A large single-center experience in management of pediatric intussusception.

BACKGROUND: The objective of this study was to present the results of a comprehensive single-center study of the management and outcome of intussusception over a 10-year period and to review the recent literature. METHODS: A retrospective analysis was carried out of all children less than 16 years old, admitted with intussusception to our tertiary center between January 2007 and December 2016. Air enema was attempted routinely, with primary surgery reserved for selected cases. If air enema failed, open surgery was performed. The data collected included age, enema reduction rate, need for laparotomy, detail of bowel resection, hospital stay, and complications noted. RESULTS: One hundred and ninety-one children presented with intussusception, totaling 200 admissions. One hundred and seventy-four patients (87%) underwent air enema. There was a complete reduction in 66% of these cases and a perforation rate of 1.1%. Twenty-six patients (13%) underwent primary surgery. Of the 59 patients with incomplete enema reduction, 50.8% required bowel resection while 49.2% required only manual reduction. Bowel resection was necessitated in 26% of total admissions and 61.2% of those requiring surgery. Hospital stays ranged from 3-97 days (median 7 days). There were four complications (2%). CONCLUSION: This comprehensive study reveals a higher rate of surgical intervention and bowel resection than was anticipated from selective series in published literature. Institutional variation in outcome is likely multifactorial but incomplete data make comparisons difficult.

Effect of general anesthesia on delayed repeat enema in pediatric intussusception.

BACKGROUND: The study aimed to assess the efficacy and safety of delayed repeated enema (DRE) and to evaluate the effect of general anesthesia (GA) on DRE. METHODS: A retrospective analysis was conducted of all children below 3 years with primary intussusception who were offered DRE in our tertiary center, from 2014 until 2019. Following a standardized pneumatic enema protocol, those who showed a partially successful result were offered DRE 2 h later, either awake (Group A) or under GA (Group B). DRE under GA was our preferred procedure unless there were no pediatric anesthetists available at that time. Data collected for each group included age, sex, duration of symptoms, success rate of the DRE, and any complications noted. RESULTS: The study included 57 children (32 males and 25 females). The median age in Group A (31 patients) was 10 months while in Group B (26 patients) it was 11 months. The number of patients with duration of symptoms < 24 h vs > 24 h was 12:19 and 9:17 in Group A and B patients respectively. DRE was successful in 14/31 (45.2%) of Group A patients with one complication and in 9/26 (34.6%) of Group B patients with no complications. There was no statistically significant difference between both groups' success rate and complication rate. Both groups were similar in age, sex, and duration of symptoms. CONCLUSIONS: DRE can effectively increase the overall success rate of pneumatic enema in selected patients with pediatric intussusception. However, the current evidence does not justify the routine use of GA during attempts DRE attempts.

How far can one-stage laparoscopic Fowler-Stephens orchiopexy be implemented in intra-abdominal testes with short spermatic vessels?

OBJECTIVE: The aim of the study was to compare the outcome of the prospective cohort who had one-stage laparoscopic Fowler-Stephens orchiopexy (LFSO) with an earlier, similar cohort who had a two-stage LFSO. Both cohorts included only intra-abdominal testes (IATs) with short spermatic vessels. STUDY DESIGN: The present study initially included all patients between the age of six months and preschool age, presenting with an IAT to the authors' tertiary clinic from January 2012 to December 2014. Only intra-abdominal testes with short testicular vessels, correlating to type 3A, 3B and 4A as per the updated Ain Shams classification, were included in this study. One-stage LFSO was performed on all patients. Patients with bilateral intra-abdominal testes had the procedure performed on the contralateral side 6-8 weeks later. Follow-up was performed at 6, 12 and 36 months postoperatively by means of Doppler ultrasound in the first two visits. A similar subgroup of the historical cohort from years 2002 to 2010 had a two-stage LFSO, with the second stage being performed 12-16 weeks later. In bilateral cases, a three-interval surgery based on two-stage LFSO was performed, with a follow-up at 6 months postoperatively. RESULTS: The recent cohort included 16 IATs (10 unilateral and 3 bilateral). The median age of the patients was 1.41 years. At 6-month follow-up, 4 testes were found atrophic (25%), whereas the remaining 12 testes (75%) were viable. In those viable, only half of them had a low scrotal position. No difference was found at 12- or 36-month follow-up. Doppler ultrasound confirmed adequate intratesticular blood flow at 6 and 12 months postoperatively. In the similar subgroup of the historical cohort, 3 of 25 (12%) testes were found atrophied at six months postoperatively, with only one testis (4%) having a high scrotal position. In a comparison of both cohorts, the two-stage LFSO was found to be associated with a halving of the testicular atrophy rate (p value = 0.401) and a higher incidence of low scrotal position (p value = 0.004). A comparison of both cohorts is shown in the summary table. CONCLUSION: Although one-stage LFSO may seem tempting, it still holds a higher rate of testicular atrophy, which is not justified. LEVEL OF EVIDENCE: Level III (Case-control study).

Role of ultrasound in the follow-up of intra-abdominal testes post Fowler-Stephens orchiopexy.

OBJECTIVE: To review the role of various ultrasound (US) modalities in their ability to determine testicular viability in prepubertal testes following Fowler-Stephens orchiopexy (FSO). MATERIAL & METHODS: Our prospective study included all patients from the year 2012 to 2017 with intra-abdominal testes (IAT) who had one-stage or staged FSO in our tertiary centre. Follow-up was done at 6 months to assess testicular viability and testicular position by clinical examination, and this was correlated with conventional and Doppler US results then. RESULTS: This study included 28 IAT in total, who had one-stage (n = 16) and staged (n = 12) laparoscopic FSO. Median age was 1.27 years. Testicular atrophy was noted by clinical examination in 6 testes. In these 6 testes, conventional US confirmed an atrophic testicular nubbin and both Color Doppler US (CDU) and Power Doppler US (PDU) failed to show any parenchymal testicular vessels. Spectral Mode Analysis (SMA) also showed no significant arterial waveform. As for the remaining 22 viable testes by clinical examination, conventional US showed normal testicular morphology in all, while CDU and PDU confirmed adequate parenchymal blood flow in only 15 and 20 testes respectively. SMA revealed a normal arterial resistive index in only 21 testes. CONCLUSION: There is no evident role for US in the follow-up of prepubertal testes post-FSO as US results are strongly correlated to clinical examination findings. Blood flow assessment in prepubertal testes following FSO can be difficult, unclear and undetectable in cases. This can be due to the prepubertal testicular stage, technique or unrecognized testicular atrophy despite normal morphology. LEVEL OF EVIDENCE: Level IV: Case series with no comparison group.

Early start of clean intermittent catheterization versus expectant management in children with spina bifida.

PURPOSE: We instituted early clean intermittent catheterization (CIC) in 1997 for all newborn infants with spina bifida (SB). We compared this group to a historical group managed expectantly to see if early catheterization was associated with a reduction in renal scar rate as determined by DMSA scanning. METHODS: Data were studied retrospectively on all infants with SB over a recent 13-year period who were treated with early universal CIC in a regional pediatric urology department. These were compared to our previously published outcomes in a historical group (1985-1994) that was managed expectantly [Brown et al. Chronic pyelonephritis in association with neuropathic bladder. Eur J Pediatr Surg 1999;9 Suppl 1:29-30.] RESULTS: 114 infants were born with SB from 1997 to 2010, of which 13 were excluded from this analysis. Mean follow-up was 11.4 years. In the historical cohort there were 126 infants born from 1985 to 1994, with 26 exclusions; follow-up then ranged from 4 to 13 years. DMSA scan showed renal scarring in 19/101 (18.8%) of the recent cohort versus 39/100 (39%) of the previous group (P = 0.002). Renal scarring at a later age also appeared to be a feature of the recent group, with first detection occuring by 4 years in only 9/19 (47%) in the latest cohort compared to 28/39 (72%) in the historical cohort. CONCLUSION: Based on these renal protective data, we recommend indwelling and then intermittent catheterization from birth in all patients with SB. LEVEL OF EVIDENCE: Level III. TYPE OF STUDY: Retrospective, cohort comparison study.