Laparoscopic cholecystectomy in children: A systematic review and meta-analysis.

BACKGROUND: Laparoscopic cholecystectomy (LC) has become the procedure of choice for the removal of gallbladder within the paediatric population. The aim of this study was to perform a systematic review and meta-analysis of the literature spanning the last 20 years to understand the indications for and safety of LCs in children. METHODS: A comprehensive search of the published English language literature from January 2000 to June 2020 was done on PubMed, MEDLINE, and Google Scholar. RESULTS: In total, 76,524 LC cases were identified from 114 studies. 78.9% of the patients were female and average age was 12 years old. Associated haematological disorders were identified in 16% of cases. The commonest indication for LC was cholelithiasis (68.4% in 66 studies), followed by cholecystitis (59.2% in 53 studies). Median operating time was 77 min. Median hospital stay was 2 days. The overall postoperative complication rate was 3.4% Major complications included bile duct injury (0.4%) and intra- or post-operative bleeding (0.9%). The conversion rate to open procedure was 2%. When comparing post-operative outcomes between emergency and elective admissions, three papers lent themselves to meta-analysis demonstrating no significant difference (p = 0.42). There was no statistically significant difference in postoperative complication rate between "hot" and "cold" laparoscopic cholecystectomies (p = 0.6). CONCLUSION: This systematic review and meta-analysis is the largest collection of subjects on laparoscopic cholecystectomies in children. Laparoscopic cholecystectomy is a safe operation in children, with complication rates similar or comparable to the adult literature. Cholelithiasis, cholecystitis and biliary dyskinesia were the commonest indications for LC.

Systematic review and meta-analysis of appendiceal carcinoid tumors in children.

OBJECTIVE: The study's aim was to review the literature regarding past and current practices in managing incidental appendiceal carcinoid tumors and need for more procedures. METHOD: A search of MEDLINE, Embase, CINAHL, and Cochrane databases of systematic reviews was undertaken of the English language literature. The mesh terms used were "carcinoid" or "neuroendocrine," "tumour" or "tumor," "appendix," "appendicectomy," or "appendectomy," and "child," "pediatric," or "paediatric." Of the 369 articles found, 37 met the inclusion criteria. Our hospital records and pathology database identified 11 patients with confirmed histological diagnosis of appendicular carcinoids from January 1996 to December 2016. Those cases were also included in this study. RESULTS: A total of 958 cases were identified from the literature and our own experience. There were 566 females and 343 males giving us a ratio of 1.65:1. The frequency was 0.3% of appendicectomies. There was a 28-fold increase in the risk of having a positive lymph node if the tumor size was >2 cm compared with the risk of having a positive lymph node if the tumor size was ≤2 cm. There was no recurrence or mortality for those with criteria for secondary surgery, who were observed after appendicectomy compared to those that had secondary surgery. Mean follow-up was 58.6 months (4.8 years) with a range of 0-396 months (33 years). CONCLUSION: Appendicectomy alone is an adequate treatment for an appendicular carcinoid in children irrespective of size, position, lymph node, or mesenteric involvement. Post-appendicectomy investigations were found to be not helpful in this study.

Sigmoid volvulus in an adolescent girl: staged management with emergency colonoscopic reduction and decompression followed by elective sigmoid colectomy.

A case of acute sigmoid volvulus in a 14-year-old adolescent girl presenting with acute low large bowel obstruction with a background of chronic constipation has been presented. Abdominal radiograph and CT scan helped in diagnosis. She underwent emergency colonoscopic detorsion and decompression uneventfully. Lower gastrointestinal contrast study showed very redundant sigmoid colonic loop without any transition zone and she subsequently underwent elective sigmoid colectomy with good outcome. The sigmoid volvulus should be considered in the differential diagnosis of paediatric acute abdomen presenting with marked abdominal distention, absolute constipation and pain but without vomiting. Plain abdominal radiograph and the CT scan are helpful to confirm the diagnosis. Early colonoscopic detorsion and decompression allows direct visualisation of the vascular compromise, assessment of band width of the volvulus and can reduce complications and mortality. Associated Hirschsprung's disease should be suspected if clinical and radiological features are suggestive in which case a rectal biopsy before definitive surgery should be considered.

Outcome of peripherally inserted central venous catheters in surgical and medical neonates.

BACKGROUND/PURPOSE: Peripherally inserted central venous catheters (PICCs) are commonly used for neonatal vascular access. The aim of this study was to look at PICC line complication rates and possible predictors of PICC infection in a neonatal intensive care unit. METHOD: This was a prospective study of 226 neonates who had PICCs on our neonatal intensive care unit between January 2006 and June 2009. Complete data was available on 218 neonates who had 294 PICC lines. Criteria for catheter-related sepsis was positive blood cultures (peripheral/central) and/or a positive catheter tip culture after removal in the presence of a clinical suspicion of line sepsis. RESULTS: Of 218 neonates, 132 (169 lines) were medical, and 86 (125 lines) were surgical. Our PICC line infection rate was 17 infections per 1000 catheter-days. Surgical neonates had infection rates of 24.8% compared with 18.3% of medical neonates (P < .18). The odds ratio for a PICC infection was 3.1 (95% confidence interval, 1.64-5.87) if the catheter was in situ for 9 days or more, P < .01. Coagulase-negative staphylococcus was isolated from 55 (89%) of 62 blood cultures. CONCLUSIONS: Our PICC infection rate was 17 per 1000 catheter-days. The length of catheter stay was the only predictor of PICC infection.

Systematic review and meta-analysis of the postnatal management of congenital cystic lung lesions.

BACKGROUND: Antenatally detected asymptomatic congenital cystic lung lesions may be managed conservatively or by surgical resection. We undertook a systematic review and meta-analysis to quantify the risks of elective surgery, emergency surgery, and observation. METHODS: All series published between 1996 and 2008, where the postnatal management of congenital cystic lung lesions was described, were reviewed. A meta-analysis was performed to determine whether elective or emergency surgery was associated with a higher risk of adverse outcomes. RESULTS: There were 41 reports describing 1070 patients (of whom 79% were antenatally detected). Five hundred five neonates survived without surgery into infancy, of whom only 16 (3.2%) became symptomatic. For all ages, elective surgery was associated with significantly less complications than emergency surgery. The risk ratio was 2.8 (95% confidence interval, 1.4-5.5; P < .005) when comparing complications after elective surgery with emergency surgery. CONCLUSIONS: The risk of asymptomatic cases developing symptoms is small. However, elective surgery is associated with a better outcome than emergency surgery. If elective surgery is undertaken, it should be performed before 10 months. Although no prognostic indicators have so far been identified in the literature, a conservative approach may be appropriate for small lesions.

Postnatal outcome in gastroschisis: effect of birth weight and gestational age.

INTRODUCTION: Early elective delivery of antenatally diagnosed gastroschisis has been proposed as a strategy to minimize postnatal morbidity. This hypothesis was tested by analyzing outcome in relationship to gestational age and birth weight at delivery. METHODS: Single-center retrospective review of infants born with gastroschisis over a 13-year period (January 1993-December 2005). Standard outcome measures were compared using nonparametric methods. Data are quoted as median values (range). RESULTS: The study population consisted of 110 infants with gastroschisis. They were divided according to gestational age (group A, <35 weeks; group B, 35-37 weeks; group C, >37 weeks) and birth weight (group D, <2 kg; group E, 2-2.5 kg; group F, >2.5 kg). Duration in hospital (P < .01) and time to full enteral feeding (P = .05) was increased in group A vs groups B and C. In comparison, duration in hospital (P < .01), days ventilated (P = .03), establishment of full feeds (P = .01), and parenteral nutrition (P = .02) were all prolonged in group D vs groups E and F. Six (5%) infants died (group D, n = 3; group E, n = 3). Necrotizing enterocolitis was found in 7 infants, and confined to groups D and E (chi2 for trend P = .06). CONCLUSION: There is no evidence that prematurity confers an advantage in restitution of gastrointestinal function in infants with gastroschisis; indeed, the opposite appears true. Birth weight, rather than gestational age, appears a better predictor of outcome.

Six thousand three hundred sixty-one pediatric inguinal hernias: a 35-year review.

PURPOSE: This study, by its mere size and uniformity (1 pediatric surgeon), aims to corroborate or refute the teachings and myths of the pediatric inguinal hernia. METHODS: From July 1969 to January 2004, 6361 infants and children with inguinal hernias were seen, operated on, and followed by the senior author. A retrospective survey of their charts was carried out to evaluate the demographics and clinical aspects of these patients. The hospital's research ethics board approved of this study. RESULTS: The ages ranged from premature to 18 years (mean age, 3.3 years) with a male-to female ratio of 5:1. There were 59% right, 29% left, and 12% bilateral hernias (almost all indirect). Hydroceles were found in 19%. Incarceration occurred in 12%. A modified Ferguson repair was used. An opposite-side hernia developed in 5%, 95% within the first 5 years, and was not sex or age specific. There were 1.2% recurrences, 96% within 5 years. Thirteen percent had ventriculo-peritoneal shunts, 1.2% wound infections, and 0.3% testicular atrophy. There were no postoperative deaths. One percent had a documented hernia disappearance. CONCLUSIONS: Three of our results have not corresponded with previous teachings and myths: (1) a hernia of a premature baby should be fixed sooner than later; (2) routine contralateral groin exploration is not indicated in any situation; and (3) teenage recurrence rate is 4 times greater than the overall series.

Management of suspected common bile duct stones in children: role of selective intraoperative cholangiogram and endoscopic retrograde cholangiopancreatography.

BACKGROUND: Evidence for diagnostic accuracy and clinical efficacy of intraoperative cholangiogram (IOC) and endoscopic retrograde cholangiopancreatography (ERCP) in the management of common bile duct (CBD) stones in children is sparse and unclear. METHODS: Retrospective analysis of 202 children who underwent laparoscopic cholecystectomy (LC) between 1996 and 2002 was performed. Forty-eight children had suspected CBD stones on clinical, biochemical, and radiologic grounds. Two clinical pathways, LC followed by ERCP (L-->E) versus ERCP followed by LC (E-->L) were compared. RESULTS: From the cohort of 202 patients, 154 did not have suspected CBD stones. Of the 48 patients that did have suspected stones, 2 management pathways were followed: (1) ERCP first: 14 of 48 patients (including 1 failed examination). Three yielded positive findings on ERCP. Ten had negative findings on ERCP, 3 of which went on to have a subsequent IOC. All 3 had negative IOC examination findings. (2) LC +/- IOC first: 34 of 48 patients. Twenty-eight had negative findings on IOC and had no further investigations. Three patients had positive IOC examination findings and went on to have postoperative ERCP. Two of these 3 patients were positive for CBD stones. The remaining 3 of 34 patients had LC with no IOC followed by ERCP. Only 1 of 3 patients yielded a positive examination finding on ERCP. Therefore, of the 168 patients that did not have IOC, only 1 stone (0.6%) would have been missed using the selective criteria. Of those that did meet the criteria for IOC, only 2 of 31 (6.5%) had positive examination findings. There were no adverse effects of a retained or passed stone during our study, nor where there complications in those who had a concomitant sphincterotomy (12 of 20 ERCP patients, mean follow-up of 4.2 years). IOC and ERCP findings correlated in all 6 of the patients in which both procedures were performed. CONCLUSIONS: Selective IOC with LC is an acceptable and safe initial approach in suspected CBD. Most CBD stones in children pass spontaneously. Endoscopic sphincterotomy appears to be safe with no long-term sequelae.

Image-guided percutaneous approach is superior to the thoracoscopic approach in the diagnosis of pulmonary nodules in children.

BACKGROUND/PURPOSE: Image-guided, percutaneous techniques are increasingly used in diagnosis of pulmonary disease in children. The aim of this study was to determine the diagnostic accuracy and clinical outcomes of thoracoscopic versus percutaneous lung biopsy in children. METHODS: Sixty-three consecutive patients from January 1996 to December 2000 who had a thoracoscopic lung biopsy, a percutaneous ultrasound scan, or computed tomography (CT)-guided lung biopsy for well-defined and ill-defined lesions were analyzed. RESULTS: Twenty-eight patients had a thoracoscopic lung biopsy (TLB), and 35 patients had a percutaneous image-guided lung biopsy (PLB). Age ranged from 6 months to 17 years (median, 8 years). There was no significant difference between groups with regard to age, depth of lung nodule biopsied, or prebiopsy diagnoses. Seventeen patients (60%) of TLB and 23 (65%) of PLB had well-defined pulmonary nodules suspicious for malignancy at the time of biopsy. Adequate tissue for pathologic diagnosis was obtained in 28 (100%) of TLB versus 26 (80%) of PLB patients. However, 8 (28%) thoracoscopic cases needed to be converted to an open procedure. In 3 (8.5%) PLB cases the percutaneous biopsy was insufficient, and a thoracoscopic or open biopsy was required. The median hospital stay was 3 days for TLB and 4 to 6 hours for PLB (P =.023). There were no complications in the PLB group. Five (18%) of TLB patients suffered a persistent air leak treated with continued chest tube drainage, and one patient died of other causes with a persistent air leak. CONCLUSIONS: Percutaneous lung biopsy has a significantly shorter hospital stay and a lower complication rate than thoracoscopic lung biopsy. The authors propose that the percutaneous technique should be considered as the initial approach for children with pulmonary nodules.