The International Pediatric Endosurgery Group Evidence-Based Guideline on Minimal Access Approaches to the Operative Management of Inguinal Hernia in Children.

Introduction: Minimally invasive surgery (MIS) for inguinal hernia repair (IHR) in children has been reported for more than two decades. The International Pediatric Endosurgery Group (IPEG) Evidence-Based Review Committee chose MIS IHR as the inaugural topic for review and presentation at the 2016 IPEG annual meeting. Materials and Methods: English language articles published between January 1, 2009, and December 31, 2015, were reviewed and included in this evidence-based review after searching PubMed, Cochrane Reviews, ClinicalTrials.gov, Google Scholar, and EMBASE. Results: Level 1a and 1b evidence supports the recommendations that operative time for bilateral IHRs should be considered shorter and postoperative complications rates should be considered lower in MIS repair over open. Recurrence rates are similar between the two methods (level 1a and 1b evidence). No level 1 evidence exists to support one MIS technique over another or that operating on a detected contralateral patent processus vaginalis during laparoscopy makes any difference in long-term outcome to the patient. Conclusions: The advantages of lower postoperative complications and shorter operative times have been found in studies of surgeons experienced in MIS repair and differences were small. The evidence in this review supports that MIS repair is a safe, effective method of IHR with proper training and mentorship.

Decision-Making Criteria for Observational Management of Congenital Pulmonary Airway Malformations (CPAMs).

PURPOSE: The purpose of this study was to determine practice patterns of Canadian surgeons managing congenital pulmonary airway malformations (CPAMs) and factors influencing practice. METHODS: Pediatric surgeons in Canada were surveyed regarding their experience, evaluation, and management CPAMs, and what factors they feel qualify patients for observation vs resection. Data were summarized, and Fisher's-Exact and Kruskal-Wallis Tests applied where appropriate. RESULTS: Sixty eight percent (n=46) of surgeons responded. However, three surveys were incomplete and excluded. The median age of initial assessment by a pediatric surgeon was one month. 98% (42/43) use CXR for initial imaging, and 83% (36/43) recommend CT scan for further evaluation. Observation is offered always, almost always, or sometimes by 2%, 35% and 37%, respectively. Only 16% almost never, and 9% never offer it. Years in practice was not associated with this decision (p=0.41). Of surgeons who offer observation, 78% (28/37) use morphology to guide their decision, and 63% (21/37) use lesion size (<1cm to <5cms). 68%(23/37) consider the number of lesions, and 61%(14/23) of those only offer observation to solitary lesions. CONCLUSION: Most pediatric surgeons in Canada offer observational management to patients with asymptomatic CPAMs. While practice variations exist, detailed imaging with a CT scan early in life to determine the morphology, size, and number of lesions guides practice. LEVEL OF EVIDENCE: V.

Evidence supporting laparoscopic hernia repair in children.

PURPOSE OF REVIEW: Pediatric inguinal hernias are a commonly performed surgical procedure. Currently, they can be approached via open or laparoscopic surgery. We summarize the current evidence for laparoscopic inguinal hernia repairs in children. RECENT FINDINGS: Laparoscopic and open inguinal hernia repair in children are associated with similar operative times for unilateral hernia, as well as similar cosmesis, complication rates and recurrence rates. Bilateral hernia repair has been shown to be faster through a laparoscopic approach. The laparoscopic approach is associated with decreased pain scores and earlier recovery, although only in the initial postoperative period. Laparoscopy allows for easy evaluation of the patency of contralateral processus vaginalis, although the clinical significance of and need for repair of an identified defect is unclear. SUMMARY: Laparoscopic surgery for pediatric inguinal hernias offers some advantages over open repair with most outcomes being equal. It should be considered a safe alternative to open repair to children and their caregivers.

Determinants of wait time for infant inguinal hernia repair in a Canadian children's hospital.

BACKGROUND: Longer wait time for infant inguinal hernia (IH) repair is associated with higher complication rates. We wished to determine if socioeconomic and demographic factors influence wait times for IH repair. METHODS: Children <2 years old with IH at a Canadian children's hospital were retrospectively reviewed. Days from diagnosis to surgical consultation (W1) and from consultation to repair (W2) were collected along with demographic, medical, and socioeconomic data. Linear regression analysis was performed. RESULTS: A total of 131 patients were appropriate for analysis (82.4% male). Median distance to hospital was 27.5 km (IQR=10.5-50.4) and median income was $34,477 (IQR=30,127-41,986). Median W1, W2, and Wtotal (W1+W2) were 24 (IQR=8-48), 43 (IQR=21-69) and 79 (IQR=38-112) days, respectively. Wait times were shorter in infants who were male (p=0.044), symptomatic (p<0.001), diagnosed in the ED (p<0.001), or had an incarcerated hernia (p=0.006). They were longer for premature infants (p=0.009) and those with significant comorbidities (p=0.018). Neither income (p=0.328) nor distance from hospital (p=0.292) was associated with longer wait times. CONCLUSION: Wait times for IH repair were appropriately influenced by medical risk factors. Income and distance to hospital did not appear to influence wait times. A population-based study is needed to determine if these findings reflect a general trend within the Canadian health care system.

Adolescent bariatric surgery: the Canadian perspective.

Canada faces a similar epidemic of obesity in their adolescent population as other Western countries. However, the development of programs to treat obesity and manage its sequelae has evolved in a unique way. This is in part due to differences in health care funding, population distribution, public demand, and availability of expertise and resources. In this article, we will describe the evolution of adolescent bariatric care in Canada and describe the current programs and future directions. The focus will be on the province of Ontario, the site of the first adolescent bariatric program in the country.

What is the significance of contrast "blush" in pediatric blunt splenic trauma?

PURPOSE: Contrast extravasation (CE) associated with blunt splenic injuries (BSIs) in adults is commonly treated with embolization or splenectomy. Whether this is necessary in children is unclear. We sought to determine if CE on initial computed tomography (CT) is associated with negative outcomes in children with BSI. METHODS: Blunt splenic injuries presented to our pediatric trauma center between January 21, 1999, and December 31, 2006, were reviewed (minimum follow-up = 2 years). Those with initial CTs available were reviewed by a pediatric radiologist blinded to outcomes. Descriptive analysis and multivariable logistic regression were performed using Stata S/E 10.0 (Stata Corporation, College Station, Tex). RESULTS: One hundred eighty-two BSIs were treated at our center. One hundred twenty-three had available CTs (mean age, 10.7 years; male, 70.7%; mean Injury Severity Score, 17; median injury grade, 3; transfusion rate, 13.8%; overall mortality, 2.44%). Those with associated injuries comprised 47.1%. No splenectomies or splenorrhaphies were performed. One delayed splenic bleed occurred. Eight patients (6.5%) had CE on initial CT. Multivariable logistic regression controlling for multiple injuries found no association between CE and the need for transfusion, mortality, delayed splenic bleeding, length of hospitalization, or splenectomy. Contrast extravasation was positively associated with low initial and lowest hemoglobin levels (<90 g/L) (odds ratio [OR], 6.45; 95% confidence interval [CI], 1.00-39.47; P = .044 and OR, 5.63; 95% CI, 1.20-26.49; P = .029), respectively. CONCLUSION: Contrast extravasation occurred in 6.5% of our pediatric patients with BSIs. The presence of contrast "blush" on abdominal CT was not associated with negative outcomes after a minimum of 2 years of follow-up. Pediatric patients with CE can be treated without surgery and can be managed using the standard American Pediatric Surgical Association guidelines.

What's the incidence of delayed splenic bleeding in children after blunt trauma? An institutional experience and review of the literature.

BACKGROUND: The existence and incidence of delayed splenic bleeding (DSB) in children are controversial but the implications are significant. We sought to determine the incidence of DSB in children and to look for similarities between reported cases. METHODS: A retrospective cohort study of all children admitted from 1992 to 2006 to our level 1 pediatric trauma center with blunt splenic injuries to calculate the incidence of DSB. In addition, a systematic review of the literature was performed, looking for similarities between reported cases of DSB in children since 1980. RESULTS: Three hundred three children were admitted with blunt splenic injuries (mean age, 10 years +/- 4.5 years; boys 212 [70%]). Two hundred ninety-three (96%) were successfully managed nonoperatively. All-cause mortality was 20 of 303 (6.6%). We identified 1 of 303 (0.33%) children with DSB. The patient was a boy, aged 15 years. He presented 23 days after initial injury with DSB causing death. He had an uncomplicated admission after his initial grade IV injury. There have been 14 cases of DSB reported in the literature since 1980. Twelve (88%) were boys, with a mean age of 14 years +/- 4 years (with 11 of 14 (79%) being adolescent). The mean time to DSB was 10 days +/- 7 days. There were no similarities in mechanism, imaging characteristics, or presence of pseudoaneurysm between cases. CONCLUSION: DSB is exceedingly rare. Our institutional incidence is 1 of 303 (0.33%). The number and quality of reported cases is insufficient to draw conclusions on predisposing factors for DSB, however, most cases occur in adolescents.

Management of blunt splenic injury in children: evolution of the nonoperative approach.

BACKGROUND: Nonoperative management of blunt splenic injury (BSI) was first proposed at our institution in 1948. Since that time, treatment of patients with BSI has evolved from routine splenectomy to an aggressive spleen-preserving philosophy. This report summarizes our institutional experience for the last 50 years. METHODS: All children (0-18 years) admitted to our pediatric trauma center with BSI during 4 eras (1956-1965, 1972-1977, 1981-1986, and 1992-2006) were retrospectively reviewed for demographics, injury patterns, management, and complications. RESULTS: During the 4 eras captured for the last 5 decades, 486 children experienced BSI. The mean age was 10 years with 347 males (71%). Nonoperative management rate increased from 42% to 97% with improvement in splenic salvage rate (42%-99%). Mean length of stay decreased from 17 to 5 days. In patients with isolated splenic injuries (50%), nonoperative management rate increased (36%-100%) and fewer received transfusions (60%-1%). Overall mortality rate improved (19%-6.6%, 8%-0.7% in isolated injuries). CONCLUSION: The management of BSI in children has changed dramatically for the last 50 years. This study clearly demonstrates the safety of nonoperative management and documents progressively lower rates of splenectomy and transfusion, shorter hospitalization, and an extremely low risk of mortality.

Appendicitis in the obese child.

BACKGROUND/PURPOSE: Little data exist that examine the surgical challenges of obese children. We hypothesize that obesity affects the presentation, diagnosis, surgery, and postoperative course in children with appendicitis. METHODS: Cases of all children treated for appendicitis over 6 years were reviewed retrospectively. Demographics, presentation, pathology, and hospital course were examined. RESULTS: A total of 282 cases were reviewed; 25 were moderately obese and 31 very obese (VO), which were defined, respectively, as greater than 1.5 and greater than 2 standard deviations above the standardized mean weight for age. Groups were similar in age, sex, presentation, use of ultrasound, and surgical management. Compared with the nonobese group, median operative time was higher in the VO group (63.5 vs 55.5 minutes; P = .028), with the association between obesity and longer operative time maintained when stratifying for perforated/nonperforated and open/laparoscopic cases. Almost twice as many VO children were in the hospital for more than 5 days (nonobese 23.6%, VO 40.0% [odds ratio, 2.2; 95% confidence interval, 0.99-4.8]). This association between obesity and longer length of stay was seen when stratifying for both perforated and nonperforated cases. In the perforated group, higher rates of postoperative wound infections and significantly longer times to full diet and ambulation likely contributed to these longer stays. CONCLUSIONS: Childhood obesity is associated with longer surgery and hospital stays and increased risk of postoperative infections. Obesity should be considered an important variable when looking at surgical outcomes in the pediatric population.