Psychological and social impacts on carers of children with a gastrostomy: a systematic review.

To determine the psychological and social impacts of a gastrostomy in childhood on carers and families. A systematic search of OVID, Medline and Embase was undertaken using the subject headings and word variants for 'gastrostomy', 'children' and 'carers'. Studies included were those describing the impact of gastrostomies in children on family and carers, published in English. 564 articles were identified. After exclusion of duplicates, abstract and full text screening, 25 were included. Carer anxiety increases in the period leading up to, and for a short period following gastrostomy insertion. 3-6 months following gastrostomy insertion, anxiety reduced (reduced State-Trait Anxiety Inventory scores), carer quality of life improved (higher Quality of Life Scale scores), and carer satisfaction with the child's gastrostomy increased (improved Satisfaction Questionnaire with Gastrostomy Feeding scores). Reported changes in carer quality of life in the longer term following a child's gastrostomy insertion were mixed. The social and psychological burden on caregivers of a gastrostomy in childhood varies over time. There is evidence that paediatric gastrostomies have positive effects on carers' psychological and social well-being; however, aspects of carers' quality of life remain impaired. Carer education and support are vital to reduce the burden placed on carers.

Effect of time of diagnosis to surgery on outcome, including long-term neurodevelopmental outcome, in necrotizing enterocolitis.

A systematic review of the PubMed and EMBASE databases was carried out to determine if time from diagnosis to surgery affects outcomes in necrotising enterocolitis. The study was registered on the PROSPERO website. Studies reporting both time to surgery and at least one clinical outcome measure in infants undergoing surgery for NEC were included. The initial search returned 1121 articles. After removing duplicates, title, and abstract screening, 49 remained for full-text review. Of these, only two reported both timing of surgery for NEC and at least one clinical outcome. The total number of neonates included was 202. Outcomes reported were death and/or parenteral nutrition use 28 days post surgery in one study and white matter brain injury in the other. No statistically significant association was found between any of the outcomes reported and timing of surgery. There were, however, significant differences associated with non-modifiable risk factors, such as age and gestation, at presentation. However, very few studies report this as a variable. Given the continuing poor outcomes and heterogeneous nature of NEC and its treatments, further large-scale prospective studies are required to examine the impact of timing of surgery, alongside other, potentially modifiable factors on outcome in NEC.

Point Prevalence of Gastrostomy in a Paediatric Population.

OBJECTIVE: The aim of the study was to determine the prevalence of gastrostomy in a paediatric population. METHODS: A population-based cross-sectional point prevalence study of paediatric gastrostomy was performed. Patients included were ages 0 to 19 years, living within 3 inner-city London boroughs; Southwark, Lambeth, and Lewisham. Patients were identified as having a gastrostomy in situ via Home Enteral Nutrition (HEN) and community nursing databases. Electronic healthcare records were scrutinised to confirm current use of a gastrostomy. The main outcome measures were the point prevalence of gastrostomy in the paediatric population (gastrostomies/100,000 children), primary diagnosis, indication underlying gastrostomy insertion, and age at insertion. RESULTS: The total population studied was 946,709, of whom 213,920 were of age 0 to 19 years. Of these, 179 had a gastrostomy in situ giving a point prevalence for gastrostomy in the paediatric population of 83.7 (95% confidence interval [CI]: 71.4-96.0)/100,000 children. This varied between age groups: 0 to 4 years: 79.6 (57.3-102.0)/100,000, 5 to 9 years: 116.3 (88.7-143.9)/100,000, 10 to 14: years 87.9 (61.9-113.9)/100,000 and 15 to 19: years 41.4 (22.1-60.1)/100,000. The most common primary diagnoses were neurological disorders (57.1%), and structural abnormalities (16.2%). Unsafe swallow was the most common indication (61%), followed by nutritional or fluid supplementation (28.6%), and behavioural reasons (8.7%). The majority (85.1%) of gastrostomies were inserted under the age of 2 years. CONCLUSIONS: This is the first UK population-based study of paediatric gastrostomy, identifying a point prevalence of 84/100,000 children. The peak prevalence is in children ages 5 to 9 years. Gastrostomy insertion after a child reaches school age is uncommon.

Open Primary Button Versus Laparoscopic Percutaneous Endoscopic Gastrostomy: Results From a Case-control Study.

OBJECTIVES: Open primary balloon gastrostomy (PBG) presents a potential alternative to percutaneous endoscopic gastrostomy (PEG) in children as it obviates the need for change under general anaesthetic; however, the complication profile of PBG compared to PEG is not well defined. Previous series comparing the two have been hampered by the groups not being equivalent. Our paediatric surgical centre has offered PBG as an alternative PEG since 2014. We used a matched case-control study to compare outcomes for PBG and PEG. METHODS: Patients undergoing PBG were used as "cases" and matched 1:3 by age and diagnosis to patients undergoing PEG, demographics, and clinical data as "controls." Primary outcome was rate of complications classified according to Clavien-Dindo (I-V). Secondary outcomes included time to feed and length of stay. Non-parametric, categorical and multivariate logistic regression analyses were performed. Data here presented as median with interquartile range (IQR). RESULTS: We included 140 patients (35 PBG:105 PEG). The 2 groups were comparable for sex, weight at surgery, and follow-up duration. Median operative time was longer for PBG (43 min [IQR 36.5-61.5] vs 27.5 min [18.25-47.75], P < 0.001). Multivariate analysis demonstrated a statistically significant, higher incidence of symptomatic granulation tissue in PBG (10 [29%] vs 6 [6%], P = 0.0008), this remained significant on multivariate analysis (OR 7.56 [2.33-23.5], P = 0.001), no other complication remained significant. The overall complication rate was not statistically different. CONCLUSIONS: PBG and PEG have similar overall complication rates; however, PBG appears to have a higher incidence of granulation tissue. This observation must be weighed against the need for further general anaesthetic which is not insignificant in medically complex children.

Intraoperative hyperspectral label-free imaging: from system design to first-in-patient translation.

Despite advances in intraoperative surgical imaging, reliable discrimination of critical tissue during surgery remains challenging. As a result, decisions with potentially life-changing consequences for patients are still based on the surgeon's subjective visual assessment. Hyperspectral imaging (HSI) provides a promising solution for objective intraoperative tissue characterisation, with the advantages of being non-contact, non-ionising and non-invasive. However, while its potential to aid surgical decision-making has been investigated for a range of applications, to date no real-time intraoperative HSI (iHSI) system has been presented that follows critical design considerations to ensure a satisfactory integration into the surgical workflow. By establishing functional and technical requirements of an intraoperative system for surgery, we present an iHSI system design that allows for real-time wide-field HSI and responsive surgical guidance in a highly constrained operating theatre. Two systems exploiting state-of-the-art industrial HSI cameras, respectively using linescan and snapshot imaging technology, were designed and investigated by performing assessments against established design criteria and ex vivo tissue experiments. Finally, we report the use of our real-time iHSI system in a clinical feasibility case study as part of a spinal fusion surgery. Our results demonstrate seamless integration into existing surgical workflows.

Neonates living with enterostomy following necrotising enterocolitis are at high risk of becoming severely underweight.

Necrotising enterocolitis (NEC) is often managed with a temporary enterostomy. Neonates with enterostomy are at risk of growth retardation during critical neurodevelopment. We examined their growth using z-score. We identified all patients with enterostomy from NEC in two neonatal surgical units (NSU) during January 2012-December 2016. Weight-for-age z-score was calculated at birth, stoma formation and closure, noting severely underweight as z < - 3. We compared those kept in NSU until stoma closure with those discharged to local units or home (LU/H) with a stoma. A total of 74 patients were included. By stoma closure, 66 (89%) had deteriorated in z-score with 31 (42%) being severely underweight. There was no difference in z-score at stoma closure between NSU and LU/H despite babies sent to LU/H having a more distal stoma, higher birth weight and gestational age. Babies in LU/H spent a much shorter period on parenteral nutrition while living with their stoma for longer, many needing readmission.Conclusion: Growth failure is a common and severe problem in babies living with enterostomy following NEC. z-score allowed growth trajectory to be accounted for in nutrition prescription and timing of stoma closure. Care during this period should be focused on minimising harm.What is Known:• Necrotising enterocolitis (NEC) is a life-threatening condition affecting predominately premature and very low birth weight neonates. Emergency treatment with temporary enterostomy often leads to growth failure.• There is no consensus on the optimal timing for stoma reversal, hence prolonging impact on growth during crucial developmental periods. Both malnutrition and surgical NEC are independently associated with poor neurodevelopment outcome.What is New:• Our study found growth in 89% of babies deteriorated while living with a stoma, with 42% having a weight-for-age z-score < - 3, meeting the WHO criteria of being severely underweight, despite judicial use of parenteral nutrition. Applying z-score to weight measurements will allow growth trajectory to be accounted for in clinical decisions, including nutrition prescription (both enteral and parenteral), and guide timing of stoma closure.• Surgeons who target stoma closure at a certain weight risk waiting for an indefinite period of time, during which babies' growth may falter.

Patient safety in palliative care: A mixed-methods study of reports to a national database of serious incidents.

BACKGROUND: Patients receiving palliative care are vulnerable to patient safety incidents but little is known about the extent of harm caused or the origins of unsafe care in this population. AIM: To quantify and qualitatively analyse serious incident reports in order to understand the causes and impact of unsafe care in a population receiving palliative care. DESIGN: A mixed-methods approach was used. Following quantification of type of incidents and their location, a qualitative analysis using a modified framework method was used to interpret themes in reports to examine the underlying causes and the nature of resultant harms. SETTING AND PARTICIPANTS: Reports to a national database of 'serious incidents requiring investigation' involving patients receiving palliative care in the National Health Service (NHS) in England during the 12-year period, April 2002 to March 2014. RESULTS: A total of 475 reports were identified: 266 related to pressure ulcers, 91 to medication errors, 46 to falls, 21 to healthcare-associated infections (HCAIs), 18 were other instances of disturbed dying, 14 were allegations against health professions, 8 transfer incidents, 6 suicides and 5 other concerns. The frequency of report types differed according to the care setting. Underlying causes included lack of palliative care experience, under-resourcing and poor service coordination. Resultant harms included worsened symptoms, disrupted dying, serious injury and hastened death. CONCLUSION: Unsafe care presents a risk of significant harm to patients receiving palliative care. Improvements in the coordination of care delivery alongside wider availability of specialist palliative care support may reduce this risk.

Deaths following prehospital safety incidents: an analysis of a national database.

INTRODUCTION: Ensuring patient safety in the prehospital environment is difficult due to the unpredictable nature of the workload and the uncontrolled situations that care is provided in. Studying previous safety incidents can help understand risks and take action to mitigate them. We present an analysis of safety incidents related to patient deaths in ambulance services in England. METHODS: All incidents related to a patient death reported to the National Reporting and Learning System from an ambulance service between 1 June 2010 and 31 October 2012 were subjected to thematic analysis to identify the failings that led to the incident. RESULTS: Sixty-nine incidents were analysed, equating to one safety incident-related death per 168 000 calls received. Just three event categories were identified: delayed response (59%, 41/69), shortfalls in clinical care (35%, 24/69) and injury during transit (6%, 4/69). Primary failures differed for the categories: problems with dispatch caused the majority of delays in response, with equipment problems and bad weather accounting for the remainder. Failure to provide necessary care was predominantly caused by clinical misjudgements by ambulance staff and equipment issues underlay incidents that led to a patient injury. CONCLUSIONS: Improvements intended to address safety related mortality in the ambulance service should include ensuring adequate equipping and resourcing of ambulance services, improving coordination and decision-making during dispatch and supporting individual staff members in the difficult decisions they are faced with.

Abdominal Ultrasound Scanning for NEC in Babies at the Threshold of Viability: A Single Centre Experience.

AIM: Neonatal units are caring for increasing numbers of babies born <24 weeks gestation. These babies are vulnerable to developing necrotising enterocolitis (NEC). Their presentation is often atypical, both clinically and radiologically. Optimal diagnostic strategies are not yet known. We report our experience of abdominal ultrasound scanning (AUSS) to clarify its role. METHODS: All babies in a single neonatal surgical centre born <24 weeks gestation undergoing AUSS for suspected NEC from January 2015 to January 2023 were included. We compared abdominal ultrasound findings with plain radiographs and correlated these to intraoperative findings. RESULTS: Thirty-nine babies born <24 weeks gestation were diagnosed with NEC during the study period, and of these seventeen had an AUSS and formed the study cohort. Twelve underwent laparotomy at which NEC was confirmed, and the remaining five were managed non-operatively. Abdominal radiograph findings were: Paucity of gas (12), gaseous dilatation (2), paucity of gas with proximal dilatation (1), pneumatosis (1), and lucencies over the liver (1). In twelve cases who underwent surgery, AUSS findings were (more than one possible): Complex ascites (6), inflamed bowel (4), aperistaltic bowel (3), mass/collection (4), pneumatosis (1). All had NEC confirmed at laparotomy. In five cases who did not progress to surgery, findings were: Simple free fluid (2), pneumatosis (2), inflamed bowel (1), aperistaltic bowel (1). None of these cases subsequently underwent surgery or died of complications of NEC. CONCLUSION: AUSS is a useful imaging modality for NEC in babies born <24 weeks gestation. It can reliably identify babies who would benefit from surgery. TYPE OF STUDY: Retrospective cohort study.

Water beads ingestion presenting with repeated bowel obstruction in an infant.

An infant presented repeatedly with features of transient bowel obstruction 72 hours after unwitnessed ingestion of water beads. At the third presentation 5 days later, he underwent laparotomy and jejunal enterotomy for retrieval of obstructing water bead in the duodenum. Four other water beads were retrieved. Due to persistent obstructive symptoms, he had a relaparotomy on fourth postoperative day. A further obstructing bead at the duodenojejunal flexure was retrieved. Antegrade upper gastrointestinal endoscopy and retrograde endoscopy through the enterotomy were performed to ensure no further retained water beads. The patient progressed well postoperatively and was discharged home 5 days later. This case highlights the challenges involved in the diagnosis and management of water bead ingestion in children. Children under 2 years are at a higher risk of complications and most require intervention. Palpation alone can miss residual water beads at surgery. Endoscopy including intraoperative enteroscopy could be a useful adjunct.

Complete Resection of Necrotic Bowel Improves Survival in NEC Without Compromising Enteral Autonomy.

AIMS: Controversy persists regarding operative strategy for necrotising enterocolitis (NEC). Some surgeons advocate resecting all necrotic bowel, whilst others defunction with a stoma, leaving diseased bowel in situ to preserve bowel length. We reviewed our institutional experience of both approaches. METHODS: Neonates undergoing laparotomy for NEC May 2015-2019 were identified. Data extracted from electronic records included: demographics, neonatal Sequential Organ Failure Assessment (nSOFA) score at surgery, operative findings, and procedure performed. Neonates were assigned to two groups according to operative strategy: complete resection of necrotic bowel (CR) or necrotic bowel left in situ (LIS). Primary outcome was survival, and secondary outcome was enteral autonomy. Outcomes were compared between groups. RESULTS: Fifty neonates were identified. Six were excluded: 4 with NEC totalis and 2 with no visible necrosis or histological confirmation of NEC. Of the 44 remaining neonates, 27 were in the CR group and 17 in the LIS group. 32 neonates survived to discharge (73%). On univariate analysis, survival was associated with lower nSOFA score (P = 0.003), complete resection of necrotic bowel (OR 9.0, 95% CI [1.94-41.65]), and being born outside the surgical centre (OR 5.11 [1.23-21.28]). On Cox regression multivariate analysis, complete resection was still strongly associated with survival (OR 4.87 [1.51-15.70]). 28 of the 32 survivors (88%) achieved enteral autonomy. There was no association between operative approach and enteral autonomy (P = 0.373), or time to achieve this. CONCLUSION: Complete resection of necrotic bowel during surgery for NEC significantly improves likelihood of surviving without negatively impacting remaining bowel function. LEVEL OF EVIDENCE: III.

Exploring Growth Failure in Neonates With Enterostomy.

AIM OF THE STUDY: Neonatal enterostomy is a known risk for growth failure. We hypothesized that episodes of inflammation may drive a catabolic state, exploring this by assessing serum biochemistry alongside growth trajectory in enterostomy patients. METHODS: A retrospective analysis of infants with histologically confirmed NEC from 01/2012-07/2021 in a tertiary neonatal surgical centre was performed. Change in weight-for-age Z-score (ΔZ) between stoma formation and closure was calculated. Serum CRP (C-reactive protein), urea, and creatinine levels were recorded and duration of elevated levels calculated as Area Under Curve (AUC). We examined for trends of serum levels rising together using intersecting moving averages. Spearman's correlation analysis was performed, while multivariable linear regression examined factors associated with ΔZ. RESULTS: 79 neonates were included. At stoma formation, median Z-score was -1.42 [range -4.73, +1.3]. Sixty-two patients (78 %) had a fall in Z-score during their time with a stoma, 16 (20 %) had a ΔZ less than -2. Urea AUC was significantly univariably correlated with ΔZ and remained statistically significant in a multivariable model (Exp(B) x 100 = -0.57[-1, -0.09]; p = 0.022). The number of biomarker peaks correlated significantly with ΔZ for urea (r = -0.25; p = 0.025) and CRP (r = -0.35; p = 0.0017) but not Creatinine (r = -0.21; p = 0.066). Analysing the number of peaks of any combination of variables coinciding was consistently significantly correlated negatively with ΔZ (r = -0.29 to -0.27; p ≤ 0.016 for all). CONCLUSION: Our data shows that infants who were more severely affected by growth failure had more frequent and severe uremia while they had a stoma (suggesting a catabolic state). Disturbances in urea were commonly associated with CRP, suggesting that inflammation is a significant factor in growth failure in these infants. These findings promote aggressive management of sepsis in these infants, as well as suggesting an earlier closure of stoma to minimise their "at-risk"' period.

The Community Cost of Maintaining Gastrostomies in Pediatric Patients.

The use of gastrostomies in children is increasing and their need for long-term management following insertion presents a potentially significant financial and resource challenge to local healthcare systems. Objectives: The aim of this study was to determine the yearly cost of maintaining a gastrostomy in a pediatric patient. Methods: A retrospective, bottom-up cost-analysis was conducted in a cohort of 180 patients with gastrostomies aged 0-19 years. One in 5 patients were randomly selected for individual cost analysis (n = 36). Their electronic health record was interrogated from the period of March 1, 2019-March 1, 2020. Costs included in the analysis were staff contact time from the community nursing and nutrition teams, and equipment costs. Results: The mean cost of maintaining a pediatric gastrostomy across all ages was £709.87 (SD 403.18) per year. Mean annual cost varied by age, underlying diagnosis, and gastrostomy device, but this variation was only statistically significant for the type of device, with Mic-Key buttons having a mean annual cost of £834.66 (SD 307.85), Mini buttons £799.06 (SD 395.01), and percutaneous endoscopic gastrostomy tubes £279.34 (SD 297.45; P = 0.004). Conclusion: The mean cost of maintaining a gastrostomy in a pediatric patient is just over £700 per year. The cost is the highest as a child enters adulthood. Button devices have higher maintenance costs compared with percutaneous endoscopic gastrostomy tubes.

Mixed-methods feasibility study to inform a randomised controlled trial of proton pump inhibitors to reduce strictures following neonatal surgery for oesophageal atresia.

OBJECTIVES: This mixed-methods feasibility study aimed to explore parents' and medical practitioners' views on the acceptability and design of a clinical trial to determine whether routine prophylactic proton pump inhibitors (PPI) reduce the incidence of anastomotic stricture in infants with oesophageal atresia (OA). DESIGN: Semi-structured interviews with UK parents of an infant with OA and an online survey, telephone interviews and focus groups with clinicians. Data were analysed using reflexive thematic analysis and descriptive statistics. PARTICIPANTS AND SETTING: We interviewed 18 parents of infants with OA. Fifty-one clinicians (49 surgeons, 2 neonatologists) from 20/25 (80%) units involved in OA repair completed an online survey and 10 took part in 1 of 2 focus groups. Interviews were conducted with two clinicians whose survey responses indicated they had concerns about the trial. OUTCOME MEASURES: Parents and clinicians ranked the same top four outcomes ('Severity of anastomotic stricture', 'Incidence of anastomotic stricture', 'Need for treatment of reflux' and 'Presence of symptoms of reflux') as important to measure for the proposed trial. RESULTS: All parents and most clinicians found the use, dose and duration of omeprazole as the intervention medication, and the placebo control, as acceptable. Parents stated they would hypothetically consent to their child's participation in the trial. Concerns of a few parents and clinicians about infants suffering with symptomatic reflux, and the impact of this for study retention, appeared to be alleviated through the symptomatic reflux treatment pathway. Hesitant clinician views appeared to change through discussion of parental support for the study and by highlighting existing research that questions current practice of PPI treatment. CONCLUSIONS: Our findings indicate that parents and most clinicians view the proposed Treating Oesophageal Atresia with prophylactic proton pump inhibitors to prevent STricture (TOAST) trial to be feasible and acceptable so long as infants can be given PPI if clinicians deem it clinically necessary. This insight into parent and clinician views and concerns will inform pilot phase trial monitoring, staff training and the development of the trial protocol.

Oesophageal lengthening by traction in oesophageal atresia: The UK experience.

AIMS: Preliminary reports suggest a promising role for oesophageal lengthening by traction (OLBT) in long gap oesophageal atresia (LGOA). Nevertheless, these encouraging results originate from specialist centres, and real-world experience is unquantified. We report the first multicentre, nationwide study of OLBT. METHODS: Cumulative experience of OLBT was recorded through a questionnaire sent to all UK paediatric surgery centres. OLBT was defined as "any attempt to increase oesophageal length using tension sutures". Contributors submitted all cases of attempted OLBT, regardless of outcome. Demographics, surgical detail, and outcomes were analysed with summary statistics. RESULTS: The response rate was 23/26 centres. Eleven centres reported using OLBT in 22 patients (2003-2020) with 117 LGOA treated by other means. One patient died from complications of cardiac surgery and was excluded. OLBT enabled oesophageal anastomosis in 16 (76%), of which 2 died of complications of surgery, and another died of unrelated disease. Of the survivors, 7 required oesophageal dilatation 2-14 times. Oesophageal anastomosis was not achieved in 5 (24%) patients. All had pouch leak or disruption pre- or peri-operatively and underwent cervical oesophagostomy with subsequent gastric pull-up. One patient required dilatation of the oesophagogastric anastomosis. CONCLUSION: OLBT is being carried out in the UK in a limited number of centres in a minority of patients. These data suggest OLBT enables oesophageal anastomosis in 76% of infants with LGOA. Oesophageal pouch leak or disruption was common to all instances of failure to anastomose. Our findings will inform discussions between surgeons and families of babies born with LGOA.

Exomphalos with intestinal fistulation: Case series and systematic review for clinical characterization, management and embryopathogenesis.

INTRODUCTION: Exomphalos with intestinal fistulation (EIF) is a rare variant of exomphalos with intestine opening to the surface of an intact sac, and may result in a diagnostic challenge. We report 3 new cases and conducted a systematic review of the literature, to characterize its association with the type of exomphalos and vitellointestinal duct (VI) as well as to evaluate its management and outcomes. METHODS: A literature search from PubMed using keywords pertaining to exomphalos and fistulation was used to identify all unique cases reported between 1950 and 2020, in addition to the case series reported here, to establish the clinical presentation, histological findings, management and outcomes. RESULTS: We found a total of 28 cases of EIF, of which 25 had been reported in 70 years from 19 reports. There was a male predominance (4-to-1 ratio). The majority presented as an exomphalos minor (n = 23, 82%) with a prolapsing patent VI duct (n = 16, 57%), most had evidence of Meckel's diverticulum (n = 25, 89%). All but one case were managed by fistula excision with or without ileal resection and anastomosis, followed by primary closure of the abdominal wall defect. All patients, except one with Trisomy 13 who received only palliative care, underwent surgery. Post-operative complications occurred in 7 patients (25%). Congenital anomalies were present in 12 (43%) and none had Beckwith-Wiedemann syndrome. Mortality occurred in 4 patients (14%) between 3 and 17 days. One EIF with exomphalos major failed early conservative treatment due to sac disintegration and sepsis, requiring staged closure, but had a good outcome. DISCUSSION: EIF is a rare entity usually associated with exomphalos minor and vitelline duct involvement. EIF presentation is variable but primary surgery is the mainstay of treatment with generally good outcomes. Common features of EIF suggest a different embryopathogenesis to other forms of exomphalos.

The acute scrotum in infancy: A retrospective regional study.

INTRODUCTION: Testicular torsion during infancy (<1 year) is known to be a rare event with relatively few studies on the subject in the published scientific literature. We reviewed the experience of infant scrotal exploration within a paediatric surgical network of four centres serving an approximate paediatric population of 1.8 million. AIM: To review current practice of scrotal explorations in infancy and explore areas for improvement. METHOD: Retrospective review of emergency operations for acute scrotum between January 2016 and December 2018. Data are presented as median (range) and compared using non-parametric tests. P < 0.05 was regarded as significant. RESULTS: A total of 560 paediatric scrotal explorations were performed. Of these, 25 (4%) were under one year at the time of surgery, median 4 months (1 day-5 months) (Fig. 1). The most common diagnosis was "epididymitis" (11/25, 44%). Testicular torsion was found in 28% (7/25), increasing to 66% (4/6) in those under one month. Of those with confirmed testicular torsion, three (43%) underwent a primary orchiectomy with contralateral fixation and three (43%) detorsion and bilateral fixation, with all three cases found to have testicular atrophy at follow-up. The final case was of metachronous torsion, with the initial presentation not operated on and the subsequent presentation undergoing detorsion and fixation. This was the only case of testicular salvage in our series. There were no underlying urological issues in any patient and no reported complications or ongoing urological issues post-surgery. The rate of follow-up was 17/25 (68%). CONCLUSION: We present one of the only clinical series to focus on acute scrotum in the under one year old and not just the neonatal period. Testicular torsion remains a rare event in this age group but invariably leads to testicular loss.

Outcomes for necrotising enterocolitis (NEC) in babies born at the threshold of viability: a case-control study.

BACKGROUND: The threshold for active management of babies born prematurely in the UK is currently 22 weeks. The optimal management strategy for necrotising enterocolitis (NEC) in babies born at or near this threshold remains unclear. AIM: To review our institutional experience of babies born <24 weeks diagnosed with NEC, identify risk factors for NEC, and compare outcomes with a control cohort. METHODS: All infants born <24 weeks gestation January 2015-December 2021 were identified. Babies diagnosed with NEC were defined as cases and babies with no NEC diagnosis as controls. Patient demographics, clinical features, complications and outcomes were extracted from the medical record and compared between cases and controls. RESULTS: Of 56 babies, 31 (55.3%) were treated for NEC. There was no difference in NEC-specific risk factors between cases and controls. 17 babies (30.4%) underwent surgery, of these, 11/17 (64.7%) presented with a C reactive protein rise and 11/17 (64.7%) a fall in platelet count. Pneumatosis intestinalis (3/17 (17.7%)) or pneumoperitoneum (3/17 (17.7%)) were present in only a minority of cases. Abdominal ultrasound demonstrated intestinal perforation in 8/8 cases. The surgical complication rate was 5/17 (29.4%). There was no difference in the incidence of intraventricular haemorrhage, periventricular leukomalacia and survival to discharge between the groups. CONCLUSIONS: The diagnosis of NEC in infants born <24 weeks gestation is challenging with inconsistent clinical and radiological features. Ultrasound scanning is a useful imaging modality. Mortality was comparable regardless of a diagnosis of NEC. Low gestational age is not a contraindication to surgical intervention in NEC.

Fetal magnetic resonance imaging (MRI) enhances the diagnosis of congenital body anomalies.

AIMS: We sought to assess variability and concordance between fetal MRI and ultrasound (USS) in the evaluation of fetal body abnormalities. METHODS: All fetal body anomalies reported on F-MRI within the iFIND database (http://www.ifindproject.com) were included. Differences in findings regarding anomalies on contemporaneous USS were explored. Three clinical specialists evaluated each case independently, and the anomaly severity was graded: as "insignificant" to "lethal". The value of MRI in alteration of either antenatal or postnatal care was established. RESULTS: Fifty-four cases were identified consisting of 5 healthy controls, 37 with USS-identified body anomalies, and 12 with known CNS or cardiac anomalies. In fetuses with a known body anomaly, information on the MRI was relevant to change the clinical course in 59% of cases. There was also an incidental detection rate of 7% in fetuses with known cardiac or CNS anomalies, or 1.5% of normal control, although these were rarely clinically relevant. Importantly, fetuses undergoing MRI for cardiac concerns did have major anomalies that were missed (one case of oesophageal atresia and two cases of ARM). CONCLUSIONS: In cases where fetal anomalies are suspected, F-MRI is a valuable means of further characterizing anomalies and may detect additional anomalies in fetuses with recognized cardiac or CNS anomalies. In fetuses with a recognized body anomaly, more than half of those scanned by MRI had information available which changed clinical management. Importantly there were also incidental findings in healthy control fetuses, so the management of these needs to be recognized in fetal MRI research. LEVEL OF EVIDENCE: II, Prospective cohort study.