The risk of failure after primary orchidopexy: an 18 year review.

OBJECTIVE: To review the primary orchidopexy failure rate and outcome of repeat orchidopexy in a tertiary paediatric surgical centre and identify risk factors. METHODS: A prospectively collected and validated audits system was used to identify all boys having a repeat orchidopexy from August 1990 to December 2008 (18 years). RESULTS: In total, 1538 boys underwent orchidopexy with 1886 testicles operated on. Of these 348 (22.6%) patients had bilateral cryptorchidism. A need for repeat orchidopexy was identified in 31 boys resulting in a primary failure rate of 1.6% over the 18 years. Unilateral orchidopexy as the primary operation had a 1.5% failure rate. The failure rate for bilateral cryptorchidism was 1.87% per testicle rising to 1.93% per testicle when the primary operation was synchronous bilateral orchidopexy. Orchidopexy failure occurred in 9 patients (1.97%) who were under 24 months, 15 (2.67%) who were between 24 and 72 months and 7 (0.8%) over 72 months at time of first operation. CONCLUSION: Possible risk factors for primary orchidopexy failure are bilateral operation and older age at time of operation. Failure in achieving a satisfactory scrotal position (and testicular loss) following orchidopexy has been postulated as a potential surgical standard for revalidation of paediatric surgeons. This study adds important contemporary data to inform that process.

Trends in pneumonia and empyema in Scottish children in the past 25 years.

BACKGROUND: The incidence of childhood empyema, a complication of pneumonia, is increasing, and the underlying mechanisms are not understood. Whether a rise in pneumonia incidence could account for the increase in empyema remains to be seen. OBJECTIVE: To report trends for empyema admissions in the context of pneumonia and croup admissions in Scottish children over a 25-year period to 2005. DESIGN: Whole-population study with retrospective analysis using diagnosis codes (International classification of diseases, 9th and 10th revisions). SETTING: All non-obstetric and non-psychiatric hospitals in Scotland. PARTICIPANTS: Patients <15 years admitted with a diagnosis of empyema, pneumonia or croup (the latter included for reference) between 1 January 1981 and 31 December 2005. RESULTS: There were 217 admissions for empyema in children (76 1-4-year olds), 24,312 admissions for pneumonia (11,299 1-4-year olds), and 31 120 (20,332 1-4-year olds) for croup. Empyema admissions increased after 1998 from <10 per million children per annum to reach a peak of 37 per million in 2005. In the 1-4-year age group, empyema admissions rose in the late 1990s and 2000s from an average of 6.5 per million per year between 1981 and 1998 to 66 per million in 2005. Overall annual admission rates for pneumonia remained unchanged in most age groups. However, among 1-4-year olds, admissions rose steadily by an average of 50 per million per year between 1981 and 2005. Admission rates for croup in Scottish children (<15 years) remained stable over the preceding 25 years. CONCLUSIONS: This whole-population study shows that the incidence of childhood empyema has risen since 1998 and continues to rise independently of pneumonia. Croup admissions remained stable, suggesting that changes in coding or admission policies are not likely to explain the observed trends. The observations suggest that the rise in empyema is not related to an increase in pneumonia. Changes in bacterial pathogenicity and/or host susceptibility may be important.

Childhood empyema in North-East Scotland over the past 15 years.

INTRODUCTION: The incidence of paediatric empyema is rising in the United Kingdom and North America. The reasons for increasing admissions are unclear. Management in tertiary units is often required. We report our experience in North-East Scotland over the last 15 years. METHODS: Empyema patients <15 yrs admitted to the Royal Aberdeen Children's Hospital between 1 st January 1990 and 1st June 2006 were identified using discharge coding. Data was collated from case notes. Patient characteristics, microbiology results, hospital stay and management are studied. RESULTS: Twenty eight children (M:F = 1:1) were admitted. Mean age = 6.8 yrs. Twenty seven out of twenty eight presented with localising respiratory symptoms or signs. In 12/28 an organism was isolated. Streptococcus pneumoniae was the commonest isolate, and where polymerase chain reaction (PCR) testing was employed, 3/3 cases were serotype 1. Fourteen out of twenty eight required surgery: open (8/14) or thoracoscopic (6/14) decortication. Two thoracoscopic cases proceded to open decortication. No complications were observed. Mean hospital stay = 11.4 days. Twelve were managed in high dependency unit (HDU) with a mean stay of 7.1 days. DISCUSSION: We demonstrate similar trends in North-East Scotland to those reported elsewhere. Serotype 1 streptococcus pneumoniae is the most isolated. Multi-drug resistance is not seen in our population. A surveillance programme is now established and reasons for the increasing incidence should become apparent.

The accuracy of clinical data: a comparison between central and local data collection.

BACKGROUND: The recent liberalisation of public access to information, including surgical performance, emphasises the necessity for accurate data collection. The Information and Statistics Division of the Scottish Executive (ISD) collect such data for each patient episode, but there is concern about the reliability of this information compared with that collected in local surgical departmental audit. AIM: To determine if diagnostic and operative details were consistent between local audited and national non-audited data sets. METHODS: Three surgical units comprising eight consultants were studied. Epidemiological, diagnostic and operative data for each consultant were accessed from the eScrips Internet resource (ISD Data) and from the departmental database. A unique patient number and date of birth matched individual patient episodes and the correlation between datasets graded for accuracy and consistency. RESULTS: 8375 individual data entries were recorded (ISD 4642, local databases 3733). 3402 pairs, 6408 (76.5%) of the total, matched accurately. 742 (16%) of the ISD entries were duplicates, and in 21% of unpaired entries the wrong consultant was recorded. Overall a clinically acceptable match occurred in 86.9% of paired entries for diagnosis and 84.0% for operation. The highest match with ISD data for diagnosis (88.8%) and operation (91.8%) occurred in the unit which holds a weekly audit meeting to validate information. DISCUSSION: There are significant discrepancies in surgical data between the local audit databases and central data. There is significant duplication of entries and inaccurate consultant allocation in ISD data. The promulgation of inaccurate information could threaten reputation or career and clinicians should play a more active role in ensuring clinical data are correct.

Paediatric surgery: trends in UK surgical trainees' operative experience.

AIM: This study assesses the effects of the reconfiguration of postgraduate surgical training and changes to work patterns through legislation within UK on the operative experience of trainees completing specialty training in paediatric surgery. METHODS: Data were collected from the consolidation record of operative experience submitted by every candidate sitting the Intercollegiate Specialty Board Examination in Paediatric Surgery in UK from 1996 through 2004. A number of index procedures were chosen as surrogates of the overall operative experience and underwent detailed analysis. These comprised operations performed in the following categories: Neonatal Surgery, General Paediatric Surgery, Paediatric Urology, Paediatric Oncology, and Emergency Paediatric Surgery. RESULTS: Sixty-three sets of data comprising 12,866 operations were ultimately identified as being suitable for analysis. The average number of operations performed annually by trainees increased over the study period as did the number in each of the operative categories. The number of operations performed with senior assistance or supervision increased over this period by an average of 12.5%. This trend was also evident in emergency surgery where the average number of sample procedures performed by trainees increased by 28% over the study period. CONCLUSION: In 1995, reforms to the training grade within UK reduced the time spent in specialist training from a previously unregulated period to 72 months of higher surgical training. Subsequent directives in response to health and safety legislation have further abbreviated the length of time spent at the workplace, initially to 72 hours and more recently to 58 hours per week. This combination has been generally perceived throughout the surgical community as prejudicial to acquisition of clinical and operative competence. This study, however, fails to endorse this perception and suggests to the contrary that perhaps through increased delegation, the volume of training operations is being preserved and that operative training is now better supervised than ever before.

Amyand's hernia presenting as neonatal testicular ischaemia.

Testicular ischaemia presenting in the neonatal period is most often attributable to neonatal torsion. We present an unusual case of a male neonate who presented with acute appendicitis within a patent processus vaginalis, causing cord compression and consequent testicular ischaemia.

Operative management of testicular torsion: current practice within the UK and Ireland.

Several methods have been described and are currently used for fixation of testes in the operative treatment of testicular torsion. Although recurrence of torsion is generally viewed as a technical failure, the factors contributing to this failure remain unclear. This survey was conducted to establish current practice amongst paediatric surgeons in the UK and Ireland, in relation to testicular fixation, in an attempt to reflect the level of concern over the potential for recurrence as expressed in choice of procedure. The questionnaire survey indicated that 85% of paediatric surgeons use suture fixation of the testis alone or in combination with additional steps, such as eversion of the tunica vaginalis or creation of a dartos pouch, and 15% use a sutureless technique. The great majority (95%) fix the contralateral testis routinely and 85% routinely excise the appendix testis. Of the respondents, 17% have operated on a torted testis that had been previously fixed. In the absence of data from comparative trials, the method used for fixation remains a matter of personal preference. It was not possible to identify the definitive risk factors for recurrence from this study, but the use of absorbable sutures accompanied recurrence in most instances.

Children's surgery performed by adult general surgeons in Scotland: the present and future.

OBJECTIVE: The aim of this study was to determine the extent and the future of paediatric surgery performed in Scotland outside of the designated surgical paediatric centres. MATERIALS AND METHODS: An anonymous questionnaire was sent to all 111 Scottish members of the Association of Surgeons of Great Britain and Ireland. There was a response rate of 69%. RESULTS: Overall, 45% of responders operated on children. This was independent of the surgeon's age but was related to the type of hospital that the surgeon worked in. Eighty-four per cent of responders had a lower age limit under which they would not operate and 94% stated that there were specific circumstances where they would not operate. A mean of 18.5 elective procedures (range 0-250, median two) and six emergency procedures (range 0-30, median five) were carried out by each surgeon operating on children under the age of five per annum. Only 13% of responders thought that their successor would operate on children. CONCLUSIONS: Non-specialist paediatric surgery in Scotland is currently provided by a significant number of surgeons whose successors will not continue to provide a comparative paediatric service. This has implications for local provision of care, emergency management and capacity of existing children's hospitals in the future.

Congenital funnel anus: investigation and novel management strategy.

Congenital funnel anus is a rare and poorly documented condition in which treatment strategies are still evolving. The authors present 2 cases and describe the findings after magnetic resonance imaging along with the treatment regime used successfully in these children.

Laparoscopic decapsulation of congenital splenic cysts: a step forward in splenic preservation.

PURPOSE: The aim of this study was to evaluate the role of laparoscopic decapsulation in the management of congenital splenic cysts in children. METHODS: Patients who presented over the last decade with congenital splenic cysts and were treated with laparoscopic decapsulation were reviewed retrospectively. The authors performed 4 procedures in 3 patients aged 10, 11 (and later 13), and 13 years. In all cases there was progressive enlargement of a single cyst, which lay in the upper pole of the spleen in 3 instances and in the lower pole in the fourth. Pneumoperitoneum was induced using the Veress needle technique, and 3 or 4 ports were utilized. Cysts were aspirated initially before marsupialization with excision of around two thirds of the cyst wall. Both endoshears and the harmonic scalpel were used with good hemostatic effect. RESULTS: All patients had a good outcome with cyst resolution on long-term follow-up using serial ultrasound scanning. The first patient (in 1993) remained 3 days as an in patient postoperatively, and the others stayed overnight only. One patient had a new cyst near the first 30 months after the initial procedure. This again was dealt with laparoscopically, with patient discharge the following day. There were no complications in the short or long term. Histology in all cases confirmed a simple epithelial cyst. Median follow-up was 2 years (range, 6 months to 8 years). CONCLUSIONS: Our experience shows that laparoscopic decapsulation is an effective means of managing congenital splenic cysts and that both harmonic scalpel and endoshears are satisfactory dissecting instruments. Extensive marsupialization is probably unnecessary in these larger cysts, because long-term follow-up has shown no increased risk of recurrence after leaving a significant proportion of the cyst wall behind. This approach helps avoid major surgery in these cases.

Computed tomographic cholangiography in the diagnosis of bile duct injury in children.

A case of avulsion of the extrahepatic bile duct from the duodenum is described in association with severe liver trauma in a child. The value of computed tomographic (CT) cholangiography and laparoscopy in the diagnosis of this rare condition is outlined, and a paradigm for management is described.

Hospital re-admission in children with non-specific abdominal pain.

In children with non-specific abdominal pain (NSAP) who were subsequently re-admitted to hospital with a further episode of pain within 30 days, the contribution of active observation to the initial and subsequent admission was evaluated and the diagnostic process reviewed. The cohort comprised all children with a discharge diagnosis of NSAP admitted to Royal Aberdeen Children's Hospital between January 1990 and December 1999. Data were extracted from a computerised database. A measure was made of the investigations employed in the children who were re-admitted and an arbitrary score produced in an attempt to measure the intensity and degree of the diagnostic process. This investigation score was then related to both clinical outcome and the need for revision of the original diagnosis of NSAP. A total of 1,238 children (675 males, 563 females) were admitted with NSAP; 46 (22 males and 24 females, age range 4-14 years) were re-admitted with further abdominal pain within a 30-day period. The total number of re-admission events was 53. In 19 children the subsequent diagnosis was revised. Ten of the 46 children underwent an operation; in 31 cases re-admission investigations were more detailed and invasive, but contributed to a change in diagnosis in only 13. There was no recorded mortality over the study period. In children re-admitted with abdominal pain, the subsequent diagnosis thus changed from the original in over one-third of cases. Most children undergo more invasive and more detailed investigations on re-admission in comparison to the initial episode of hospitalisation. The majority, however, continue to be managed conservatively. This study endorses the continued use of active observation in the management of NSAP in children, and recognises that even intense investigation may fail to contribute to a more specific diagnosis.

Is there a role for balloon dilatation of pelvi-ureteric obstruction in children?

PURPOSE: The aim of this study was to examine the effectiveness of balloon dilatation with double J stenting in the management of children with pelvi-ureteric junction (PUJ) obstruction. METHODS: A retrospective study of a 4-year experience of PUJ balloon dilatation in children was conducted in a single unit. Information was collected on patient demographics, clinical presentation, the procedure of balloon dilatation, renal function, and antero-posterior renal pelvis diameter both pre- and postoperatively. RESULTS: There were 10 patients with a median age of 12.5 years (range, 21 months to 15 years). Four cases presented with ipsilateral flank pain, 3 with urinary tract infection, and 3 were discovered incidentally. Retrograde dilation was performed in all cases. Dilation was considered an initial success in 8 of 10 cases, and 1 patient deteriorated after 17 months. Double J stents were placed in all cases and remained in situ for a median of 7.5 weeks (range, 7 to 8.5). Median in-hospital stay was 2 days. Median follow-up was 34 months (range, 7 to 48). Ipsilateral renal excretion times (on MAG III isotope scanning) improved markedly from a median of 84 minutes (range 13 to 200) preoperatively to 7 minutes (range, 1 to 200) at 3 months and 7 minutes (range 1 to 113) at 12 months postoperatively. Median pelvic AP diameter reduced from 30 mm (range 22 to 74) to 16 mm (range, 8 to 36) at 2 months and 10 mm (range, 4 to 41) at 7 months. There were 2 immediate failed procedures, both occurred in patients who went on to open pyeloplasty and were found to have aberrant renal vessels causing extrinsic PUJ compression. One child deteriorated between 10 and 17 months and went on to open pyeloplasty. Twenty-two patients underwent open pyeloplasty in the unit during the same time period with a 95% success rate. Median stay was longer at 5 days and median age younger at 22 months (range, 6 weeks to 13 years). CONCLUSION: Balloon dilatation is a viable option in the management of PUJ obstruction, carrying minimal morbidity in experienced hands.

The presentation and management of juvenile-onset chronic inflammatory bowel disease in Northeastern Scotland.

PURPOSE: This study reviews the presentation and management of juvenile onset chronic inflammatory bowel disease and identifies changes in incidence of the disease over a 20-year period. METHODS: This was a retrospective study of all patients aged 16 and under with chronic inflammatory bowel disease diagnosed in 1 health region between 1980 and 1999. The patients were identified from computer records and the following variables studied: age, sex, mode of presentation, medical and surgical management, and length of follow-up. RESULTS: One hundred seven patients were identified: 77 with Crohn's disease and 30 with ulcerative colitis. The incidence of ulcerative colitis and Crohn's disease has risen from 0.7 in 100,000 and 2.2 in 100,000, respectively, in the years 1980 through 1989 to 1.5 in 100,000 and 4.4 in 100,000 in the period 1990 through 1999. The median age at presentation was 10.1 years for ulcerative colitis and 10.8 years for Crohn's disease. The majority of disease was diagnosed within 1 year of the onset of symptoms, which were principally abdominal pain, diarrhea, and rectal bleeding. The average length of follow-up was 6.9 years. Analysis of the surgical management of Crohn's patients has shown a low rate of surgical intervention. CONCLUSIONS: This study has shown an increasing incidence of chronic inflammatory bowel disease in the Grampian region of Scotland coupled with a low rate of surgical intervention in Crohn's disease. These findings could be the result of early referral and diagnosis, with the disease being documented earlier in its course or more aggressive preemptive medical therapy.

Recurrent cervical abscess: life-threatening presentation of chronic granulomatous disease in twin infants.

Non-identical male twins presented at 12 and 13 weeks of life, respectively, with recurrent cervical abscesses and signs of imminent upper-airway obstruction (UAO). Despite adequate initial surgical drainage, airway patency became seriously jeopardised in both cases by recurrent abscess formation requiring further intervention. Chronic granulomatous disease was eventually diagnosed in both cases. The unusual presentation of this rare condition with life-threatening UAO in twin infants, a scenario not previously described, is reported and a management protocol suggested.

Acute appendicitis: the continuing role for active observation.

We present the results of a 6-year review of appendicitis. In the event of diagnostic doubt, a policy of active observation was instituted. This review endorses the validity of such a policy, indicating that it does not expose patients to increased morbidity. Data were collected prospectively over a 6-year period on 1,479 children admitted with suspected acute appendicitis (AA); 1,028 (69.5%) were discharged with a diagnosis of non-specific abdominal pain after a mean observation period of 2.5 days, whilst in the remaining 451 a clinical diagnosis of AA was confirmed. The male-to-female ratio was equal, with no difference in the mean age of males (11 years) or females (12 years); 95% of patients were over the age of 5 years. In 324 (72%) cases surgery was performed on the day of admission, whilst in the remaining 126 (28%) it was deferred for 1 to 6 days because the clinical diagnosis of AA remained doubtful. The mean hospital stay was 4 days (range 1-32). Analysis of the histological reports of all 451 cases confirmed a positive predictive value for clinical assessment alone of 97.9% and a normal appendicectomy rate of 2.6%. No mortality was observed; surgical morbidity was recorded at 6% with no correlation between postoperative morbidity and timing of surgery evident (Spearmans correlation coefficient = -0.079, p = 0.9). Active observation for suspected AA thus remains a valid technique for achieving an accurate diagnosis and successful outcome.

Use of clinical audit for revalidation: is it sufficiently accurate?

In order to provide better patient care, clinicians will be subject to revalidation and re-certification. This may be partially based on existing and ongoing data collection, yet many units fail to incorporate mechanisms that validate the data that may be used. The accuracy of audit data was evaluated in a unit that has been using commercially available audit software for over 10 years. A total of 655 consecutive surgical admissions were documented over a 6-month period and errors in data collection and entry were gathered and analyzed. An overall accuracy of 90.5% was confirmed but examination of the data found them to be open to misinterpretation. Moreover, 13% of errors were made during a single week when locum staff were involved. The study highlights the fallibility of data collection during audit, and urges caution if using such data when judging performance-related issues as part of the process of appraisal.

Serum cytokine profile in reflux nephropathy.

Cytokines are small regulatory peptides with diverse functions. They regulate the immune system and modulate the inflammatory response, both of which are implicated in vesico-ureteric reflux (VUR) and associated reflux nephropathy (RN). The cytokine profile in VUR and RN has yet to be fully investigated. Blood was obtained from three subject groups immediately after induction of anaesthesia: group A [subjects with VUR and established RN, (N=9)]; group B [VUR alone but no associated RN, (N=6)]; and group C [age- and sex-matched controls with no history of urinary sepsis, (N=14)]. Serum cytokine levels of tumour-necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), soluble TNF receptor-1 (sTNF-R1), and interleukin-8 (IL-8) were measured using standard ELISA technique. Serum levels of IL-6 were higher in group A subjects (1.798-4.638 pg/ml, median 3.253 pg/ml) than controls (1.531-2.078 pg/ml, median 1.798 pg/ml). There was no significant difference in levels in group B subjects (1.498-3. 048 pg/ml, median 1.948 pg/ml) and controls. These same relationships were observed for levels of TNF-alpha (group A: 8. 501-14.471 pg/ml, median 13.483 pg/ml; group B: 7.088-10.650 pg/ml, median 8.886 pg/ml; group C: 6.746-13.344 pg/ml, median 7.671 pg/ml) and sTNF-R1 (group A: 690.34-5780.74 pg/ml, median 1197.38 pg/ml; group B: 366.65-1401.62 pg/ml, median 592.82 pg/ml; C: 313.49-636.33 pg/ml, median 504.17 pg/ml). IL-8 was not significantly elevated in any of the study groups (A or B) compared with control group C (group A: 27.08-56.38 pg/ml, median 31.35 pg/ml; group B: 29.90-35. 87 pg/ml, median 31.35 pg/ml; group C: 25.05-30.22 pg/ml, median 29. 90 pg/ml). These results suggest there may be an immunological basis to RN.

Emerging trends in the management of the impalpable testis.

BACKGROUND: The management of the impalpable undescended testis is controversial. The study examines emerging trends in the management of this problem. METHODS: Two groups of boys were treated consecutively and recorded prospectively from 1974 to 1984 and from 1990 to 1998 inclusive. A consistent policy of using the preperitoneal approach for impalpable testis was adopted during both time intervals but during the second study period examination under anaesthesia and diagnostic laparoscopy were introduced to ascertain testicular presence and location. RESULTS: Some 919 boys were treated for cryptorchidism during the study period. Ninety boys in the first group (23 per cent) underwent preperitoneal explorations for impalpable testes. Anorchia was present in 18 and orchidectomy was performed in two boys. Thirty boys in the later group (5 per cent) were diagnosed as having impalpable testes. Fifteen boys underwent successful preperitoneal orchidopexy, anorchia was present in 11 and four underwent orchidectomy, carried out for high intra-abdominal testes. CONCLUSION: Examination under anaesthesia and subsequent laparoscopic assessment for all impalpable testes has reduced the need for preperitoneal exploration for the impalpable undescended testis. In this large series, division of the testicular vessels in order to secure scrotal placement of the testis was required in one instance only.