Outcomes of Pediatric Endoscopic Pilonidal Sinus Treatment: A Systematic Review.

Treatment of pilonidal sinus disease with conventional excision techniques is associated with recurrence up to 20 to 30% (primary closure) or with prolonged healing that might last months (closure by secondary intention). Endoscopic pilonidal sinus treatment (EPSiT) is gaining increasing popularity. This systematic review aims to summarize and evaluate the reported outcomes of pediatric EPSiT (PEPSiT) to date. Systematic search was performed for all studies on PEPSiT in patients younger than 18 years, pertaining to demographics, technique, and outcomes. Fisher's test was used to assess the associations between success/recurrence rates and different approaches (fistuloscope vs. cystoscope, different wound care protocols). A total of 320 patients (9 studies, 2018-2022) with a weighted mean age of 15.7 years and follow-up duration of 13.5 months were included. PEPSiT was successful in 290 patients (90.9%) with weighted mean time to healing of 4.1 weeks. Recurrence was reported in 29 patients (9.1%) with weighted mean time to recurrence of 4.6 months. Outcomes were not significantly altered by the use of fistuloscope versus pediatric cystoscope (p = 1.0), or with perioperative laser epilation (p = 0.06), or postoperative regular shaving, depilatory creams, light pulse, or laser (p = 0.31). The weighted mean operative time was 38 minutes and hospital stay was 16 hours. Summary of available evidence confirms that PEPSiT is safe and effective. Added to its noninvasiveness, PEPSiT's pooled outcomes appear superior to those of numerous conventional techniques. Comparison with conventional techniques, particularly off-midline flap and semi-closure procedures, is, however, lacking. The superiority of PEPSiT needs to be confirmed in future comparative studies, including cost-benefit analysis.

Ball magnet ingestion in children: a stronger and more dangerous attraction?

INTRODUCTION: The ingestion of small, strong, rare-earth magnets, also termed 'ball magnets', can rapidly result in life-threatening bowel injuries. The objective of this study was to report the incidence and management of 'ball magnet' ingestion in children across the UK and to discuss the potential implications for policy-makers and public awareness campaigns. METHODS: In this multi-centre survey of UK major trauma centres (MTCs), paediatric patients admitted to hospital following 'ball magnet' ingestion from 1 January 2020 to 31 December 2020 were included. RESULTS: Responses were received from 11 MTCs (52%) reporting a total of 53 children admitted with 'ball magnet' ingestion over the 1-year study period. Most patients (n=51) presented following unintentional ingestion. 36 (68%) patients presented asymptomatically following witnessed or reported ingestion. In symptomatic patients, abdominal pain and vomiting were the the most common symptoms. The median number of 'ball magnets' ingested was 5.0 (IQR 3.0-7.8), range 1 to 63. 27 (51%) patients underwent operative intervention; laparotomy being the the most common (n=24, 89%). There were no deaths reported during the study period. CONCLUSION: This multi-centre survey from the UK demonstrates the serious impact of 'ball magnet' ingestion in children. Clinicians, regulators and caregivers must work symbiotically in order to prevent, recognise and reduce life-threatening bowel injuries.

Surgical Management of Esophageal Achalasia in Pediatrics: A Systematic Review.

INTRODUCTION: There are no evidence-based guidelines on the surgical management of esophageal achalasia (OA) in children. This can be a challenging condition with significant physical and psychological morbidity. Our aim was to identify the most common management modalities and their outcomes. MATERIALS AND METHODS: A systematic review was performed through a literature search of health care databases in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, aiming at identifying pediatric series discussing the diagnosis and management of OA. Duplicates, case series with < 9 patients, and follow-up of < 1 year were excluded. The included papers were analyzed for diagnostic methods, primary treatment method, complications, follow-up duration, outcome measures recorded, and outcome. RESULTS: Data from 33 papers for 742 children treated for OA was analyzed. Eleven mentioned multiple management modalities. In summary, 25 described Heller's esophagomyotomy (HM), 13 esophageal dilatation (EOD), and 6 peroral esophageal myotomy (POEM). Mean follow-up was 43.7 months (12-180). Outcome measures were heterogeneous. However, analysis of reported success showed a mean success of 78% for HM (p = 1.79 × 10-7), 44.9% for EOD (p = 0.24), and 99.3% for POEM (p = 0.001). Reported complications were 12.8% for HM, 5% for EOD, and 24.4% for POEM. Further interventions were required for 10.9% of HM, 62.3% of EOD, and 0.01% of POEM patient groups. CONCLUSION: Methods of diagnosis and measures of successful outcomes were heterogeneous, limiting the strength of evidence. HM showed superior short-term success rates to EOD. POEM is a promising modality but requires investment in equipment and training. Information about sustainability of response and long-term outcomes is lacking.

Current State of Neuromodulation for Constipation and Fecal Incontinence in Children: A Systematic Review.

BACKGROUND: Neuromodulation is the application of electrical stimulation on nerve fibers to modulate the neuronal activity. Its use for chronic constipation and fecal incontinence has increased in popularity over the past few years. Invasive and noninvasive techniques are currently available. We reviewed the current literature on the application of the neuromodulation techniques in the management of chronic constipation and fecal incontinence in children. MATERIALS AND METHODS: A search of Healthcare Database Advanced Search, Embase, Medline, and Cochrane database was performed in accordance with PRISMA guideline. Terms used in the search included neuromodulation, nerve stimulation, fecal/fecal incontinence, incontinence, constipation, children, and pediatric/pediatric. RESULTS: Two-hundred forty-one papers were screened. Fourteen papers were included for the systematic review: seven were selected for the ISNM (implantable sacral nerve modulation) technique, one for the transcutaneous tibial nerve stimulation), one for the transcutaneous sacral nerve modulation), and five for the transcutaneous interferential sacral nerve stimulation. Results showed an overall improvement in constipation symptoms in 79 to 85.7% of patients, resolution of symptoms in 40%, reduced use of ACE stoma/transanal irrigation system in 12.5 to 38.4%, and improvement in incontinence symptoms in 75%. High complication rate was reported (17-50%) in the ISNM group. No complications were reported in the non-invasive group. CONCLUSION: Neuromodulation is a promising tool in the management of constipation refractory to medical treatment and fecal incontinence in children. Noninvasive techniques provide good results with no complications. A longer term follow-up will provide more information regarding patient compliance and sustainability of benefits of these new techniques.

The Cambridge experience with buried bumpers.

AIM: Buried Bumper (BB) is a complication of percutaneous endoscopic gastrostomy (PEG) that leads to tube dysfunction and major morbidity. Although many techniques have been described to manage BB, none are universally adopted, and laparotomy remains the mainstay. We introduce a novel endoscopic technique in paediatric surgery that avoids laparotomy. METHODS: A retrospective review of medical records of patients who presented with BB to Cambridge University Hospital, UK, between January 2012 and June 2018 was done. Data collected included: demographics, tube size and type, interval between insertion and diagnosis of BB, hospital stay, technique used, and postoperative complications. The technique involved using an endoscopic snare passed from inside the stomach lumen through the PEG lumen to the outside, guided if required by a stiff nylon thread if no part of the PEG was visible, grasping the PEG tube externally after cutting it short, followed by a retrograde pull to remove the buried tube via the mouth. MAIN RESULTS: Fifteen BBs were found in ten patients. Median patient age was 5.25 years (1.2-16.6). Median time between gastrostomy insertion and diagnosis of BB was 9 months (1-32). Twelve BBs were removed endoscopically with no postoperative complications. Patients had a replacement inserted through the original track and were discharged within 24 h. Two underwent laparotomies performed by surgeons unfamiliar with endoscopic technique, and one was converted to laparotomy owing to inability to transverse an encrusted and closed PEG tube lumen. CONCLUSION: Endoscopic retrograde BB removal is a safe, easy, and quick technique with minimal complications. We strongly advocate widespread adoption of the technique before considering a laparotomy. LEVEL OF EVIDENCE: Treatment study: Level IV.

Feeding tubes in children.

PURPOSE OF REVIEW: A practical guide to different feeding tubes available for nutritional support in children, focused on indications, placement methods and complications. RECENT FINDINGS: Enteral nutritional support refers to the delivery of nutrition into the gastrointestinal tract distal to the oesophagus. Different feeding tubes are available for exclusive or supplemental nutritional support in children who are unable to independently sustain their own growth, nutritional and hydration status. Gastric feeding is the first choice; however, jejunal feeding provides a good alternative route in the presence of contraindications or intolerance. Feeding tubes can be short or long term: nasogastric and nasojejunal tubes provide short-term nutrition support, gastrostomy and jejunostomy tubes, long-term enteral feeding. The latter are established surgically through the formation of a stoma, an artificial connection between gastric or jejunal lumen and the abdominal wall, performed either endoscopically (percutaneous endoscopic gastrostomy, percutaneous endoscopic gastrojejunostomy) or surgically (gastrostomy, direct jejunostomy). Awareness of different available options, technical considerations and potential risks will inform the decision-making process for an individual patient to ensure the correct balance between adequate enteral nutritional and unnecessary morbidity. SUMMARY: Successful administration of nutrition support requires knowledge of the correct indication, route and specific functional details of the appropriate feeding tube.

Esophageal Atresia: Improved Outcome in High-Risk Groups Revisited.

Objectives Improved survival in infants with esophageal atresia (EA) with a birth weight < 1,500 g or a major cardiac anomaly has been reported when compared with the original Spitz classification proposed in 1994. Aim We reviewed outcome data for infants born over the last decade in our institution to update previously reported survival statistics. Materials and Methods The records of all neonates (n = 200) with a diagnosis of EA managed in a single institution between 2001 and 2011 were reviewed and compared with data from the original Spitz study and the subsequent reported cohort from the same institution. Data were obtained on birth weight, presence of a major cardiac anomaly, and survival. Differences in survival were compared using the Yates-corrected chi-square test. Local ethical study approval was obtained. Results Infants born over the last decade had a comparable overall survival rate of 93% (186/200) versus 92.6% (174/188) in the previously reported cohort (1993-2004). We demonstrate an improved survival as compared to the Spitz cohort (87.6%, 326 /372, p = 0.06) and a statistically significant improvement in survival in Group II (p = 0.01). Within this group, 12/51 neonates had a birth weight < 1,500 g and 39/51 had major cardiac anomalies. Of interest, of the nine deaths in Group II, eight were in the subgroup with major cardiac anomalies. Conclusion The survival of neonates in Group II has significantly improved. Mortalities within this group were predominantly in the subgroup with major cardiac anomalies suggesting birth weight is of less significance than in previous years reflecting recent advances in neonatal care. We propose an updated prognostic classification that makes a distinction between cardiac and low-birth-weight infants.

Single centre experience: long term outcomes in spina bifida patients.

OBJECTIVE: To determine our single centre experience of long term renal function and mortality rates of our cohort of spina bifida patients born since 1970. MATERIALS AND METHODS: We collected a prospective database and included all patients born with spina bifida between 1970 and 2011 managed by our centre. Data we collected included the glomerular filtration rates, results of renal tract imaging, management strategies and mortalities. RESULTS: Of 160 patients identified, 120 were included for analysis with a mean age of 20 years. In our cohort 48% (58/120) had normal renal function and only 1.6% (2/120) had severe renal impairment or end stage renal failure. There was a mortality rate of 4.4% and there were no deaths from renal failure. CONCLUSION: Spina bifida patients have been reported to have high mortality rates and high morbidity secondary to renal failure. Historical data does not appear to reflect current advancements and we would therefore be more optimistic when counselling families about long term survival into adulthood.

Just another case of diarrhea and vomiting?

Chronic intussusception is a treatable cause of failure to thrive. It is an uncommon condition often diagnosed late. The presenting features differ from acute intussusception. Chronic intussusception presents with a varying combination of abdominal pain, vomiting, weight loss/failure to thrive, diarrhea, and blood per rectum. An abdominal mass may or may not be palpable. The classic triad of abdominal pain, vomiting, and blood per rectum is uncommon. The purpose of this report is to present a small series of 3 cases and review 19 previously reported cases of chronic intussusception. Considering the diagnosis of chronic intussusception in children who present with failure to thrive and recurrent nonspecific abdominal symptoms is emphasized.