-negative group. The annual ulcer recurrence rates were estimated to be 5.2% (95% CI 4.2-6.3) and 11.4% (95% CI 9.1-13.6) for positive and negative groups, respectively (P<0.05). Multivariate logistic regression suggested H pylori-negative status and ulcer size >1cm were indepen-dent risk factors for recurrence. CONCLUSIONS: Our report suggests that H pylori-negative primary ulcers exist in children with their own distinct features. In contrast to H pylori-positive ulcers, H pylori-negative ulcers develop in younger children, affect both sexes equally, and carry a higher recurrence risk.

A population-based study of Helicobacter pylori infection in Chinese children resident in Hong Kong: prevalence and potential risk factors.

BACKGROUND: Data of Helicobacter pylori prevalence in children and its risk factors provide clues to the health authority to estimate burden of H. pylori-associated diseases usually encountered in adulthood and facilitate healthcare planning. MATERIALS AND METHODS: A cross-sectional population-based study was conducted in Chinese children in elementary and high schools. Schools were selected from all three major areas of Hong Kong. H. pylori infection was defined by a positive (13)C-urea breath test. Study subjects were stratified into six age groups for estimation of prevalence. Potential risk factors were analyzed from data of self-administered questionnaires. RESULTS: A total of 2480 children (aged 6-19, male: 47.3%) participated in the study. Overall, 324 (13.1%) were positive for H. pylori. There was no difference in prevalence between sexes, and no statistical trend in the prevalence across the six age groups. Multivariate logistic regression identified lack of formal education of mother (OR = 2.43, 95%CI 1.36-4.34), family history of gastric cancer (OR = 2.19, 95%CI 1.09-4.41), and household member > 5 (OR = 1.57, 95%CI 1.12-2.19) to be positively associated with H. pylori infection in our children. CONCLUSIONS: The H. pylori prevalence of Hong Kong children is comparable to the data of developed countries. The association with family history of gastric cancer justifies further study to investigate the cost-benefit of community screening program for such children to decrease the incidence of gastric cancer in adulthood.