Paediatric surgery for childhood cancer: Lasting experiences and needs of children and parents.

OBJECTIVE: Surgery for paediatric cancer presents many stresses on patients and families. The authors aimed to understand the long-term impact of childhood cancer surgery on survivors and parents. METHODS: The study recruited participants from 11 Australia/New Zealand hospitals for telephone interviews. The authors used descriptive statistics to analyse participants' quantitative distress ratings and conducted thematic analysis of shared surgical experiences and needs. RESULTS: Of 32 participants (n = 17 survivors, n = 15 parents), survivors' mean age at surgery was 6.9 (SD = 5.17) and parents' children were 2.1 years old (SD = 1.41) at time of surgery. Survivors had surgery on average 15.2 years ago (SD = 6.72) and parents' children 11.5 years ago (SD = 3.94). Parents and survivors rated surgery as highly distressing. Pre-operatively, survivors recalled experiencing fear and pain mainly associated with pre-operative procedures. Post-operatively, survivors reported immobility and some lasting behavioural disturbances. Parents described pre- and intra-operative anxiety and stress and some lasting post-operative psychological disturbances. Experiences appeared to improve with clear/consistent communication from hospital staff, proximity to hospital, and with support for parents and children post-operatively. CONCLUSIONS: Surgical treatment for childhood cancer can have a lasting impact for survivors and parents. Better information provision may improve families' surgical experience whilst reducing anxiety, distress and physical discomfort.

The Psychosocial Experiences and Needs of Children Undergoing Surgery and Their Parents: A Systematic Review.

INTRODUCTION: Surgery in children can be difficult for patients and parents. We aimed to summarize pediatric patients' and parents' psychosocial experiences and needs in surgery. METHOD: We used the Ovid search engine and screened 877 abstracts across three databases to extract data on pediatric patients' and parents' surgical experiences. RESULTS: Our search yielded 11 eligible studies representing 1,307 children undergoing surgery and their parents. Children's adverse experiences included psychological and behavioral changes before, during, and after surgery (e.g., anxiety, eating disturbances). Parents commonly experienced psychological distress. Children's needs related to medical and health care services, whereas parents had high information needs. DISCUSSION: Children's adverse experiences can negatively affect medical outcomes. Children's experiences are inextricably linked to their parents' and can become negatively affected by their parents' adverse experiences. Patients and parents with previous hospitalizations and surgeries had worse surgical experiences, highlighting further research in the context of chronic illness.

Can transcutaneous near infrared spectroscopy detect severe hepatic ischemia: a juvenile porcine model.

BACKGROUND: Vascular complications following pediatric liver transplantation occur in 8-10% of cases, and no continuous, non-invasive monitoring for this problem exists. Near infrared spectroscopy (NIRS) allows non-invasive, continuous, transcutaneous assessment of hemoglobin oxygenation (StO2 ) 1-4 cm below the skin surface. AIMS: We hypothesized that transcutaneous NIRS would be able to detect severe hepatic ischemia, and tested this in an animal model using 15-20 kg and 5-7 kg juvenile pigs. MATERIALS AND METHODS: Direct liver surface and transcutaneous hepatic tissue hemoglobin oxygen saturation (StO2 ) were measured during occlusions of the hepatic artery and portal vein. Changes in hepatic delivery of oxygen (HepDO2 ) were calculated for each ischemic challenge and compared to changes in direct liver surface (DirHepStO2 ) and transcutaneous liver StO2 measurements (CutHepStO2 ). RESULTS: In the 15-20 kg animals during complete occlusion, CutHepStO2 decreased by 6.0(±4.9)%, whilst DirHepStO2 decreased by 83.7(±7.2)%. In the 5-7 kg animals during complete occlusion, CutHepStO2 decreased by 27.4(±8.5)%, whilst DirHepStO2 decreased by 82.8(±4.6)%. CONCLUSION: Transcutaneous hepatic StO2 monitoring cannot reliably detect severe hepatic ischemia in a juvenile porcine model, although a stronger and potentially useful signal is seen in 5-7 kg pigs. Trials of this technology should be currently restricted to situations where the organ is less than 1 cm from the skin surface, corresponding to infants of <10 kg.

Comparison of in-hospital morbidity and mortality in HIV-infected and uninfected children after surgery.

PURPOSE: Increasingly HIV-infected children can be expected to require surgery. The aim of this study was to compare the outcome of HIV-infected and HIV-unexposed children undergoing surgery. PATIENTS AND METHODS: A prospective study of children less than or equal to 60 months admitted to a tertiary pediatric surgical service from July 2004 to July 2008. Children underwent age-definitive HIV testing and were followed up postoperatively for complications, length of stay and mortality. RESULTS: Three hundred and twenty-seven children were enrolled: 82 (23 %) HIV-infected and 245 (67 %) were HIV-unexposed. Eighty-four (26 %) children were malnourished, which was higher in the HIV-infected group [41 (50.0 %) vs. 43 (17.5 %), relative risk (RR) 2.9; 95 % confidence interval (CI) 2.0-4.1; p < 0.0001]. Three hundred and twenty-eight surgical procedures were performed. A similar number of major [28 (34.2 %) vs. 64 (26.1 %); p = 0.2] and emergency procedures [37 (45.1 %) vs. 95 (38.8 %); p = 0.34] were performed in each group. HIV-infected children had a higher rate of contamination at surgery [40 (48.7 %) vs. 49 (20 %); RR 2.43 (CI 1.7-3.4); p < 0.0001]. There were more complications in the HIV-infected group [34 (41.5 %) vs. 14 (5.7 %); RR 7.3 (CI 4.1-12.8); p < 0.0001]. The most common complications were surgical site complications 30 (55 %), followed by postoperative infections, 19 (34 %). Infections with drug-resistant organisms occurred more commonly in HIV-infected children [11/19 (58 %) vs. 2/13 (15 %); RR 3.8 (CI 1.3-14.2); p = 0.02]. The median length of hospital stay was longer in the HIV-infected group [4 (IQR 2-14) vs. 2 (IQR 1-4) days; p = 0.0001]. There was a higher mortality amongst the HIV-infected group [6 (7.3 %) vs. 0 (0 %); p < 0.0001]. CONCLUSION: HIV-infected children have a higher rate of postoperative complications and mortality compared with HIV-unexposed children.

Outcome of HIV-exposed uninfected children undergoing surgery.

BACKGROUND: HIV-exposed uninfected (HIVe) children are a rapidly growing population that may be at an increased risk of illness compared to HIV-unexposed children (HIVn). The aim of this study was to investigate the morbidity and mortality of HIVe compared to both HIVn and HIV-infected (HIVi) children after a general surgical procedure. METHODS: A prospective study of children less than 60 months of age undergoing general surgery at a paediatric referral hospital from July 2004 to July 2008 inclusive. Children underwent age-definitive HIV testing and were followed up post operatively for the development of complications, length of stay and mortality. RESULTS: Three hundred and eighty children were enrolled; 4 died and 11 were lost to follow up prior to HIV testing, thus 365 children were included. Of these, 38(10.4%) were HIVe, 245(67.1%) were HIVn and 82(22.5%) were HIVi children.The overall mortality was low, with 2(5.2%) deaths in the HIVe group, 0 in the HIVn group and 6(7.3%) in the HIVi group (p = 0.0003). HIVe had a longer stay than HIVn children (3 (2-7) vs. 2 (1-4) days p = 0.02). There was no significant difference in length of stay between the HIVe and HIVi groups. HIVe children had a higher rate of complications compared to HIVn children, (9 (23.7%) vs. 14(5.7%) (RR 3.8(2.1-7) p < 0.0001) but a similar rate of complications compared to HIVi children 34 (41.5%) (RR = 0.6 (0.3-1.1) p = 0.06). CONCLUSION: HIVe children have a higher risk of developing complications and mortality after surgery compared to HIVn children. However, the risk of complications is lower than that of HIVi children.

Definitive abdominal wall closure using a porcine intestinal submucosa biodegradable membrane in pediatric transplantation.

Abdominal closure in children less than 10 kg following liver or kidney transplantation can be challenging. Excessive pressure attained from a tight closure can result in abdominal compartment syndrome, graft compromise and loss. Concerns over using prosthetic patches are that of infection and dehiscence. We report a series of definitive abdominal wall closure using a biodegradable membrane from porcine intestinal submucosa (Surgisis; Cook Biotech Incorporated, West Lafayette, IN, USA). A prospective collection and follow up of liver and kidney transplant patients weighing less than 10 kg who required abdominal wall augmentation with Surgisis in order to achieve satisfactory closure. There were 10 liver and two renal transplant patients. The average weight of the liver transplant patients was 6.6 kg (5.4-8.5 kg) and the renal 9.8 kg. The average area of Surgisis used was 71.2 cm(2) (25-160 cm(2)) and length of follow up was 15.3 months (1-27 months). Concomitant measures to aid abdominal closure included bilateral recipient nephrectomy for the renal patients and reduction by 33% of the lateral segmental grafts in two liver transplant patients. Delayed closure occurred in all patients except one and the average days to closure from the first surgery was 3.75 days (0-6 days). Following liver transplantation one patient died from multiple organ failure at one month secondary to hemophagocytosis from underlying combined immune deficiency syndrome and one patient with hepatic artery thrombosis was salvaged at re-exploration. There were two wound complications, one patient developed two small sinuses and some skin dehiscence which healed over four months and the second developed a skin sinus following trans-patch liver biopsy which healed in three wk. Both had positive microbial cultures but neither necessitated removal of the graft. There were no incisional hernias. Surgisis is a safe method for facilitating abdominal closure in pediatric transplant patients. It appears to have long-term durability with no incisional hernias on short- and medium-term follow up, and is fairly resistant to infection.

Primary paraesophageal hernia in children.

BACKGROUND: Paraesophageal hernias are uncommon in children and are distinctively different from the more common sliding hiatus hernias and those occurring after antireflux surgery in anatomy, pathology, symptoms, complications, and management. We reviewed a single institution's experience with the pathology of paraesophageal hernias. METHODS: We conducted a retrospective analysis of patient records. RESULTS: Fifty-nine children with paraesophageal hernias were treated during a 42-year period. Their mean age at presentation was 23.4 months (range, 1 day to 11 years). Presenting complaints were recurrent chest infections (n = 32), vomiting (n = 24), symptomatic anemia (n = 20), failure to thrive (n = 18), and dysphagia (n = 6). Five children were asymptomatic, and their diagnosis was established when they were investigated for incidentally noted asymptomatic anemia (n = 3), scoliosis (n = 2), and mumps (n = 1). Radiology typically showed cystic masses in the posterior mediastinum in the right lower chest and occasionally had an air-fluid level in the cystic mass or a dilated esophagus. None presented with strangulation or hematemesis. All patients were operated on. Surgical findings included a peritoneal lined sac and herniation through a widened diaphragmatic hiatus, containing the stomach and at times the transverse colon, spleen, and small bowel. The hernial sac usually occurred on the right. Principles of surgery included reduction of the contents, partial excision of the sac, crural approximation, and a fundoplication in 39 patients. No fundoplication was done in the earlier years in 20 patients, of whom 12 had recurrent reflux symptoms. Postoperative complications were bowel obstruction (n = 6), intussusception (n = 3), dysphagia (n = 3), breakdown of the repair (n = 3), and pneumothorax (n = 1). There was one mortality caused by preoperative aspiration. CONCLUSION: Paraesophageal hernias in children are uncommon and most likely caused by a congenital defect. They are associated with considerable morbidity. Strangulation is not a feature. Principles of repair are well established and should include an antireflux procedure.

Glutaraldehyde-induced bowel injury after laparoscopy.

We document the sequelae of the inadvertent introduction of glutaraldehyde into the peritoneal cavity. It describes the clinical course, progressive histological changes to the bowel at different periods over the course of 1 year, and what long-term morbidity remains. The chemical structure, effects, and pathogenesis of glutaraldehyde are described as well as suggestions for avoiding similar problems in the future.