Day-case laparoscopic cholecystectomy in childhood: outcomes from a clinical care pathway.

AIM: The aim of this study was to report clinical outcomes following the use of a pediatric day-case laparoscopic cholecystectomy (DCLC) clinical care pathway. The pathway was modified in September 2009 and we compare the clinical outcomes before and after this modification. METHODS: A care pathway for DCLC was introduced in 2008 with emphasis on the day of admission, timing of surgery, choice of anesthetic agents, analgesia, postoperative feeding, mobilization, and pain scoring. Demographic and clinical data were recorded prospectively from January 2008 to January 2012. In September 2009, two modifications were made to the pathway. Induction of anesthesia was changed to total intravenous anesthesia, using propofol (target 4 to 6 µg/mL) and remifentanil (target 3 to 5 ng/mL) and the use of the gaseous anesthetic sevoflurane was eliminated with the aim of reducing the risk of postoperative nausea and vomiting (PONV). The postoperative feeding regime was changed from unrestricted to light diet for 72 hours. The rest of the pathway was unchanged. Data before (group 1) and following the modifications (group 2) were compared. RESULTS: We admitted 25 children with symptomatic cholelithiasis for DCLC under the care of one surgeon: 12 in group 1 and 13 in group 2. There were no significant differences in age between group 1 (median 13 [range 6 to 15] years) and group 2 (median 15 [9 to 16] years) (p = 0.07). There were no intra- or postoperative complications. The day-case rate increased from 6/12 (50%) in group 1 to 12/13 (92%) in group 2 (p = 0.03). The incidence of PONV reduced from 7/12 (58%) in group 1 to 0/13 in group 2 (p = 0.002). PONV in group 1 resulted in overnight stay (n = 6) and readmission (n = 1). One patient in group 2 had an overnight stay due to poor mobilization. CONCLUSIONS: Adoption of a DCLC pathway is feasible and safe for children. Emphasis on adequate pain management and avoidance of PONV results in a high rate of day-case surgery equivalent to that achieved in adult practice.

A rare pitfall in the diagnosis of oesophageal atresia.

The diagnosis of oesophageal atresia (OA) is usually made soon after birth. Two diagnostic criteria are failure to pass a nasogastric (NG) tube and a chest radiograph demonstrating a curled NG tube in the upper oesophageal pouch. A 6-day-old neonate was referred to our institution with persistence of symptoms following exclusion of the diagnosis of OA on the basis of an NG tube radiologically confirmed to reach the stomach. Persistent oxygen desaturations and copious salivation led to further investigations, and a delayed diagnosis of oesophageal atresia and tracheo-oesophageal fistula was made. Radiological demonstration of an NG tube reaching the stomach does not exclude the diagnosis of oesophageal atresia and can be falsely reassuring and lead to diagnostic delay.

Gastrostomy insertion in the 21st century: PEG or laparoscopic? Report from a large single-centre series.

PURPOSE: To determine whether laparoscopic-assisted gastrostomy (LAG) has superseded percutaneous endoscopic gastrostomy (PEG) based on the clinical outcomes. METHODS: A retrospective study was undertaken for the period January 06-December 09. Demographic and clinical outcomes were recorded and the two groups were compared. RESULTS: 164 patients were studied (PEG, n = 107; LAG, n = 57). 93.5 % of PEG patients required two general anaesthetics compared with 8 % of LAG patients. Median time to using the gastrostomy was 24 (range 0-168) h in PEG and 0 (0-96) h in LAG patients (p < 0.001). Major complications occurred in 15/107 (14 %) of PEG and 2/57 (3.5 %) of LAG patients (p = 0.05). Re-operation rate following complications was 18/107 (16.8 %) for PEG and 3/57 (5.2 %) for LAG (p = 0.05). Minor complications arose in 41/107 (38 %) of PEG and 32/57 (56 %) of LAG (p = 0.05). Post-operative hospital stay was 2 (1-40) days for PEG and 2 (0-20) days for LAG (p = 0.01). The day-case rate was 0/107 for PEG and 5/57 (9 %) for LAG. There was no gastrostomy-related mortality in the series. CONCLUSION: LAG requires fewer anaesthetics, is associated with shorter time to feeding, shortened hospital stay and has a reduced risk of major complications. LAG is a very good alternative to the PEG in children.

Management of gastroesophageal reflux associated with malrotation in children.

AIM: Children being investigated for gastroesophageal reflux (GOR) have a high incidence of malrotation. Current literature suggests these patients should be managed with a combined antireflux and Ladd's procedure. We review our experience, the largest series to date, of performing an elective Ladd's procedure as the first-line intervention. METHOD: Retrospective case note review of 20 children with significant symptoms of GOR and an incidental finding of malrotation. Children presenting immediately with bilious vomiting were excluded. All patients underwent a Ladd's procedure as their sole primary operative intervention. RESULTS: Median age at operation was 7 months (21 days-12 years). Fifteen patients (75%) had evidence of reflux on barium contrast study. All children were followed up for at least 6 months. Eighteen (90%) had resolution or significant improvement of their symptoms postsurgery. Only 3 have not managed to tolerate a full oral diet, all unrelated to GOR. None of our series required an antireflux procedure. CONCLUSION: In children with debilitating vomiting necessitating surgical management, a contrast study is imperative in the work up. The high incidence of GOR and the significant improvement after correction of malrotation show the relationship between delayed gastric emptying and GOR. We suggest that when an abnormally placed duodenojejunal flexure is found, a Ladd's procedure alone is sufficient and may obviate the need for a more invasive antireflux procedure.

Laparoscopic retrieval of disconnected shunt catheters from the peritoneal cavity as a day-case procedure in children--early feasibility report.

PURPOSE: The aim of this study was to report our experience with laparoscopic retrieval of disconnected shunt catheters in children. METHODS: Demographic data, indications for shunt insertion, time to disconnection, symptomatology, time to retrieval, operative details, length of stay and complications were recorded retrospectively. Laparoscopy was performed using two 5-mm ports and 10-12-mmHg CO(2) pneumoperitoneum. RESULTS: Seven children (five boys, two girls) had laparoscopic retrieval of disconnected ventriculoperitoneal (VP; n = 6) and lumboperitoneal (n = 1) shunt catheters between 2006 and 2008. Median age was 8 (5-15) years. The indications for shunt insertion were hydrocephalus (n = 4), traumatic subdural haematoma (n = 1), pinealoblastoma (n = 1) and idiopathic intracranial hypertension (n = 1). Median interval from insertion to disconnection was 3 (range 1-10) years. Presenting symptoms were headache (n = 3) and neck swelling (n = 1). Three children were asymptomatic. Median referral-to-procedure time was 69 (range 2-224) days. One child underwent emergency removal of disconnected shunt with laparoscopic-assisted VP shunt insertion under the same anaesthetic. One child had a laparotomy as the catheter tip had penetrated the sigmoid mesocolon close to the bowel and could not be safely removed laparoscopically. Of the remaining five children, four had the procedure performed as day cases. There was no intra- or post-operative morbidity or subsequent shunt infections. CONCLUSIONS: Peritoneally migrated shunt catheters have a risk of viscus injury, particularly bowel perforation. In our experience, laparoscopic retrieval of migrated shunt catheters was safe both as an emergency procedure and electively, when it was performed as a day-case basis in selected patients with excellent outcome.

Efficacy of video-assisted thoracoscopic surgery in managing childhood empyema: a large single-centre study.

BACKGROUND/PURPOSE: A randomised controlled trial evaluating the role of video-assisted thoracoscopic surgery (VATS) in childhood empyema reported a failure rate of 16.6%. Our aim is to determine the outcome of VATS in a large series of children managed by 3 paediatric surgeons experienced in endoscopic surgery. METHOD: A retrospective study of all children with empyema admitted under the care of the 3 surgeons between February 2004 and February 2008 was undertaken. Recorded details included demographic data, mode of presentation, preoperative investigations, operative details, antibiotic usage, microbiological data, postoperative course, follow-up data and complications. RESULTS: 114 children (69 boys, 45 girls) had VATS for empyema. Their median age was 5 (0.2-15) years. The pleural cavity was drained for a median of 4 (2-13) days. Median postoperative hospital stay was 7 (4-36) days. Median follow-up was 8 (1-24) months. There were 8 (7%) treatment failures: 5 conversions to thoracotomy and 3 recurrent empyemas. There were 7 complications (6%): air leak (n = 6) and lung injury (n = 1). 104 (91%) children had full resolution of symptoms. There were no deaths. CONCLUSION: Video-assisted thoracoscopic surgery has a better outcome in childhood empyema than reported in a recent randomised trial and it has an important role in the management of this condition.

Small bowel evisceration through the rectum in childhood.

Small bowel evisceration through the rectum is extremely rare in childhood and has previously been reported in association with swimming pool suction injuries. We report a case of ileal evisceration resulting from a self-inflicted injury in a teenaged boy. Such a mechanism of injury leading to evisceration of the small bowel is previously unreported in children or adults.

Antenatal rectal perforation presenting in the neonate.

Perforation of the rectum in the antenatal period is extremely rare. Three cases have been reported worldwide. Its aetiology and pathophysiology are poorly understood. Rapid recognition by its classical signs is mandatory as delay in diagnosis leads to serious morbidity. We report a fourth case, and make recommendations regarding management.