Rapid utilisation of telehealth services for specialist paediatric general surgery outpatient clinics in response to COVID-19.

Background: The COVID-19 pandemic is highly infectious and prompted, amongst other changes, strict social distancing requirements for medical practitioners in Western Australia. Despite significant previous research into telehealth, uptake had been limited beyond servicing rural patients, in spite of numerous purported benefits. Results: Rapid adoption of telehealth for a majority of outpatient appointments was instituted in the sole tertiary paediatric general surgery with high overall success rates - a satisfactory outcome being achieved without requiring an in-person appointment (97.1% for telephone consults, 93.8% for videoconferencing) during the initial COVID-19 crisis from April to June 2020. Success of appointments was lowest for new referrals for undescended testicles at 81.3%. Operations booked through telehealth consultations were only altered in 1 case (5%), and this was not significantly different to in-person bookings (p > 0.05). No cases of COVID-19 were incurred by the surgical team or patients during the study period. Conclusions: We found that with existing technology and minimal training, paediatric surgical consultations were able to be performed via telehealth with high success, high accuracy, and without significant adverse outcomes.

Lung abscess: 14 years of experience in a tertiary paediatric hospital.

BACKGROUND: Lung abscess is a rare condition in paediatrics with a paucity of literature. Intravenous antibiotics is the main therapy; however interventional radiological approaches have led to the use of percutaneous drainage. Surgery is reserved for the management of complications. The aim of this study was to describe lung abscess in a cohort of paediatric patients' and determine associations between factors at presentation and outcomes. METHODS: A 14-year retrospective cohort study was conducted including all children who presented to a tertiary paediatric hospital in Western Australia with lung abscess. Clinical characteristics, laboratory and radiologic findings, management options and clinical outcomes were examined. RESULTS: Sixty-eight patients (median age 3.6 (0.08-17.6) years; 44.1% female) were identified to have a lung abscess, with 81% being primary lung abscess. Staphylococcus aureus (including MRSA) and Streptococcus pneumoniae were the most common organisms identified, with S. aureus being most common in Aboriginal patients (80%). A total of 25 antibiotics were prescribed on initiation of treatment in over 20 combinations. 44.9% of patients had complications and hospitalization was prolonged. Patients with S. aureus had longer hospitalization (20.5 days (3-67) than those without (median 13 days (3-52), p = 0.04). There were no associations between factors at presentation and subsequent outcomes. Factors at presentation were not associated with outcomes. CONCLUSION: There is unwarranted variation in management of paediatric lung abscess and high complication rates. There is a need for collaboration and clinical practice guidelines to standardize care for lung abscess in children.

Trans-anastomotic tube feeding in the management of congenital duodenal obstruction: a systematic review and meta-analysis.

BACKGROUND: Feed intolerance is a common problem in neonates with congenital duodenal obstruction (CDO). Some surgeons insert trans-anastomotic tubes (TAT) to facilitate feed tolerance. We conducted a systematic review to evaluate the efficacy and safety of TATs in CDO. METHODS: Medline, EmBase, CINAHL, and Cochrane Library were searched till July 2020. Risk of bias was assessed using ROBINS-I tool. Meta-analysis was conducted using Random Effects Model. RESULTS: No randomized controlled trials addressing the question were identified. In the 6 included observational studies, 96 infants underwent intraoperative TAT placement and 117 did not. Four studies reported benefits of TAT such as early attainment of full feeds and decreased need for parenteral nutrition. Two studies reported better outcomes in the no-TAT group. Accidental removal of TAT without clinical harm was reported in three studies [5/37 (14%), 4/17 (23%), and 2/4 (50%)]. Overall meta-analysis found no differences between the groups on any outcome. However, sensitivity analysis after excluding two studies with high risk of bias found that TAT tubes are associated with shorter duration of PN and shorter time to full enteral feeds. GRADE of evidence was very low for all outcomes. CONCLUSIONS: Evidence is limited regarding the efficacy and safety of intraoperative TAT placement in neonates with CDO. Well-designed RCTs are needed to address the issue definitively.

Predictors of poor outcomes in children with tracheoesophageal fistula/oesophageal atresia: an Australian experience.

Objective: The aim of this study is to characterize long-term morbidities of oesophageal atresia (OA) with or without tracheoesophageal fistula (TOF). Methods: Infants born with OA/TOF from 2000 to 2016 in Western Australia were included for analysis. Infants were categorized into high-risk and low-risk groups based on the presence of one or more perioperative risk factors [low birth weight, vertebraldefects, anal atresia, cardiac defects, TOF, renalanomalies, limb abnormalities (VACTERL), anastomotic leak, long gap OA, and failure to establish oral feeds within the first month] identified by a previous Canadian study. Frequency of morbidities in infants with perioperative risk factors was compared. Results: Of 102 patients, 88 (86%) had OA with distal TOF (type C). The most common morbidities in our cohort were anastomotic oesophageal strictures (AS) (n=53, 52%), tracheomalacia (n=48, 47%), gastroesophageal reflux disease (GORD) (n=42, 41%) and recurrent respiratory tract infections (n=40, 39%). Presence of GORD (30/59 vs 12/43, p=0.04) and median frequency of AS dilatations (8 vs 3, n=59, p=0.03) were greater in the high-risk group. This study further confirmed that inability to be fed orally within the first month was associated with high morbidities. Conclusions: Gastrointestinal and respiratory morbidities remain high in OA/TOF regardless of perioperative risk factors. Inability to be fed orally within the first month is a predictor of poor outcomes with high frequency of gastrointestinal and respiratory comorbidities.

Laparoscopic repair of intra-abdominal bladder perforation in preschool children.

Intraperitoneal bladder rupture is uncommon in very young children, but its incidence may increase with increasing use of seat and lap belts. To the best of our knowledge, there are no prior reports of laparoscopic repair of this injury in children. We describe two recent cases and discuss useful technical points that facilitate a successful laparoscopic repair. Both our patients were preschool age girls who sustained seat and lap belt injuries. Contrast computed tomography scan suggested a large amount of free peritoneal fluid and cystogram confirmed intraperitoneal bladder perforation (isolated injury). The injury was repaired using delayed absorbable sutures and intracorporeal suturing (continuous in 1, interrupted in 1) using a 3 port laparoscopic technique. Meticulous peritoneal lavage was carried out to minimise urinary peritonitis and the bladder as well as the peritoneal cavity were drained. Check cystograms (day 7) revealed no leaks. Young girls appear to be at risk of intraperitoneal bladder injuries following lap belt injuries. After exclusion of life-threatening injuries and concurrent abdominal injuries which need rapid control or preclude pneumoperitoneum, a laparoscopic repair can be safely performed.

Does continuous positive airway pressure for extubation in congenital tracheoesophageal fistula increase the risk of anastomotic leak? A retrospective cohort study.

AIM: Immediate post-operative care of tracheoesophageal fistula (TEF) and oesophageal atresia (EA) requires mechanical ventilation. Early extubation is preferred, but subsequent respiratory distress may warrant re-intubation. Continuous positive airway pressure (CPAP) is a well-established modality to prevent extubation failures in preterm infants. However, it is not favoured in TEF/EA, because of the theoretical risk of oesophageal anastomotic leak (AL). The aim of this study was to find out if post-extubation CPAP is associated with increased risk of AL. METHODS: Retrospective cohort study (2007-2014). RESULTS: Fifty-one infants underwent primary repair in the newborn period. Median age at surgery was 24 h (interquartile range: 12, 24). In the post-extubation period, 10 received CPAP, whereas 41 did not. The median post-operative day at the commencement of CPAP was 2.5 days (interquartile range: 1, 6 days). Zero out of 10 in the CPAP group and 4/41 in the 'no CPAP' group developed AL on routine post-operative contrast studies (P = 0.57). Zero out of 10 in the CPAP group and 1/41 in the 'no CPAP group' developed recurrence of TEF necessitating re-surgery (P = 1.00). The neonate with recurrent fistula also had coarctation of aorta and needed protracted hospitalisation of 6 months, mainly because of the recurrence of TEF. CONCLUSION: The use of CPAP in the immediate post-extubation period after corrective surgery for TEF/EA appears to be safe and may not be associated with increased risk of AL or recurrence of the fistula. Information from other centres, surveys and large databases is needed to define the benefits and risks of use of CPAP in these infants.

Opsoclonus-Myoclonus Syndrome, Neuroblastoma, and Insulin-Dependent Diabetes Mellitus in a Child: A Unique Patient.

AIM: We present a new and unique association of opsoclonus-myoclonus-ataxia syndrome with neuroblastoma and type 1 diabetes mellitus. PATIENT DESCRIPTION: This 17-month-old child presented with opsoclonus-myoclonus-ataxia syndrome. Investigations revealed a thoracic neuroblastoma. Eleven days later, she re-presented with diabetic ketoacidosis. The neuroblastoma was resected, and she was given immunotherapy. At 12 months' follow-up, her neurological signs and symptoms have significantly improved, but she continues to be insulin dependent. DISCUSSION: This child expands the clinical spectrum of autoimmune disorders associated with opsoclonus-myoclonus-ataxia syndrome.

Surgically managed perinatal testicular torsion: a single centre experience.

OBJECTIVE: The objective of this series is to describe the clinical features and immediate outcomes of surgically managed perinatal testicular torsion (PTT). METHODS: A retrospective chart review of the cases of PTT diagnosed in neonates less than 1 month of age was conducted. The cases were identified from the hospital database maintained prospectively over 24 years at the sole tertiary referral centre for the state of Western Australia. RESULTS: Twenty eight cases of PTT were identified, being 23 unilateral and 5 bilateral. All the five bilateral cases were asynchronous and three were identified incidentally on surgical exploration of unilateral torsion. The testis was clinically salvaged in two newborns at the time of follow-up. CONCLUSION: Asynchronous bilateral PTT could be missed on physical examination and identified on surgical exploration of unilateral PTT. Emergency exploration may result in salvage of the contralateral torted testis.

Carcinoid tumours of the appendix in children having appendicectomies at Princess Margaret Hospital since 1995.

AIM: The diagnosis of carcinoid tumour is a relatively rare one. Our surgical approach has changed over the last two decades from predominantly open to predominately laparoscopic with a tendency to leave the mesoappendix in situ. The aim of this audit was to identify how many cases we had at PMH and to see whether the shift in surgical approach allowed us to make prognostic decisions in keeping with current best practice and whether this made any difference in further surgery requirements or outcome for patients. METHODS: A retrospective review of all cases of carcinoid identified in our search of all appendicectomy histopathology results was conducted. Results were compared to those found in other studies. Duration of follow up and further investigations was reviewed, as was whether or not there was any recurrence. RESULTS: Our incidence of carcinoid tumours in patients undergoing appendicectomy since 1995 was 0.35%, similar to that in other centres. None of our patients had surgery beyond an appendicectomy and our active follow up varied from none to 6 months. There were no recurrences in this time. CONCLUSIONS: The literature review carried out suggests further meta-analysis is needed including data on long term follow up before definitive guidelines regarding extent of surgical treatment and follow up based on histopathology are created. The condition is rare and the studies small, resulting in no clear consensus on the best practice for tumours measuring between 1 and 1.5 cm in diameter. Our surgical approach to appendicectomies has changed; it is unclear whether this has resulted in a change in outcome.

Review of the radiation exposure during screening of surgically implanted central venous access devices.

PURPOSE: Ionizing radiation is used for the insertion of surgically implanted venous access devices (SIVADs) with children at the highest risk of cumulative radiation effects from these procedures. This study examines the radiation dose in a pediatric population during intraoperative radiological screening. METHODS: A retrospective study looked at all pediatric patients in a tertiary hospital between January 2008 and January 2014 who had a surgically implanted venous access device inserted using intraoperative fluoroscopy. Patient demographics, reason for SIVAD insertion, the type and method of insertion, fluoroscopy time and radiation dose area product were determined. RESULTS: A total of 505 patients had 682 SIVADs inserted, with 123 patients receiving multiple SIVAD over the six year period. There were two types of SIVAD inserted, 492 were totally implanted venous access devices (TIVAD) and 190 were tunneled central venous catheters (cuffed central line). Five hundred seven of the SIVAD inserted recorded the dose area product and fluoroscopy time. The median time for screening was 5seconds (range 1 to 275seconds) and the median dose area product was 0.00352mGym(2) (range 0.000001mGym(2) to 0.28mGym(2)). Of the 507 SIVAD that recorded the radiation data, 479 were open surgical cut-down insertion and 27 were percutaneous insertion. Percutaneously inserted surgically implanted venous access devices (mean 0.0060mGym(2)) had a longer dose area product than open insertion (mean 0.0034mGym(2); p=0.05). CONCLUSION: Screening of SIVAD involves low levels of radiation exposure and is comparable to a chest x-ray or a transatlantic flight. The excess lifetime cancer risk to patients is estimated to be very low and is considered to be outweighed by the benefits of insertion. Open surgical cut-down insertion has a significantly reduced radiation exposure compared to percutaneous techniques. Although radiation dose is higher with percutaneous procedures, the clinical effects are considered minimal, and the resultant radiation risk is estimated to be very low. Radiation dose should not determine technique of insertion of SIVAD.

Low risk, but not no risk, of umbilical hernia complications requiring acute surgery in childhood.

AIMS: Umbilical hernias are a common finding in the paediatric community, with a preponderance to affect Afro-Caribbean and premature children. The rate of incarceration varies greatly between populations. Therefore, it is valuable to obtain some Australian data on this topic. METHODS: We undertook a retrospective study of the records of all patients who underwent umbilical hernia repair over a 12-year period of between October 1999 and May 2012 at Princess Margaret Hospital. From this group, all patients that had an umbilical hernia repair for reason of acute complication were identified and analysed for age, ethnicity and co-morbidities. RESULTS: Between October 1999 and May 2012, 433 umbilical hernias were repaired at Princess Margaret Hospital, five of which were as the direct result of an acutely complicated umbilical hernia. The mean age of hernia repair was 5 years old, and the mean age of acute complication was 5 years old. Out of the patients with acutely complicated umbilical hernia, there were no Afro-Caribbean patients, and one was premature complicated by hyaline membrane disease and broncho-pulmonary dysplasia. CONCLUSIONS: Western Australia has an incidence of acutely complicated umbilical hernia requiring operative intervention of 1:3000 to 1:11,000. On an international scale, this is low, and studies with similar incidence do not advocate for immediate repair of all identified umbilical hernias. The authors believe repair should be guided by patient and guardian, but if there is an episode of incarceration, acute repair is advised.