Parents' experiences of sham feeding their child with esophageal atresia at home while awaiting reconstructive surgery. A qualitative interview study.

PURPOSE: This study aimed to explore parents' experience of sham feeding their baby born with esophageal atresia at home, waiting for reconstructive surgery. METHOD: Semi-structured interviews were conducted with parents of six children born with esophageal atresia waiting for delayed reconstruction. The interviews were analyzed using qualitative content analysis. RESULTS: Parents experienced that sham feed reinforced the healthy abilities in their baby. They had faith in their own ability as parents to care for their child as well as to see to their baby's strength to cope with difficulties. Parents expressed that the health care system can hinder as well as be a major support on their way to a more normal life at home while waiting for reconstructive surgery. CONCLUSION: The experience of sham feeding at home while waiting for reconstructive surgery is characterized by positive aspects both for children born with esophageal atresia and their parents.

Long-Term Outcome of Nonoperative Treatment of Appendicitis.

This cohort study uses registry data to report the long-term outcomes of patients who participated in randomized clinical trials of antibiotics vs surgery in Sweden in the 1990s.

Complication rate after gastrostomy placement in children can be reduced by simple surgical steps.

AIM: To evaluate if the incidence of postoperative complications after gastrostomy placement is correlated to perioperative parameters or patient characteristics. METHODS: In this prospective observational study, children <18 years of age planned to receive a gastrostomy at partaking clinics between 2014 and 2019 were invited. Pre-, peri- and postoperative variables were collected and followed up 3 months postoperatively. RESULTS: Five hundred and eighty-two patients were included (median age: 26 months, median weight: 10.8 kg), mainly laparoscopic (52.0%) and push-PEG (30.2%) technique used. The incidence of complications was lower in the group of patients receiving a gastrostomy tube that was 2 mm longer than the gastrostomy canal (p < 0.001-0.025), and a thickness of 12 Fr (p < 0.001-0.009). These findings were confirmed by multivariate analysis also including operative technique, age and weight. Patients with oncological disease had significantly higher incidence of pain and infection but the lowest incidence of granulomas (p < 0.001-0.01). CONCLUSION: This study indicates that a 12 Fr gastrostomy tube that is 2 mm longer than the gastrostomy canal is correlated with the lowest incidence of postoperative complications the first 3 months after surgery. Oncological patients had the lowest incidence of granulomas which probably is related to chemotherapy.

Management of COVID-19-Positive Pediatric Patients Undergoing Minimally Invasive Surgical Procedures: Systematic Review and Recommendations of the Board of European Society of Pediatric Endoscopic Surgeons.

Introduction: Hospital response to the COVID-19 outbreak has involved the cancellation of elective, deferrable surgeries throughout Europe in order to ensure capacity for emergent surgery and a selection of elective but non-deferrable surgeries. The purpose of this document is to propose technical strategies to assist the pediatric surgeons to minimize the potential aerosolization of viral particles in COVID-19 patients undergoing urgent or emergent surgical treatment using laparoscopic approaches, based on the currently available literature. The situation and recommendations are subject to change with emerging information. Materials and Methods: The Scientific Committee and the Board of the European Society of Pediatric Endoscopic Surgeons gathered together in order to address the issue of minimally invasive surgery during this COVID-19 pandemic. A systematic search through PubMed, Embase, and World Wide Web of the terms "COVID-19," "Coronavirus," and "SARS-CoV-2" matched with "pneumoperitoneum," "laparoscopy," "thoracoscopy," "retroperitoneoscopy," and "surgery" was performed. Non-English language papers were excluded. A PRISMA report was performed. Criticalities were identified and a consensus was achieved over a number of key aspects. Results: We identified 121 documents. A total of 11 full-text documents were assessed to address all concerns related to the adoption of minimally invasive surgery. All aspect of pediatric minimally invasive surgery, including elective surgery, urgent surgery, laparoscopy, thoracoscopy, retroperitoneoscopy, and pneumoperitoneum creation and maintainance were extensively addressed through systematic review. A consensus regarding urgent laparoscopic procedures, setting and operation techniques was obtained within the Committee and the Board. Conclusions: The ESPES proposes the following recommendations in case minimally invasive surgery is needed in a COVID-19 positive pediatric patients: (1) consider conservative treatment whenever safely possible, (2) dedicate a theater, columns and reusable laparoscopic instrumentation to COVID-19 pediatric patients, (3) prefer disposable instrumentation and cables, (4) use low CO2 insufflation pressures, (5) use low power electrocautery, (6) prefer closed-systems CO2 insufflation and desufflation systems, and (7) avoid leaks through ports. These recommendations are subject to change with emerging information and might be amended in the near future.

Low Plasma Sodium Concentration Predicts Perforated Acute Appendicitis in Children: A Prospective Diagnostic Accuracy Study.

INTRODUCTION: Early differentiation between perforated and nonperforated acute appendicitis (AA) in children is of major benefit for the selection of proper treatment. Based on pilot study data, we hypothesized that plasma sodium concentration at hospital admission is a diagnostic marker for perforation in children with AA. MATERIALS AND METHODS: This was a prospective diagnostic accuracy study, including previously healthy children, 1 to 14 years of age, with AA. Blood sampling included plasma sodium concentration, plasma glucose, base excess, white blood cell count, plasma arginine vasopressin (AVP), and C-reactive protein. RESULTS: Eighty children with histopathologically confirmed AA were included in the study. Median plasma sodium concentration on admission in patients with perforated AA (134 mmol/L, [interquartile range 132-136]) was significantly lower than in children with nonperforated AA (139 mmol/L, [137-140]). The receiver operating characteristic curve of plasma sodium concentration identifying patients with perforated AA showed an area under the curve of 0.93 (95% confidence interval, 0.87-0.99), with a sensitivity and specificity of 0.82 (0.70-0.90) and 0.87 (0.60-0.98), respectively. Plasma sodium concentrations ≤136 mmol/L resulted in an odds ratio of 31.9 (6.3-161.9) for perforation. The association between low plasma sodium concentration and perforated AA was confirmed in a multivariate logistic regression analysis. Median plasma AVP on admission was higher in patients with perforated (8.6 pg/mL [5.0-14.6]) as compared with nonperforated AA (3.4 pg/mL [2.5-6.6]). CONCLUSION: In children with AA, there is a strong association between low plasma sodium concentration and perforation, a novel and not previously described finding.

Nonoperative Treatment Versus Appendectomy for Acute Nonperforated Appendicitis in Children: Five-year Follow Up of a Randomized Controlled Pilot Trial.

OBJECTIVE: The aim of this study was to evaluate the safety and feasibility of nonoperative treatment of acute nonperforated appendicitis in children during 5 years of follow-up. METHODS: A 4-year follow-up of a previous randomized controlled pilot trial, including 50 children with acute nonperforated appendicitis, was performed. The patients were initially randomized to nonoperative treatment with antibiotics or appendectomy with 1-year follow-up previously reported. Data were extracted from the computerized notes and telephone interviews.The primary outcome was treatment failure, defined as need for a secondary intervention under general anesthesia, related to the previous diagnosis of acute nonperforated appendicitis. RESULTS: The children were followed up for at least 5 years [median 5.3 (range 5.0-5.6)] after inclusion. There were no failures in the appendectomy group (0/26) and 11 failures in the nonoperative group (11/24). Nine failures had occurred during the first year after inclusion, 2 of whom had histologically confirmed appendicitis. There were 2 further patients with recurrent acute appendicitis 1 to 5 years after inclusion. Both these patients had uncomplicated laparoscopic appendectomies for histologically confirmed acute appendicitis. There were no losses to follow-up. CONCLUSIONS: At 5 years of follow-up 46% of children treated with antibiotics for acute nonperforated appendicitis had undergone an appendectomy, although acute appendicitis was only histologically confirmed in 4/24 (17%). Treatment with antibiotics seems to be safe in the intermediate-term; none of the children previously treated nonoperatively re-presented with complicated appendicitis.

Population-based cohort study of the correlation between provision of care and the risk for complications after appendectomy in children.

PURPOSE: To investigate the impact of hospital administrative level and caseload of pediatric appendectomies on the morbidity and mortality after appendectomy in a population-based cohort of Swedish children. METHODS: Population-based cohort study including all Swedish children less than 15 years of age that underwent appendectomy for suspected appendicitis, 1987-2009. Patient characteristics and data on postoperative morbidity and mortality were collected from the Swedish National Patient Register and the Swedish Death Register. Primary endpoints were postoperative morbidity and mortality. Two explanatory variables were investigated: hospital administrative level and hospital annual caseload of pediatric appendectomies. Data were analyzed in regression models adjusting for available confounders. RESULTS: The cohort comprised 55,591 children. The risk for postoperative complications was reduced in specialized pediatric surgical centers and in high caseload centers, compared to other hospitals. There were only seven postoperative deaths within 90 days of appendectomy. CONCLUSIONS: We found clinically relevant risk reductions for reoperation and for readmission after appendectomy in specialized pediatric surgical centers. Importantly, the risk for postoperative complications was also reduced with increased hospital caseload, indicating that the merit from centralizing the management of pediatric appendectomies to specialized pediatric surgical centers may also be achieved by increasing hospital caseload of pediatric appendectomies in non-pediatric surgical units. TYPE OF STUDY: Treatment study. LEVEL OF EVIDENCE: Level II.

Intraoperative cultures during appendectomy in children are poor predictors of pathogens and resistance patterns in cultures from postoperative abscesses.

BACKGROUND: Intraoperative cultures are commonly sent in complicated appendicitis. Culture-guided antibiotics used to prevent postoperative infectious complications are debated. In this study, we describe the microbial overlap between intraoperative and abscess cultures, and antibiotic resistance patterns. METHOD: A local register of a children's hospital treating children 0-15 years old with appendicitis between 2006 and 2013 was used to find cases with intraoperative cultures, and cultures from drained or aspirated postoperative intraabdominal abscesses. Culture results, administered antibiotics, their nominal coverage of the identified microorganisms, and rationales given for changes in antibiotic regimens were collected from electronic medical records. RESULTS: In 25 of 35 patients who met inclusion criteria, there was no overlap between the intraoperative and abscess cultures. In 33 of 35 patients, all identified intraoperative organisms were covered with postoperative antibiotics. In 14 patients, organisms in the abscess culture were not covered by administered antibiotics. Enterococci not found in the intraoperative culture were found in 12 of 35 abscesses. We found no difference in the antibiotic coverage between rationales given for antibiotic changes. CONCLUSION: The overlap between intraoperative cultures and cultures from subsequent abscesses was small. Lack of antibiotic coverage of intraoperative cultures was not an important factor in abscess formation.

Outcomes of biliary atresia in the Nordic countries - a multicenter study of 158 patients during 2005-2016.

BACKGROUND/PURPOSE: Biliary atresia is the most common reason for newborn cholestasis and pediatric liver transplantation. Even after normalization of serum bilirubin after portoenterostomy, most patients require liver transplantation by adulthood due to expanding fibrosis. We addressed contemporary outcomes of biliary atresia in the Nordic countries. METHODS: Data on center and patients characteristics, diagnostic practices, surgical treatment, adjuvant medical therapy after portoenterostomy, follow-up and outcomes were collected from all the Nordic centers involved with biliary atresia care during 2005-2016. RESULTS: Of the 154 patients, 148 underwent portoenterostomy mostly by assigned surgical teams at median age of 64 (interquartile range 37-79) days, and 95 patients (64%) normalized their serum bilirubin concentration while living with native liver. Postoperative adjuvant medical therapy, including steroids, ursodeoxycholic acid and antibiotics was given to 137 (93%) patients. Clearance of jaundice associated with young age at surgery and favorable anatomic type of biliary atresia, whereas annual center caseload >3 patients and diagnostic protocol without routine liver biopsy predicted early performance of portoenterostomy. The cumulative 5-year native liver and overall survival estimate was 53% (95% CI 45-62) and 88% (95% CI 83-94), respectively. Portoenterostomy age <65days and annual center caseload >3 patients were predictive for long-term native liver survival, while normalization of serum bilirubin after portoenterostomy was the major predictor of both native liver and overall 5-year survival. CONCLUSIONS: The outcomes of biliary atresia in the Nordic countries compared well with previous European studies. Further improvement should be pursued by active measures to reduce patient age at portoenterostomy. RETROSPECTIVE PROGNOSIS STUDY: Level II.

In-hospital Surgical Delay Does Not Increase the Risk for Perforated Appendicitis in Children: A Single-center Retrospective Cohort Study.

OBJECTIVE: To investigate the correlation between in-hospital surgical delay before appendectomy for suspected appendicitis and the finding of perforated appendicitis in children. METHODS: All children undergoing acute appendectomy for suspected acute appendicitis at Karolinska University Hospital, Stockholm, Sweden from 2006 to 2013 were reviewed for the exposure of surgical delay. Primary endpoint was the histopathologic finding of perforated appendicitis. The main explanatory variable was in-hospital surgical delay, using surgery within 12 hours as reference. Secondary endpoints were postoperative wound infection, intra-abdominal abscess, reoperation, length of hospital stay, and readmission. To adjust for selection bias, a logistic regression model was created to estimate odds ratios for the main outcome measures. Missing data were replaced using multiple imputation. RESULTS: The study comprised 2756 children operated for acute appendicitis. Six hundred sixty-one (24.0%) had a histopathologic diagnosis of perforated appendicitis. In the multivariate logistic regression analysis, increased time to surgery was not associated with increased risk of histopathologic perforation. There was no association between the timing of surgery and postoperative wound infection, intra-abdominal abscess, reoperation, or readmission. CONCLUSIONS: In-hospital delay of acute appendectomy in children was not associated with an increased rate of histopathologic perforation. Timing of surgery was not an independent risk factor for postoperative complications. The results were not dependent on the magnitude of the surgical delay. The findings are analogous with previous findings in adults and may aid the utilization of available hospital- and operative resources.

Outcome after introduction of laparoscopic appendectomy in children: A cohort study.

INTRODUCTION: Acute appendicitis in children is common and the optimal treatment modality is still debated, even if recent data suggest that laparoscopic surgery may result in shorter postoperative length of stay without an increased number of complications. The aim of the study was to compare the outcome of open and laparoscopic appendectomies during a transition period. MATERIALS AND METHODS: This was a retrospective cohort study with prospectively collected data. All patients who underwent an operation for suspected appendicitis at the Astrid Lindgren Children's Hospital in Stockholm between 2006 and 2010 were included in the study. RESULTS: 1745 children were included in this study, of whom 1010 had a laparoscopic intervention. There were no significant differences in the rate of postoperative abscesses, wound infections, readmissions or reoperations between the two groups. The median operating time was longer for laparoscopic appendectomy than for open appendectomy, 51 vs. 37minutes (p<0.05). The postoperative length of stay was similar in the two groups. A simple comparison between the groups suggested that laparoscopic appendectomy had a shorter median postoperative length of stay, 43 vs. 57hours (p<0.05). However, there was a trend in time for a shorter postoperative length of stay, and a trend for more of the procedures to be performed laparoscopically over time so on regression analysis, the apparent decrease in length of stay with laparoscopy could be ascribed to the general trend toward decreased length of stay over time, with no specific additional effect of laparoscopy. CONCLUSIONS: Our data show no difference in outcome between open and laparoscopic surgery for acute appendicitis in children in regard of complications. The initial assumption that the patients treated with laparoscopic surgery had a shorter postoperative stay was not confirmed with linear regression, which showed that the assumed difference was due only to a trend toward shorter postoperative length of stay over time, regardless of the surgical intervention.

Nonoperative treatment with antibiotics versus surgery for acute nonperforated appendicitis in children: a pilot randomized controlled trial.

OBJECTIVE: The aim of this study was to evaluate the feasibility and safety of nonoperative treatment of acute nonperforated appendicitis with antibiotics in children. METHODS: A pilot randomized controlled trial was performed comparing nonoperative treatment with antibiotics versus surgery for acute appendicitis in children. Patients with imaging-confirmed acute nonperforated appendicitis who would normally have had emergency appendectomy were randomized either to treatment with antibiotics or to surgery. Follow-up was for 1 year. RESULTS: Fifty patients were enrolled; 26 were randomized to surgery and 24 to nonoperative treatment with antibiotics. All children in the surgery group had histopathologically confirmed acute appendicitis, and there were no significant complications in this group. Two of 24 patients in the nonoperative treatment group had appendectomy within the time of primary antibiotic treatment and 1 patient after 9 months for recurrent acute appendicitis. Another 6 patients have had an appendectomy due to recurrent abdominal pain (n = 5) or parental wish (n = 1) during the follow-up period; none of these 6 patients had evidence of appendicitis on histopathological examination. CONCLUSIONS: Twenty-two of 24 patients (92%) treated with antibiotics had initial resolution of symptoms. Of these 22, only 1 patient (5%) had recurrence of acute appendicitis during follow-up. Overall, 62% of patients have not had an appendectomy during the follow-up period. This pilot trial suggests that nonoperative treatment of acute appendicitis in children is feasible and safe and that further investigation of nonoperative treatment is warranted.

Single-site incision laparoscopic cholecystectomy in children: a single-center initial experience.

Laparoscopic cholecystectomy is the standard approach in most pediatric surgical centers. In an attempt to further minimize the surgical trauma and improve cosmetic outcome, new techniques with a single incision through the umbilicus have been proposed. There are still few reports concerning this technique in the pediatric population. We evaluated the feasibility of the single incision for laparoscopic cholecystectomy in children. We performed the operation in 10 patients, with a mean age of 12 years, mean operating time of 122 minutes, and mean hospital stay of 2 days. No complications occurred, and no conversion to open surgery was needed. In 1 patient, an extra 5-mm port was necessary. The cosmetic results were very satisfactory. In our experience, despite its technical difficulty and initial learning curve, single-incision laparoscopic cholecystectomy in the pediatric population is a safe and feasible method.

Cosmetic and functional outcome after stoma site skin closure in children.

PURPOSE: To evaluate the functional and cosmetic outcome of stoma closure in children after straight closure (SC) versus purse-string closure (PSC). METHODS: The patients (n = 33, age 16-159 months), operated at a median age of 6 months (1-121 months) between 2007 and 2009 in our hospital, were studied to evaluate whether the proposed superiority of the PSC technique is applicable in children. The patients were operated with SC or PSC. The most common causes of the temporary stomas were necrotizing enterocolitis, Hirschsprung's disease and anal atresia. A validated scoring-system questionnaire (patient and observer scar assessment scale),POSAS was sent to the parents containing questions concerning pain, itchiness, colour, stiffness, thickness and irregularity of the scar completed by a visual analogue scale to evaluate an overall opinion. RESULTS: 25 families (SC; n = 12, PSC;n = 13) participated. The differences between the two groups are largest, although not statistically significant, for discoloration, stiffness, thickness and irregularity, with better scores in the PSC group. There was a better total POSAS score in the PSC group whilst the VAS shows very modest differences. CONCLUSION: Our study indicates advantages of the PSC technique after stoma closure with better cosmetic and functional outcome. To be able to show statistically significant differences between PSC and SC a larger study would be useful.

Nerve growth factor receptor immunohistochemistry has a limited additional value to diagnose Hirschsprung's disease.

PURPOSE: The diagnosis of Hirschsprung's disease (HSCR) is based on the histopathological evaluation of rectal suction biopsies (RSB), using haematoxylin and eosin (H&E) stains and acetylcholinesterase (AChE) histochemistry. The use of different immunohistochemical markers, such as nerve growth factor receptor (NGFR), has been suggested to facilitate the diagnosis of HSCR. The aim of this study was to evaluate the addition of NGFR immunohistochemistry to diagnose HSCR. METHODS: RSB from 23 HSCR patients and 16 patients investigated for, but not diagnosed with, HSCR were retrospectively reviewed. The histopathology report supported or did not support the diagnosis of HSCR. RESULTS: In patients with HSCR, the primary biopsies confirmed the diagnosis in 21 of 23 cases with H&E staining, in 16 of 23 cases with AChE histochemistry, and in 8 of 23 cases with NGFR immunohistochemistry. Due to inadequate biopsies or equivocal interpretation, the biopsies were repeated in seven of the patients with HSCR and two patients underwent biopsies a third time. In the 16 patients investigated for but not diagnosed with HSCR, the three tests were normal in all cases. CONCLUSION: We conclude that NGFR immunohistochemistry has limited additional value to diagnose HSCR.

Efficacy of preoperative radiochemotherapy in patients with locally advanced pancreatic carcinoma.

BACKGROUND: The optimal care for patients with unresectable, non-metastatic pancreatic adenocarcinoma (PAC) is debated. We treated 17 consecutive cases with preoperative radiochemotherapy (RCT) as a means for downstaging their tumours and compared outcome with 35 patients undergoing direct surgery for primarily resectable PAC during the same time period. METHODS: The patients had biopsy proven, unresectable, non-metastatic PAC which engaged >or=50% of the circumference of a patent mesenteric/portal vein for a distance >or=2 cm and/or <50% of the circumference of a central artery for <2 cm. The preop therapy included two courses of Xelox (oxaliplatin 130 mg/m(2) d1; capecitabine 2 000 mg/m(2) d1-14 q 3 w) followed by 3-D conformal radiotherapy (50.4 Gy; 1.8 Gy fractions) with reduced Xelox (d1-5 q 1 w X 6). RESULTS: No incident of RCT-related CTC Grade 3-4 haematologic and six cases of non-haematologic side-effects were diagnosed. Sixteen patients completed the RCT and were rescanned with CT and reevaluated for surgery 4 weeks post-RCT. Five cases were diagnosed with new metastases to the liver. Eleven patients were accepted for surgery whereof eight underwent a curative R(0)-resection. The median overall survival for the latter group was 29 months, which compared favourably with our control group of patients undergoing direct curative surgery for primarily resectable PAC (median OS: 16 months; R(O)-rate: 75%). Perioperative morbidity was similar in the two cohorts but the duration of surgery was longer (576 vs. 477 min) and the op blood loss was greater (3288 vs. 1460 ml) in the RCT-cohort (p < 0.05). The 30-day mortality was zero in both groups. CONCLUSION: Preoperative RCT in patients with locally advanced PAC resulted in a high rate of curative resections and promising median survival in our treatment series. This trimodality approach merits further exploration in new studies, which are currently underway at our Department.