A Minimally Interventional Approach to Oesophageal Atresia Repair With Early Enteral Feeding is Safe, Optimises Neonatal Outcomes, and Reduces Resource use.

PURPOSE: Recent series of newborn Oesophageal Atresia (OA) repair continue to report widespread use of chest drains, gastrostomy, routine contrast studies and parenteral nutrition (PN) despite evidence suggesting these are superfluous. We report outcomes using a minimally interventional approach to post-operative recovery. METHODS: Ethically approved (15/WA/0153), single-centre, retrospective case-note review of consecutive infants with OA 2000-2022. Infants with OA and distal trache-oesophageal fistula undergoing primary oesophageal anastomosis at initial surgery were included (including those with comorbidities such as duodenal atresia, anorectal malformation and cardiac lesions). Our practice includes routine use of a trans-anastomotic tube (TAT), no routine chest drain nor gastrostomy, early enteral and oral feeding, no routine PN and no routine contrast study. Data are median (IQR). RESULTS: Of total 186 cases of OA treated during the time period, 157 met the inclusion criteria of which 2 were excluded as casenotes unavailable. TAT was used in 150 infants. A chest drain was required in 13 (8%) and two infants had a neonatal gastrostomy. Enteral feeds were started on postoperative day 2 (2-3), full enteral feeds established by day 4 (4-6) and oral feeds started on day 5 (4-8). PN was required in 15%. Median postoperative length of stay was 10 days (8-17). Progress was quicker in term infants than preterm. One infant died of cardiac disease prior to neonatal discharge. Two planned post-operative contrast studies were performed (surgeon preference) and a further 7 due to clinical suspicion of anastomotic leak. Contrast study was therefore avoided in 94%. There were 2 anastomotic leaks; both presented clinically at day 4 and day 8 after oral feeds had been started. CONCLUSION: Our minimally interventional approach is safe. It facilitates prompt recovery with lower resource use, reduced demand on nursing staff, reduced radiation burden, and early discharge home compared to published series without adversely affecting outcomes. LEVEL OF EVIDENCE: Level 4.

Does peritoneal lavage influence the rate of complications following pediatric Laparoscopic Appendicectomy in Children with Complicated Appendicitis? A Prospective Randomized Clinical Trial.

BACKGROUND: There is ongoing debate concerning the use of peritoneal irrigation in the setting of complicated appendicitis (CA) in children. Our aim was to conduct a prospective randomized controlled trial for the treatment of CA during a laparoscopic appendicectomy in children. METHODS: Following ethical approval (REC10138B), pediatric patients (≤16 years old) were recruited from a single institution over a 3-year time period (2015-2018). Randomization occurred following intraoperative diagnosis of CA to either peritoneal lavage (PL) or suction only (SO). Primary outcome was the length of stay (LoS), and secondary outcomes were the presence of a postoperative intraabdominal abscess (IAA), wound infection (WI), or adhesive small bowel obstruction (ASBO). Data are reported as number of cases (%), median (range), odds ratio [OR] and analyzed using t-test and Fisher's exact test. A p-value ≤0.05 was considered significant. RESULTS: A total of 100 pediatric patients were recruited into the trial. Sixteen were excluded owing to either recruitment or protocol violations, and therefore a total of 86 underwent final analysis: 44 PL and 42 SO. There was no significant difference in the LoS: 5.7 (PL) vs 5.6 (SO) days, p = 0.75. Only 1 IAA occurred in the PL group: 1/44(2.3%) vs 0/42(0%), p = 1.0. There was 1 ASBOs in the PL group (2.3%, p = 1.0) and no WIs in either of the groups. CONCLUSION: This prospective randomized control trial has revealed equivalence in techniques for the treatment of complicated appendicitis. It has also revealed a low complication rate following pediatric LA with either PL or SO. TYPE OF STUDY: Randomized controlled trial. LEVEL OF EVIDENCE: Level I.

Peer-Led Academic Support for Pre-Arrival Students of the BVM&S Degree Program.

Mental health challenges are of growing concern to the veterinary community. Within veterinary education, there has been increasing focus on building resilience in students and identifying likely stressors, such as the transition into the veterinary curriculum for first-year students. In this study, we evaluated a peer-led project to provide pre-arrival materials to incoming students. Through a combination of learner analytics and post-course surveys, we investigated usage of resources and the effects on student's attitudes toward the veterinary curriculum. Over the 2 years the course has been running, 159 students (64% of total) have visited the course, but only 39% (n = 98) have actively engaged with the materials. The course was most frequently accessed from Friday to Sunday (53% of visits), and over 50% of the visits occurred 1 week before arrival. The post-course questionnaire in the first year of the course's delivery had a 17% response rate (n = 24) and most students (71%) reflected on feeling anxious about beginning their studies. 88% said they felt they had benefited from the material's availability. While not all students used the resources, providing peer-led teaching opportunities at high-stress points is an effective method of easing transitions.

The burden of excluding malrotation in term neonates with bile stained vomiting.

PURPOSE: To determine the number of term infants with bilious vomiting (BV) referred to a neonatal surgical centre for exclusion of malrotation by upper gastrointestinal contrast (UGI) examination. METHODS: Retrospective review of term (>37/40) neonates <28 days of age undergoing UGI for exclusion of malrotation between Jan 2010 and Dec 2014 in a neonatal network with 30,000 term deliveries annually. Only infants with BV in the absence of alternative clinical/radiological diagnosis were included. RESULTS: One hundred and sixty-six infants met the inclusion criteria. Fourteen (9 %) infants had malrotation diagnosed by UGI and confirmed at laparotomy. Only 1 of 110 infants referred at 0-2 days of age had positive UGI compared to 13 of 56 infants referred after this age (p < 0.01). An increase in referrals followed the death of an infant from midgut volvulus and as a result one in 500 term infants are currently being referred. CONCLUSION: Increasing awareness of the potential consequences of bilious vomiting appears to have resulted in increased referrals with no increase in detection of malrotation. Prospective studies are required to determine whether investigation of all infants with unexplained bilious vomiting is required and if it is possible to select cases for surgical referral.

One hundred years of pyloric stenosis in the Royal Hospital for Sick Children Edinburgh.

AIM: Pyloric stenosis was first reported in 1717 and was treatable from the start of the 1900s. Our hospital opened in 1860. In this study we report the historical account of the management of pyloric stenosis in Edinburgh from 1910 to 2013. METHOD: Historic discharge summaries, theatre records, and distinguished surgeons' operation and lecture notes dating back to 1910 with regard to pyloric stenosis were identified and reviewed. We present this history and compare our contemporary data. RESULTS: In February 1911, Harold Styles performed a pyloromyotomy, but did not report it at the time. However, the record of this operation and date were later published by Mason Brown in 1956. For the period 1926-1936, we report the management of 7 patients, of which only 3 survived. For the period 1947-1956, 515 patients were treated, with a mortality rate of 4.08%. Our current series for 1999-2012 has a mortality rate of zero and complication rate of 5.3%. CONCLUSIONS: During the period 1910 to present day in Edinburgh, pyloric stenosis has gone from being medically managed with bad outcomes to a condition with 100% survival. The only surgical advance has been the development of the Rammstedt pyloromyotomy. Of interest we document that a pyloromyotomy was performed here in February 1910. The improved outcome is mainly due to better understanding of the physiological disturbance in pyloric stenosis and advances in anaesthetics and microbiology.

Bladder calculus formation on the tip of a migrated disused ventriculoperitoneal shunt.

Bladder stones in children are rare. They generally occur in children with one or more predisposing risk factors to stone formation. In this unique case report we discuss the formation and successful endoscopic treatment of a large stone in a neuropathic bladder on the tip of a migrated VP shunt.

Thoracoscopic pleural biopsy as an aid to diagnosis in pediatric tuberculosis with pleural involvement.

INTRODUCTION: Successful treatment of tuberculosis relies on microbiological diagnosis and drug sensitivities. Due to the pauci-bacillary nature of childhood infection, this is often not possible. We describe the successful microbiological diagnosis of tuberculosis using thoracoscopic pleural nodule biopsy. MATERIAL AND METHODS: In seven patients presenting with pulmonary tuberculosis and pleural involvement, but in whom microbiological diagnosis could not be established, thoracoscopic pleural biopsy was performed and analyzed for histology, acid-fast bacilli, polymerase chain reaction (PCR), DNA, culture, and drug sensitivities. RESULTS: In five out of the seven patients we achieved positive histology, culture, and drug sensitivities. In the remaining two patients, histology, PCR, and DNA probe were positive for tuberculosis. CONCLUSIONS: Thoracoscopic pleural biopsy is a sensitive aid to the diagnosis of pleural tuberculosis in children.

Retractile testes: a review of the current literature.

The current evidence for the management of retractile testes is discussed in this review. Issues such as clinical definitions, natural history, possible outcomes and evidence for surgical intervention are evaluated. After reviewing the literature, the authors summarize that currently there is not enough evidence to warrant surgery for retractile testes, but rather a strategy of surveillance should be adopted.

Trend of severe abdominal injuries from bicycle accidents in children: a preventable condition.

AIM: Bicycle riding is a common recreational and sport activity enjoyed by many children. Bicycle accidents are a common cause of abdominal injuries. We aim to establish the trend and the associated risk factor(s) of bicycle-related abdominal injuries. METHODS: A retrospective review of all children admitted following bicycle accidents to a single tertiary referral centre was carried out over an approximately 5-year period. The data were tabulated and regression analyses were carried out. RESULTS: Over the study period, 196 children were admitted into the Emergency Department. Abdominal injuries (16%) were the third largest group after orthopaedic and head injuries. There were 19 major visceral injuries, seven of whom underwent major surgeries. Forty-two percent (8/19) of these major injuries were related to stunts. Over the same period, no child with head injury required any surgical intervention. In addition, there was a definite trend that abdominal injuries were accounting for greater percentage of bicycle-related injuries in children. CONCLUSIONS: Severe intra-abdominal trauma following bicycle injuries appears to be seen more often in adolescent males, especially when related to BMX stunts. These injuries have surpassed head injuries as the prime cause of morbidity from bicycle accidents. These injuries are largely preventable.

Double duodenal atresia with perforation: a case report.

Duodenal atresia is a common cause of neonatal bowel obstruction. Double duodenal atresia has been reported as a rare variation of duodenal atresia. This report discusses the importance of an appreciation of unusual anatomy in neonatal duodenal obstruction and highlights the importance of assessing bowel continuity intraoperatively.

Laparoscopic surgery for varicoceles in children: an audit in a single centre.

BACKGROUND: Varicoceles are associated with a time dependent decline in testicular function. The pathophysiology and timing of this remains unclear. However surgery for adolescent varicoceles is a relatively common procedure. There are several treatment options for this condition and in 1999 laparoscopic management was commenced at our institute. We performed an audit to compare our results with those reported in the literature. METHODS: A retrospective case-note review of patients identified from our theater database was performed. We reviewed patient demographics, indications, technique used, grade of surgeon, and outcomes. A review of the literature was carried out to identify a gold standard to compare our results with. RESULTS: Between 1999-2007 we operated on 24 adolescent varicoceles, all left side. Median age was 13.5 years (range 8-16). Indications for surgery included high grade varicocele, discomfort and testicular atrophy. All patients underwent laparoscopic Palomo technique dividing all vessels and lymphatics. The grade of primary operator was consultant (54%) and trainee (46%). Complications included wound infection (4.1%), hydrocele (12.5%), and recurrence (8.3%). We found no consensus view regarding the management of varicoceles in adolescents within the literature; however, our outcomes compared favorably with other published results using the laparoscopic Palomo technique. CONCLUSIONS: Laparoscopic management of varicoceles is safe and effective at our institute. The indications and timing of surgery remain varied. The surgery is performed by both consultants and trainees.

Gastroschisis: the cost of an epidemic.

BACKGROUND: The rising incidence of gastroschisis has been highlighted by the Department of Health as a growing concern. As well as the health implications for the increasing number of affected infants, this increase in incidence will have an impact of the costs of health care. This study was undertaken to estimate the financial cost of treating this condition in one tertiary neonatal surgical center. METHODS: A retrospective analysis was performed of all patients admitted to a tertiary neonatal surgical center with gastroschisis from January 1996 to December 2005. The main outcome measures were incidence, length of hospital stay, and total cost for all patients each year. RESULTS: The incidence of gastroschisis has risen 3-fold in 10 years. The median cost per patient is relatively constant. A few patients with severe intestinal dysmotility require prolonged hospital stay. As the condition becomes more common, there are an increasing number of complex patients and thus an increase in annual costs, which is disproportionate to the increase in numbers of cases. We estimate that the annual cost to the National Health Service (NHS) of this condition in England and Wales has risen from pound3.6 million in 1996 to in excess of pound15 million in 2005. CONCLUSIONS: Urgent research is required into the etiology of gastroschisis and into the severe intestinal dysmotility that occurs in some complex patients.

Oesophageal atresia: improved outcome in high-risk groups?

PURPOSE: The Spitz classification of oesophageal atresia (OA) based on the birth weight and the presence of a major cardiac anomaly was proposed 1994. Advances in neonatal care have led us to question if these outcome figures are still valid. We tested the hypothesis that the outcome of neonates with OA has improved during the last decade. METHODS: The records of all neonates (n = 188) born with OA and treated in a single institution between 1993 and 2004 were reviewed and compared with data from the original Spitz study. Data were obtained on the birth weight, presence of a major cardiac anomaly, and survival. Differences in survival were compared using the Yates-corrected chi2 test. RESULTS: In the early period, 326 neonates survived (87.6%) compared with 174 (91.5%) in the most recent decade (P = .10). Based on Spitz classification, the outcome comparing both periods was the following: group I, 97% (283/293) and 98.5% (130/132) (P = .44); group II, 59% (41/70) and 82% (41/50) (P = .01); group III, 22% (2/9) and 50% (3/6) (P = .57), respectively. CONCLUSIONS: The Spitz classification remains valid. It may be of use when counselling parents and in comparing outcome among centres. In our centre, the overall survival of neonates with OA has not significantly changed in the recent decade. The improvement in survival of neonates in group II, however, demonstrated the recent advances in neonatal, paediatric surgical, and cardiac care.