Peritoneal lavage during laparoscopic appendectomy for complex appendicitis is associated with increased post-operative morbidity.

Aim: Appendicitis is one of the most common paediatric surgical pathologies seen by paediatric surgeons worldwide. Laparoscopic appendectomy is undertaken for all cases of appendicitis in our institute. Intraperitoneal lavage following appendectomy is the conventional way of managing complicated appendicitis; however, some surgeons debate the efficacy of this practice. The aim of this study was to compare outcomes of intraperitoneal lavage versus suction only in children with complicated appendicitis. Methods: Data were collected retrospectively between January 2018 and January 2019. All patients undergoing laparoscopic appendectomy for complex appendicitis were included and divided into two groups, patients who had suction only and those who had lavage and suction. Outcome parameters studied were the length of stay (LOS), number of temperature spikes > 37.7 (TS), operative times (OT) and readmission for intra-abdominal collections. Comparison between the two groups was performed using two sample t-test with unequal variance, significance was set at P < 0.05. Results: A total of 115 patients were included (lavage n = 52, Suction n = 63). The LOS (P = 0.0054), TS (0.0109), OT (P < 0.0001) were significantly higher in the lavage group compared to the suction-only group. Overall rates of readmission were similar between groups, however, readmission for the confirmed intra-abdominal collection was more common in the lavage group. Conclusion: Based on our study, it appears that there is no advantage in performing an intraperitoneal lavage for complex appendicitis. It resulted in a prolonged stay, more post-operative TS and longer operative duration. The likelihood of being readmitted with an intra-abdominal collection following a lavage was higher compared to suction only.

Emergency scrotal exploration in children: Is it time for a change in mindset in the UK?

INTRODUCTION: Acute scrotal pain is a common problem in children. Amongst the various causes, only testicular torsion (TT) needs urgent, and arguably any, surgical intervention. However TT accounts for only approximately 25% of cases. The diagnosis of TT is currently based mainly on history and clinical examination in the UK. OBJECTIVE: We sought to find the incidence of finding TT during emergency scrotal exploration in four paediatric surgical centres in the UK. We also assessed the preoperative utilisation of clinical risk scores and Doppler ultrasound (DUS) to aid in the diagnosis. PATIENTS AND METHODS: A retrospective review of 50 consecutive scrotal explorations done for acute scrotal pain at four tertiary pediatric surgical centres in 2019, including the preoperative utilisation of DUS, was analysed. Additionally an online survey was also sent out to consultant members of the British Association of Paediatric Urology to gauge their threshold for exploration, use of preoperative investigations and incidence of finding TT in their practice. RESULTS: In the four UK centres reviewed, TT was found in 24.5% (SD = 8.54) of explorations. The overall utilisation of preoperative DUS was 10%. The online survey revealed a low threshold for exploration. However 72% of respondents recalled finding TT in <50% of explorations, with just over a third reporting finding TT in only 10% of explorations. There was low utilisation of preoperative DUS and clinical risk scores. DISCUSSION: The incidence of finding TT during exploration in this cohort is the same as the incidence of TT in a population of children presenting with acute scrotal pain. We hypothesise that this is due to low accuracy of clinical assessment, low utilisation of preoperative clinical and radiological aids and the practice of exploring torted testicular appendages. Improving awareness and training in these modalities will increase diagnostic accuracy, limiting emergency scrotal explorations to those children with a higher risk of testicular torsion. A care pathway for children presenting with acute scrotal pain is suggested () CONCLUSIONS: There is a low incidence of finding testicular torsion during paediatric scrotal explorations in the UK. There is low preoperative utilisation of clinical risk scores and Doppler ultrasound, which if utilised, could improve diagnostic accuracy.

A low-cost stoma simulator.

Stoma formation is a common paediatric surgical procedure and yet, there is no low-cost stoma model for technical skills training. We describe a low-cost low-fidelity simulator for stoma formation made from simple easily available materials using porcine bowel and skin. The model was introduced at a regional training day for paediatric surgical registrars. All the trainees rated it as excellent and life-like. We describe an inexpensive stoma model for simulation-based training in technical skills especially in low-middle-income countries (LMICs) due to the cost benefit.

Meconium pseudocyst presenting as massive ascites in a new-born.

Meconium pseudocyst (MPC) is a rare but well-known surgical condition due to prenatal bowel perforation. A case of MPC secondary to prenatal bowel perforation is presented. Massive ascites requiring peritoneal drainage and disappearance of prenatal intraperitoneal calcifications have not been previously reported in MPC. MPC may present at birth with large ascites requiring peritoneal drainage to establish breathing and ventilation. Absence of prenatal intra-abdominal calcifications does not rule out MPC.

Outcomes During a Transition Period from Open to Laparoscopic Pyloromyotomy.

BACKGROUND: Previous studies suggest that laparosopic pyloromyotomy may have some benefits over an open approach. We examined our results during a transition period from open to laparoscopic pyloromyotomy to see whether these benefits are sustained during the learning curve. METHODS: This is a retrospective case note review of all patients undergoing pyloromyotomy at a tertiary institution for a 5-year period (2010-2015). Data are presented as median (range). Statistical analysis was performed with Fisher's exact and Student's t-test. RESULTS: A total of 185 pyloromyotomies were performed, with data available for 90 open and 60 laparoscopic procedures. Duration of surgery was 42 (16-102) minutes for open and 28 (14-97) minutes for laparoscopic procedures (P = .0001). Total paracetamol requirements were 23.5 (0-169.4) mg/kg for open and 13.9 (0-95.3) mg/kg for laparoscopic cases (P = .008). No postoperative analgesia was required for 23 open and 29 laparoscopic patients (P = .005). Complications in the open group included incomplete pyloromyotomy (n = 1) and wound infection (n = 4); complications in the laparoscopic group included incisional hernia (n = 1), omental port-site herniation (n = 2), and suspected perforation with conversion to open procedure, although no perforation was found (n = 1; P = 1.000). CONCLUSION: Our results suggest that when the laparoscopic technique is first introduced, overall complication rates are not statistically higher, and operative times and analgesia requirements are significantly shorter, despite the learning curve.

13 ribs as a predictor of long gap esophageal atresia: myth or reality? Analysis of associated findings of esophageal atresia and abnormal rib count.

BACKGROUND: The presence of 13 pairs of ribs on pre-operative chest x-ray has been postulated to be an indicator for long gap esophageal atresia (EA). This study sought to determine the validity of this theory and identify associated pathological conditions in patients with EA and abnormal rib count. METHODS: Babies with EA from January 2005 - December 2012 were retrospectively analyzed. Information was gathered from neonatal health records and operation notes. Chest x-rays were reviewed to determine rib count. Long gap EA was defined as failure to achieve primary esophageal anastomosis. Statistical analysis performed with Fisher's exact test. RESULTS: Seventy-six patients were identified. Eight patients had long gap EA, with none of these patients having 13 pairs of ribs. Paradoxically, 10 patients with esophageal atresia +/- trachea-esophageal atresia (EA +/- TEF) and supernumerary ribs underwent primary repair. Nine patients had 11 pairs of ribs, of which 2 had pure EA and a long gap. Using Fisher's exact test to compare the groups of supernumary ribs and non-supernumary ribs there is a p value of 0.587. VACTERL association was identified in 40% of those with supernumerary ribs. Various associated syndromes and concomitant abnormalities were identified. CONCLUSION: We found no association between 13 pairs of ribs and long gap in esophageal atresia. Those with 13 pairs of ribs were more likely to have associated anomalies, although this was not statistically significant. Our cohort of patients was found to have a range of pathology related to genetic syndromes, further atresias, and malformations, which is well known to be associated with children born with EA +/- TEF. LEVEL OF EVIDENCE: Prognosis study - level IV.

Tap water iontophoresis in the treatment of pediatric hyperhidrosis.

AIM OF THE STUDY: The treatment options for localized hyperhidrosis include antiperspirants, anticholinergics, iontophoresis, botulinum toxin and surgery. Tap water iontophoresis (TWI) involves immersing the affected area in tap water and passing a small electrical current through the area. Our aim was to assess the success of this therapy in a pediatric cohort. METHODS: Retrospective case note review of all patients younger than 18years who underwent TWI between 2002 and 2015. Demographic data, number of treatment sessions, side effects and overall success were analyzed. Individuals undergo 7 treatments over 4weeks. A positive outcome was determined as an improvement in symptoms. Pre- and posttreatment hyperhidrosis disease severity scale (HDSS) was measured. Data are presented as mean (range). Statistical analysis was by paired t-test. A P value of <0.05 was regarded as significant. RESULTS: There were 43 patients (30 females) with a mean age of 15 (8-17) years. Palmar and/or plantar hyperhidrosis (PPH) was present in 39/43 (91%) patients. Axillary hyperhidrosis (AH) was present in 19/43 (44%) patients. All patients (with the exception of one) underwent 7 sessions (5-7). Side effects included paresthesia (88%), pruritus (26%), pain (26%), erythema (14%), dryness (12%) as well as vesicle formation and abrasions in one patient (2%). A positive outcome was found in 84% (36/43) of patients. There was a significant reduction in mean HDSS (pre 3.5 vs. post 2; P=0.0001). CONCLUSION: TWI is a safe and effective modality of treatment for both PPH and AH in the pediatric population, with minimal side effects. Pediatric surgeons should offer this treatment option before considering more invasive surgical procedures. LEVEL OF EVIDENCE: IV: Retrospective study.

Pediatric Benign Cystic Peritoneal Mesothelioma.

BACKGROUND: Benign cystic peritoneal mesothelioma is a rare tumor comprising multiple cysts typically found within the abdominal cavity. Although the literature has numerous accounts of this entity in adults, only a handful of cases have been published regarding its presence in the pediatric population. CASE: We present the case of a prepubertal 10-year-old girl with the finding of benign cystic peritoneal mesothelioma at laparoscopy for suspected appendicitis, the management, and outcome. SUMMARY AND CONCLUSION: Although benign cystic peritoneal mesothelioma can be treated with primary excision, the high recurrence rate in adult cases of this disease necessitates the need for long-term follow-up of these patients and provides a challenge to surgeons in providing continuing care.

Paediatric trauma with hyperamylasemia.

In this case report, we describe a paediatric case of hyperamylasemia following parotid trauma. A 12-year-old boy was hit by a motorcycle, sustaining only superficial lacerations to the face overlying the parotid. A hyperamylasemia was noted, and further characterised by a fractionated isoamylase test, as being predominantly of the salivary type. Serum lipase levels were low. Based on these investigations, pancreatic injury was judged unlikely with the minor parotid trauma being the probable source of the hyperamylasemia. The patient was spared further unnecessary investigations and managed conservatively.

Spontaneous Splenic Hemorrhage in the Newborn.

Spontaneous splenic hemorrhage in the newborn is a rare entity. The presentation is usually with a triad of bleeding, abdominal distension, and hemoperitoneum. Rapid diagnosis is essential as left untreated, death is inevitable. We present a case with an unusual initial presentation of a scrotal hematocele and ultrasonography suggesting an adrenal hemorrhage. At laparotomy, splenic preservation was unsuccessful, and therefore, splenectomy was performed. The child recovered well from the procedure.

Inflammatory myofibroblastic tumor of the pancreas: a case report of 2 pediatric cases--steroids or surgery?

Inflammatory pseudotumors also termed inflammatory myofibroblastic tumors (IMTs) are rare, benign, solid lesions of unclear etiology more usually found in the lung and very rarely in the pancreas. We report 2 cases and outline our management for each. The first case was treated surgically, whereas the second was treated with high-dose steroids. This represents the first reported case whereby steroid treatment has been successful in pancreatic IMT.

The appendix as ureteral substitute: a report of 10 cases.

BACKGROUND: Ureteric replacement in part or in total is rarely needed in children. We present our experience in using the appendix to replace the ureter. METHODS: A retrospective case note review was carried out at Sheffield Children's Hospital (UK), Ekta Institute of Child Health (Raipur, Chhattisgarh, India) and Christian Medical College Hospital (Vellore, India) of all cases of ureteric substitution using the appendix. RESULTS: Ten patients were identified, operated in 2002-2007: seven males and three females with a median age of 2.5 years (range 2.5 months to 12 years). The reasons for ureteric replacement were traumatic ureteric avulsion (n=1), congenital ureteric stenosis (n=5), non-drainage following previous pyeloplasty for pelvi-ureteric junction obstruction (n=3) and ureteric stricture following reimplantation for vesico-ureteric reflux (n=1). The appendix was used in an anti-peristaltic manner in all cases, and in one case a transureteroureterostomy was performed. At a median follow up of 16months (1-72 months), all the patients were well except one whose kidney function had deteriorated. CONCLUSIONS: Total or partial replacement of the ureter using the appendix, even in the first year of life, preserved renal function in nine cases. Ureteric continuity can be successfully restored in children using the appendix.

An ovarian tumour with a potential appendiceal origin.

A 14-year-old girl underwent left oopherectomy for a multicystic ovarian mass. Histology revealed this to be an intestinal type mucinous borderline tumour (IMBT). In view of this, a semi-urgent laparoscopic appendicectomy was carried out. The appendix was histologically normal. IMBT of the ovary is a mucinous tumour with atypical proliferation of the goblet cell containing epithelium. It is known to occur simultaneously with tumours of the appendix. Paediatric surgeons need to be aware of this rare tumour and when operating on any ovarian pathology should always inspect the peritoneal cavity for mucinous deposits and examine the appendix.

Testicular microlithiasis: what does it mean clinically?

OBJECTIVE: To review our current practice of follow-up for boys with testicular microlithiasis (TM), an uncommon condition characterized by calcification within the seminiferous tubules, detected by ultrasonography (US); TM has been associated with both benign and malignant conditions of the testes but the natural history of TM in children remains unclear. PATIENTS AND METHODS: All boys diagnosed with TM over a 14-year period were included in this study. A search of the radiology database was carried out using the keywords 'testicular microlithiasis' and 'testicular calcification'. A retrospective case-note review was then used to determine age at diagnosis, presenting symptoms, indication for testicular US, outcome and follow-up. We also searched Medline/PubMed, using the same keywords for published data on TM from 1970 to 2006. RESULTS: Over the study period 711 testicular scans were taken in 623 patients; seven cases (1.1%) of TM were identified. The mean (range) age at presentation was 12 (7-15) years. The presenting symptoms were testicular pain (three), undescended testes (two), hydrocele (one) and asymptomatic scrotal swelling (one). In five cases the TM was bilateral and in two a solitary kidney was identified. Only one patient had tumour markers measured (beta-human chorionic gonadotrophin and alpha-fetoprotein) and these were within normal limits. On yearly US follow-up, the TM was less prominent in one patient, unchanged in four and two were lost to follow-up. Three patients are currently on yearly US follow-up while two are under the care of adult general surgeons. The analysis of reports published to date indicated that malignancy only develops when TM is associated with other predisposing factors. CONCLUSION: There is no convincing evidence that TM alone is premalignant. However, when it accompanies other potentially premalignant features we recommend annual US follow-up.