Chronic appendicitis in children.

QUESTION: While the diagnosis of acute appendicitis is relatively straightforward, chronic appendicitis is an entity that can be controversial and is often misdiagnosed. How and when should clinicians be investigating chronic appendicitis as a cause of chronic and recurrent abdominal pain in the pediatric population? ANSWER: Chronic appendicitis is a long-standing inflammation or fibrosis of the appendix that presents clinically as prolonged or intermittent abdominal pain. It is often a challenging diagnosis and might result in complications such as intra-abdominal infections or bowel obstruction or perforation. Clinical presentation, along with imaging studies, can help the clinician rule out other conditions, and among those who are diagnosed, for many children, appendectomy results in partial or complete resolution of pain symptoms.

Perioperative outcomes of primary renal tumour resections: comparison of in-hours to out-of-hours surgery.

PURPOSE: Primary resection is typically performed for children with localised suspected Wilms tumours. Resource limitation may necessitate performing these operations nights and weekends. We hypothesise that outcomes will be worse in patients having nephrectomies out-of-hours (OOH) compared to those in-hours (IH). METHODS: With IRB ethics approval, primary renal tumour resections performed on oncology patients from 1989-2011 were reviewed retrospectively. IH operations were defined as Monday-Friday 0745-1530 hours. Outcomes included major intraoperative complications, capsule rupture, and blood loss. Data were analysed using Fischer Exact and Mann-Whitney U tests. RESULTS: There were 64 patients with renal tumours who underwent primary resection. Forty-five procedures were performed IH, and 19 OOH. Groups were similar in age, ASA status, tumour size and grade. In a comparison of major intraoperative complications, capsule rupture, and mean blood loss, differences were 2 vs. 26% (p = 0.007), 27 vs. 42% (p = 0.12), 178 vs. 244 ml (p = 0.15) for IH and OOH respectively. There was one perioperative mortality (OOH). CONCLUSIONS: Primary renal tumour resections performed OOH were associated with an increase in major complications compared to those performed in standard hours. Avoidance of OOH operating where possible may reduce morbidity for children undergoing primary renal tumour resections.

The 51st annual meeting of the canadian association of pediatric surgeons.

This is the report of the 51st Annual Meeting of the Canadian Association of Pediatric Surgeons held in Quebec City, Quebec, Canada, from September 19-21, 2019.

The 50th Annual Meeting of the Canadian Association of Pediatric Surgeons.

This is the report of the 50th Annual Meeting of the Canadian Association of Pediatric Surgeons (CAPS) held in Toronto, Ontario, Canada, from September 26th to September 28th, 2018.

Stapled versus hand-sewn pediatric intestinal anastomoses: A retrospective cohort study.

BACKGROUND: Whereas the adult literature has demonstrated the acceptable safety profile of stapled anastomoses when compared to the hand-sewn alternative, the choice of intestinal anastomosis using sutures or staples remains inadequately investigated in children. The purpose of this study is to compare the anastomotic outcomes of both techniques in children under 5years of age. METHODS: A retrospective analysis of patients undergoing intestinal anastomosis at a single tertiary centre (2012-2016) was undertaken. Demographics, diagnosis, anatomy, and complications were compared between the hand-sewn (HS) and stapled anastomosis (SA) groups. Primary outcomes were anastomotic leak and/or stricture requiring intervention. RESULTS: There were 72 patients with 90 intestinal anastomoses (67 HS, 23 SA). Baseline demographics between the two anastomotic groups were comparable. The overall anastomotic complication rate was 23.9% (HS) and 17.4% (SA). In the ileocolic subgroup, anastomotic complications occurred in 3/7 HS vs. 0/5 SA (ns). There were no statistically significant differences in primary outcomes between HS and SA. All SA complications occurred with 3.5 or 3.8mm staples. CONCLUSIONS: In our study population, no statistically significant difference between hand-sewn and stapled intestinal anastomosis outcomes was found. However, further investigation is warranted. LEVEL OF EVIDENCE: 3 (Retrospective Comparative Treatment Study).

Pleurectomy versus pleural abrasion for primary spontaneous pneumothorax in children.

PURPOSE: Primary spontaneous pneumothorax (PSP) represents a common indication for urgent surgical intervention in children. First episodes are often managed with thoracostomy tube, whereas recurrent episodes typically prompt surgery involving apical bleb resection and pleurodesis, either via pleurectomy or pleural abrasion. The purpose of this study was to assess whether pleurectomy or pleural abrasion was associated with lower postoperative recurrence. METHODS: The records of patients undergoing surgery for PSP between February 2005 and December 2015 were retrospectively reviewed. Recurrence was defined as an ipsilateral pneumothorax requiring surgical intervention. Bivariate logistic regressions were used to identify factors associated with recurrence. RESULTS: Fifty-two patients underwent 64 index operations for PSP (12 patients had surgery for contralateral pneumothorax, and each instance was analyzed separately). The mean age was 15.7±1.2years, and 79.7% (n=51) of patients were male. In addition to apical wedge resection, 53.1% (n=34) of patients underwent pleurectomy, 39.1% (n=25) underwent pleural abrasion, and 7.8% (n=5) had no pleural treatment. The overall recurrence rate was 23.4% (n=15). Recurrence was significantly lower in patients who underwent pleurectomy rather than pleural abrasion (8.8% vs. 40%, p<0.01). In patients who underwent pleural abrasion without pleurectomy, the relative risk of recurrence was 2.36 [1.41-3.92, p<0.01]. CONCLUSION: Recurrence of PSP is significantly reduced in patients undergoing pleurectomy compared to pleural abrasion. LEVEL OF EVIDENCE: Level III, retrospective comparative therapeutic study.

Audit of emergent and urgent surgery for acutely ill pediatric patients: is access timely?

UNLABELLED: There is a paucity of literature about wait times for urgent/emergent surgeries in Canada. Delays and performance of non-emergent operations overnight increase morbidity and mortality. The study aim was to determine patterns of delays and performance of less-emergent surgery overnight. METHODS: A retrospective analysis (June 2011-December 2013) of emergent/urgent surgeries was conducted using the ORSOS database (prospective patient and operative data). Surgeries were classified: class 1, 2A, 2B, and 3: target times of 1, 6, 24 and 72h. In hours (IH)=7:45AM-3:30PM, M-F; others were out of hours (OOH) and overnight =2300-0700. RESULTS: There were 4668 operations: class 1 (5.8%), 2A (29.1%), 2B (42.1%), and 3(23%). For class 1, 2A, 2B, and 3 surgeries, mean in-room times were 2, 4.7, 15.4, and 54h respectively; 59.2% (class 1), 81.9% (class 2A), 81.2% (class 2B) and 74.4%(class 3) were performed in target. OOH occurred for 73.2% (class 1), 71.5%(class 2A), 54.7% (class 2B), and 27.7% (class 3). There were 37 class 2B and 3 surgeries overnight. There was a significant increase surgeries IH: 41.8% to 49.6%. CONCLUSION: The majority of urgent/emergent surgery occurred OOH and the most unstable patients are least likely to have their operation within target. LEVEL OF EVIDENCE: 4.

A comparison of surgical outcomes between in-hours and after-hours tracheoesophageal fistula repairs.

BACKGROUND: Emerging literature has found increased complications for some patients undergoing nonemergent surgeries performed after-hours. For infants born with esophageal atresia and tracheoesophageal fistula (EA/TEF), no literature exists addressing the impact of the timing of surgery on outcomes. METHODS: With IRB approval, EA/TEF repairs (2005-2010) performed at a tertiary children's hospital were reviewed retrospectively. All patients had an esophageal anastomosis. After-hours surgeries were defined as 1530-0800 Monday to Friday, weekends/holidays. Demographics, EA/TEF type, operative details, anastomotic tension, and complications were compared. Outcomes measured included intraoperative desaturations, esophageal complications (leak, stricture, recurrence), pneumothorax, and mortality. RESULTS: There were 28 patients, of which 21 underwent the procedure in-hours and 7 after-hours. Patient age, gestational age, weight, EA/TEF type, cardiac anomalies, and preoperative, intraoperative, and postoperative variables were not different between the groups. Operative time, intraoperative desaturations, anastomotic tension, blood loss, total ventilation days, or length of hospitalization were not significantly different. There was a significant increase in esophageal leaks in the after-hours group (n=3) vs. the in-hours (n=0) group (p=0.014). CONCLUSIONS: In this study, infants with an EA/TEF repaired after-hours had a significant increase in anastomotic leaks. The observed increase in leaks requires further evaluation to ensure more optimal outcomes for this fragile group of patients.

Major thrombotic complications with lower limb PICCs in surgical neonates.

BACKGROUND: PICC lines are now used routinely to provide central access for neonatal intensive care unit (NICU) patients. Neonates are known to be at risk for venous thromboembolism (VTE) related to central catheters. No literature exists about VTE PICC-related morbidity in the NICU abdominal surgery subgroup. METHODS: With REB approval, a retrospective review of a NICU database of PICC insertions performed at a tertiary children's hospital was conducted (January 2010-June 2013). Information about PICCs and complications was recorded. For patients with a major thrombotic complication, charts were reviewed. A major thrombotic complication was defined as a thrombosis which required medical and/or surgical intervention. RESULTS: 692 PICCs were inserted (485 in the upper extremity, 142 in the lower extremity, and 65 in the scalp). Seventy-four patients had significant intraabdominal pathology, and 5 had a major thrombotic complication. All patients with a major thrombotic complication had a lower extremity PICC which was at or below L1 (L1-S1) running parenteral nutrition. CONCLUSIONS: In the current study, only neonates with abdominal pathology and a lower extremity insertion site suffered major thrombotic complications from PICC lines. Given all patients' PICC tips were below the recommended location, more rigorous surveillance (with repositioning if required) may avoid these complications for future patients.

Mucous fistula refeeding in neonates with enterostomies.

BACKGROUND/PURPOSE: Neonates with intestinal pathology may require staged surgery with creation of an enterostomy and mucous fistula (MF). Refeeding (MFR) of ostomy output may minimize fluid and electrolyte losses and reduce dependence on parenteral nutrition (PN), though a paucity of evidence exists to support this practice. The purpose of this study was to assess the outcomes of infants undergoing MFR and document associated complications. METHODS: With REB approval, infants with intestinal failure undergoing MFR between January 2000 and December 2012 were identified. A chart review was conducted and relevant data were collected. Descriptive statistics were used. RESULTS: Twenty-three neonates underwent MFR. Mean gestational age and birth weight were 35weeks and 2416grams. Pathologies included intestinal atresia (n=12), necrotizing enterocolitis (n=5), meconium ileus (n=4), and other (n=6). Seven patients were able to wean from PN. Four patients had complications: 3 had perforation of the MF, 1 had bleeding. Four patients died, with one death directly attributable to MFR. CONCLUSIONS: In this cohort MF refeeding was associated with significant complications and ongoing PN dependence. With advances in intestinal rehabilitation and PN, the benefit of MF refeeding must be weighed against the potential complications.

Morbidity and mortality associated with intraperitoneal chemotherapy for Pseudomyxoma peritonei.

BACKGROUND: Many centers include intraperitoneal chemotherapy for treatment of pseudomyxoma peritonei. This study documented the morbidity of intraperitoneal chemotherapy in a single institution. METHODS: A retrospective review of pseudomyxoma peritonei over a 6-year period was undertaken. Treatment, morbidity, and outcome were documented. RESULTS: Eleven patients were identified with an average of 1.9 debulking procedures and 0.8 chemotherapy courses (0.3 complete). Intraperitoneal chemotherapy was not completed in 5 patients because of complications (56%): severe abdominal pain, seizure, neutropenia, and thrombocytopenia (the latter resulted in 1 patient's death). There was no association between incomplete chemotherapy and recurrence. Recurrence was 64% in those without chemotherapy and 44% in those with. Follow-up averaged 26 months and actual 3-year survival was 60%. CONCLUSIONS: Intraperitoneal chemotherapeutic morbidity and mortality were 56% and 11%, respectively. Chemotherapy was associated with decreased recurrence. To optimize outcomes, multicenter prospective trials will likely be required to further refine intraperitoneal chemotherapy protocols.

Evaluation of sodium deficit in infants undergoing intestinal surgery.

BACKGROUND: Sodium is a critical growth factor for children. Severe deficits cause growth impairment and cognitive dysfunction. Both the diagnosis and risk of sodium depletion in children undergoing intestinal surgery are poorly understood. METHODS: With IRB approval, children undergoing intestinal surgery (2009-2012) who had a urine sodium measurement were retrospectively reviewed. Sodium deficits were defined: urine sodium <30 mmol/L and <10 mmol/L were deficient and severely deficient, respectively. Demographics, weight changes, and intake (sodium, fluid, and nutritional) were tabulated. Data were analyzed using regression analysis and Mann Whitney U tests. RESULTS: Thirty-nine patients, 51.3% female, with a gestational age of 32.2 weeks and weight of 1.43 kg were identified. The most common diagnoses were NEC (38.5%), intestinal atresia (20.5%), and isolated perforation (10.3%). Sodium deficiency was documented in 36/39 (92%) and 92.9% for those in continuity. Severe deficiency occurred in 64%. Urine sodium was significantly correlated with weight gain (p=0.002). Weight gain in patients with urine sodium <30 mmol/L was significantly decreased vs. those ≥30 mmol/L (+0.58 g/d vs. +21.6 g/d, p=0.016). CONCLUSION: In this population, sodium depletion is common in children undergoing intestinal surgery, even when the colon is in continuity. Correction of the sodium deficit to achieve urine sodium >30 mmol/L is associated with improved weight gain.

An open and shut case for early VATS treatment of primary spontaneous pneumothorax in children.

BACKGROUND: Treatment of primary spontaneous pneumothorax (SP) involves thoracostomy tube (TT) drainage, with surgery reserved for persistent or recurrent air leaks. We hypothesized that the advent of video-assisted thoracic surgery (VATS) would change indications and outcomes for surgical treatment of SP in our centre. METHODS: We performed a retrospective (1993-2003) review of children treated for SP. Patients with persistent or recurrent air leaks underwent either limited axillary thoracotomy (LAT), 1993-2001, or VATS, 2001-2003. We included the following outcomes: preoperative SP episodes, TT days (that is, patient days with TT in situ, before surgery), length of hospital stay (LOS), narcotic use and freedom from recurrence. We evaluated the predictive value of preoperative CT scans in guiding treatment of the contralateral side. RESULTS: Among 31 patients with 19 ipsilateral or contralateral recurrences (61%), 11 were managed nonoperatively. Twenty-six surgeries (13 LAT, 13 VATS) were performed in 20 patients, with 9 undergoing bilateral procedures (3 LAT, 6 VATS). VATS patients were treated earlier, had a diminished narcotic requirement postoperatively and had a shorter LOS with an equivalent recurrence rate, compared with LAT patients. The absence of contralateral blebs did not predict freedom from SP on the contralateral side in patients undergoing surgery for ipsilateral SP. CONCLUSIONS: Compared with LAT, VATS causes less pain, has a shorter LOS and encourages earlier surgical treatment (including prophylactic, contralateral treatment) of SP in children.

Necrotizing soft tissue infections--are they different in healthy vs immunocompromised children?

PURPOSE: Necrotizing soft tissue infection (NSTI) is rare and often devastating. We sought to define our experience and determine if differences in immune status influenced outcome. METHODS: A retrospective review (1993-2004), with institutional review board approval, was undertaken on children with NSTI. Presentation, laboratory results, and outcome were assessed. RESULTS: There were 19 cases; the median age was 5.9 years (range, 6 days-14 years). Eight were immunocompromised (IC). At presentation, 95% had pain and swelling; fever and tachycardia occurred in 84% and 74%, respectively. Severe tenderness was found in 100% of healthy vs 25% of IC patients. Compared with the healthy, in IC patients, more infections were perineal/buttock (75% vs 32%), polymicrobial (75% vs 58%), and fungal (38% vs 0%). Median intensive care unit stay and length of hospital stay in IC vs healthy were 4 vs 2 and 27 vs 16.5 days, respectively. Mortality rate was 16% (2 healthy and 1 IC). CONCLUSIONS: Most children with NSTI present with fever, tachycardia, pain, and swelling. Compared with healthy children, IC patients are less likely to have severe tenderness and more likely to have polymicrobial perineal/buttock infections. Although IC patients had a longer length of intensive care unit and hospital stay, their mortality (12%) was actually better than that seen in the otherwise healthy children (18%). Coagulopathy developed in 64% of the patients and may be an early marker for the presence of necrotizing soft tissue infections.

Postnatal spontaneous resolution of congenital cystic adenomatoid malformations.

PURPOSE: Although antenatal resolution of congenital cystic adenomatoid malformations (CCAMs) is well documented, complete spontaneous postnatal resolution is rare, its existence even questioned by some. METHODS: All cases of antenatally diagnosed CCAMs over 7 years were retrospectively reviewed. Inclusion criteria were the following: (1) antenatal diagnosis of CCAM, (2) persistence on postnatal imaging, and (3) subsequent spontaneous resolution on postnatal imaging. RESULTS: Of 56 antenatally diagnosed CCAMs, 2 patients were identified. Both had macrocystic lesions. In case 1, the CCAM that filled the hemithorax on antenatal ultrasound was smaller on postnatal chest radiograph and disappeared by age 37 months on computed tomography. Case 2 had significant reduction of the CCAM at birth (persistence of the lesion on initial radiographs and ultrasound was documented). By 5 months, the lesion was not evident on computed tomography. Neither case was associated with symptoms, polyhydramnios, hydrops, or other abnormalities. CONCLUSIONS: In patients with an antenatal diagnosis of CCAM, spontaneous resolution may occur postnatally in 4% of cases. Significant reduction in CCAM size may portend possible disappearance and therefore warrants an observational period before resection.

Meconium thorax: A case of Bochdalek hernia and cecal perforation in a neonate with Job's syndrome.

Meconium peritonitis most often is associated with congenital intestinal obstruction and meconium ileus. Uncommonly, other etiologies are identified. Hyperimmunoglobulin E syndrome (Job's syndrome) is a rare genetic disorder that is characterized by recurrent staphylococcal respiratory and skin infections in addition to elevated serum IgE levels. There have been 2 previously reported cases of intestinal complications associated with Job's syndrome. The current case is the third such case and is the first report of meconium peritonitis in a patient with hyperimmunoglobulin E syndrome. The patient presented with a meconium thorax as a result of a concurrent congenital diaphragmatic hernia.