Outcome a decade after laparoscopic and open Nissen fundoplication in children: results from a randomized controlled trial.

BACKGROUND: Randomized controlled trials (RCT) comparing long-term outcome after laparoscopic (LF) and open fundoplication (OF) in children are lacking. Here we report recurrence rates and time to recurrence, frequency of re-interventions, use of antisecretory drugs, gastrointestinal symptoms, and patient/parental satisfaction a decade after children were randomized to LF or OF. METHODS: Cross-sectional long-term follow-up study of a two-center RCT that included patients during 2003-2009. Patients/parents were interviewed and medical charts reviewed for any events that might be related to the fundoplication. If suspicion of recurrence, further diagnostics were performed. Informed consent and ethical approval were obtained. CLINICALTRIALS: gov: NCT01551134. RESULTS: Eighty-eight children, 56 (64%) boys, were randomized (LF 44, OF 44) at median 4.4 [interquartile range (IQR) 2.0-8.9] years. 46 (52%) had neurological impairment. Three were lost to follow-up before first scheduled control. Recurrence was significantly more frequent after LF (24/43, 56%) than after OF (13/42, 31%, p = 0.004). Median time to recurrence was 1.0 [IQR 0.3-2.2] and 5.1 [IQR 1.5-9.3] years after LF and OF, respectively. Eight (19%) underwent redo fundoplication after LF and three (7%) after OF (p = 0.094). Seventy patients/parents were interviewed median 11.9 [IQR 9.9-12.8] years postoperatively. Among these, use of anti-secretory drugs was significantly decreased from preoperatively after both LF (94% vs. 35%, p < 0.001) and OF (97% vs. 19%, p < 0.001). Regurgitation/vomiting were observed in 6% after LF and 3% after OF (p = 0.609), and heartburn in 14% after LF and 17% after OF (p = 1.000). Overall opinion of the surgical scars was good in both groups (LF: 95%, OF: 86%, p = 0.610). Patient/parental satisfaction with outcome was high, independent of surgical approach (LF: 81%, OF: 88%, p = 0.500). CONCLUSIONS: The recurrence rate was higher and recurrence occurred earlier after LF than after OF. Patient/parental satisfaction with outcome after both LF and OF was equally high.

Evaluation of diagnostic factors used to refer children with constipation for rectal biopsies.

PURPOSE: Children with constipation and suspected Hirschsprung's disease are referred for rectal biopsy. Since this is an invasive procedure, appropriate indications should be applied to minimize the number of "unnecessary" biopsies. METHODS: We reviewed all constipated children who underwent a rectal biopsy to diagnose a possible Hirschsprung's disease at a tertiary referral hospital over a 6-year period (2013-2018). We registered clinical and demographic factors in these children and conducted correlation and multivariate regression analysis to evaluate the relation between these factors and a diagnosis of Hirschsprung's disease. RESULTS: We identified 225 children, aged 0-17 years. In total, Hirschsprung's disease was diagnosed in only 49/225 (22%). Among the 49 children with Hirschsprung's disease, 29 (59%) were diagnosed in the neonatal period. Among girls, HD was confirmed in only 10/101 (10%) children, and only 1 of these 10 girls was older than 6 months at the time of the biopsy. The following factors correlated significantly with Hirschsprung's disease diagnosis in children older than 1 month: "male sex", "failure to thrive", "gross abdominal distention plus vomiting" and "fulfils the Rome 4 criteria for functional constipation". CONCLUSION: In children referred for rectal biopsy, the factors most indicative of Hirschsprung's disease were "male sex", "failure to thrive", "gross abdominal distention plus vomiting" and "fulfils the Rome 4 criteria for functional constipation". Notably, the prevalence of Hirschsprung's disease decreased with the increasing age of the children. Girls referred for a biopsy rarely had Hirschsprung's disease, especially those older than 1 month.

Nutritional Status in Adolescents with Esophageal Atresia.

OBJECTIVES: To examine factors that may affect nutritional status in adolescents with esophageal atresia. STUDY DESIGN: Anthropometric measurements, blood samples, pH measuring, mapping of dysphagia with a modified Easting Assessment Test questionnaire, 4-day dietary record, and a semistructured interview about eating habits and nutrition counseling were performed in a cross-sectional cohort of adolescents with esophageal atresia. RESULTS: Out of 102 eligible patients, 68 (67%) participated. The median height-for-age Z score was -0.6 (-4.6 to 1.8). Ten (15%) were classified as stunted (height-for-age Z score <-2). Fourteen (21%) were overweight. More than two-thirds reported symptoms of dysphagia (Easting Assessment Test score ≥3) and avoided specific foods. Forty-eight (71%) completed the 4-day dietary record, which showed daily intake of energy below age-appropriate recommendations. One-third reported an energy intake below their estimated basal metabolic rate. Only 24% had received counselling from a dietitian. CONCLUSIONS: Adolescents with a history of esophageal atresia have growth below reference values and energy intake below recommendations. Energy intake and its relation to stunting needs to be further studied in patients with esophageal atresia.

Psychologic Distress and Anxiety in Mothers of Children With Gastroesophageal Reflux Undergoing Antireflux Surgery.

OBJECTIVES: Parents of children with a chronic illness are at risk for impaired psychosocial functioning. Gastroesophageal reflux disease (GERD) is such a disease, and no studies have investigated effects of antireflux surgery on parental psychological distress. The aims of this study were to assess psychological distress and state and trait anxiety in mothers of children with GERD, and to explore possible changes after antireflux surgery. METHODS: Mothers of children referred for antireflux surgery were included in this prospective study. Standardized questionnaires were used to evaluate psychological distress and state and trait anxiety before and 12 months after antireflux surgery. RESULTS: Of 87 eligible mothers of children with GERD, 62 (71%) agreed to participate. All children had objectively verified GERD by 24-hour pH-monitoring and/or upper gastrointestinal contrast study and unsatisfactory symptom relief of pharmacological treatment. Thirty-one (50%) mothers returned questionnaires postoperatively. Preoperatively, mothers of children undergoing antireflux surgery reported high levels of psychological distress and state anxiety, and 54% had scores indicating clinically significant psychological distress. None of the preoperative child characteristics were found to significantly influence maternal psychological distress or state anxiety. Twelve months postoperatively, both psychological distress and state anxiety were reduced. CONCLUSIONS: Mothers of children undergoing antireflux surgery reported reduced levels of psychological distress and state anxiety 12 months after the operation.

Outcome for biliary atresia patients treated at a low-volume centre.

OBJECTIVES: The importance of case load for treatment of extrahepatic biliary atresia (BA) is debated. The aim of this study was to register results of BA treatment in a small volume centre. METHODS: Retrospective chart review study of patients with BA treated from 2000 to 2017. The institutional review board approved the study. RESULTS: Forty-five babies were identified of which 42 (93%) are alive. Forty-one patients had a Kasai portoenterostomy (PE), two had a hepaticojejunostomy and two had a primary liver transplantation. The age at PE/hepaticojejunostomy was median 63 (4-145 days). Seven surgeons performed the operations, and the median duration of the diagnostic work-up was 8 (3-24) days. Clearance of jaundice was achieved in 23/43 (53%) babies, and 3- and 5-year native liver survival was 47% and 40%, respectively. Clearance of jaundice post-PE/hepaticojejunostomy was a strong predictor of native liver survival (adjusted OR: 0.027; 95%; p = .009). Plasma level of conjugated bilirubin at time of referral was also a significant predictor of native liver survival (adjusted OR: 1.053; p = .017). CONCLUSION: A small volume centre may achieve satisfactory results for BA patients. The study has, however, identified factors that may further improve results; earlier referral, optimizing diagnostic work-up and establishing one dedicated surgical team.

Trends in the use of gastrostomies at a tertiary paediatric referral centre.

OBJECTIVES: The aims of this study were to describe the population of paediatric patients undergoing gastrostomy placement at a Norwegian tertiary referral centre and to investigate trends over time in patient characteristics and operative technique. MATERIALS AND METHODS: Patients <15 years of age getting a primary gastrostomy from 1994 to 2012 were included in this retrospective observational study. Patient data were collected from medical records and the National Registry. RESULTS: Six-hundred forty-nine patients with a median age of 1.2 years [gestational week 30-14.9 years] were included. Neurological disorders (ND) was the most common underlying group of diagnosis (n = 311, 48%), followed by cardiac disease 104 (16%), congenital anomalies 85 (13%), respiratory disease 43 (7%), malignancy 29 (5%), and others 77 (12%). At follow-up, 162 (25%) patients were dead. A percutaneous endoscopic technique (PEG) was used in 401 (62%) patients, open surgery (OPEN) in 201 (31%) and laparoscopy (LAP) in 47 (7%). The number of gastrostomies per year more than doubled during the period (p < 0.001). More patients with cardiac disease and congenital anomalies were given a gastrostomy during the last years (all p < 0.05), whereas the number of patients with ND remained stable. Furthermore, there has been a decrease in median age and an increase in the number of PEG and LAP (p < 0.05). CONCLUSION: The number of gastrostomy insertions has increased from 1994 to 2012. NDs is the most common underlying diagnosis in patients receiving a gastrostomy, PEG is the most common technique and patient characteristics have changed during the study period.

Randomized Controlled Trial of Laparoscopic and Open Nissen Fundoplication in Children.

OBJECTIVE: The aim was to compare recurrence of gastroesophageal reflux disease (GERD) in children randomized to laparoscopic (LF) or open Nissen fundoplication (OF). BACKGROUND: LF is considered superior to OF by most pediatric surgeons even though this has not been shown in any randomized controlled trial in children. METHODS: Patients referred for fundoplication between 2003 and 2009 were eligible for inclusion in this 2-center, unstratified, randomized, parallel-group study conducted in Norway. The main outcome measure was recurrence of GERD, which was defined as GERD combined with a reflux index greater than 4 on pH monitoring and/or gastroesophageal reflux and/or herniated wrap on upper gastrointestinal (UGI) contrast study. Only experienced laparoscopic surgeons performed the LF. Postoperative follow-up included 24-hour pH monitoring, UGI contrast study, and a clinical examination at 6 months and phone interviews after 1, 2, and 4 years. RESULTS: Eighty-seven children were included and randomized to either LF (n = 44) or OF (n = 43). Median age was 4.7 years (0.2-15.4) in the LF group and 3.7 years (0.2-14.2) in the OF group. Twenty-three patients in both groups were neurologically impaired. Median follow-up time was 4.0 years (0.3-8.9). Significantly more patients undergoing LF (37%) experienced recurrence of GERD compared to those undergoing OF (7%); risk ratio for recurrence in the LF group was 5.2 (95% confidence interval: 1.6-16.6) (P = 0.001). CONCLUSIONS: Children operated with LF have a higher recurrence rate of GERD than those operated with OF.

Inflammatory response after open and laparoscopic Nissen fundoplication in children: a randomized study.

PURPOSE: It is assumed that laparoscopic surgery generally induces less inflammatory responses than open surgery. Since few studies have compared immune responses after laparoscopic and open surgery in children, we examined inflammatory markers in children randomized to open (ONF) or laparoscopic Nissen fundoplication (LNF). METHODS: Blood samples were collected prior to surgery (D0), and on postoperative day 1 (D1) and day 2 (D2). Inflammatory markers were measured using a multiplex antibody bead kit. The postoperative levels of inflammatory markers were statistically analyzed using a linear mixed model. A P value <0.05 was considered statistically significant. RESULTS: Twenty-nine patients randomized to ONF or LNF were included. Median age was 3.1 years (range 1.0-14.2) in the ONF group and 4.0 years (range 0.2-14.2) in the LNF group. Plasma levels of the anti-inflammatory cytokine interleukin (IL)-10 were significantly higher in the ONF group than in the LNF group postoperatively (P = 0.04). However, there were no significant differences between the groups in the levels of pro-inflammatory markers tumor necrosis factor-α, IL-6, IL-8, monocyte chemoattractant protein-1, white blood cell count, or C-reactive protein. CONCLUSIONS: We did not find that laparoscopy induced a substantially less inflammatory response than laparotomy in children undergoing fundoplication.

New insights in the prevalence of scoliosis and musculoskeletal asymmetries in adolescents with esophageal atresia.

BACKGROUND: Increased risk of scoliosis and musculoskeletal abnormalities in adolescents with esophageal atresia (EA) is reported, but the impact of these abnormalities on physical fitness and motor skills are not known. METHODS: Scoliosis was assessed radiographically and shoulder and chest abnormalities by a standardized protocol. Physical fitness was evaluated with Grippit, Six-minute walk test, and International Physical Activity Questionnaire and motor skills by Motor Assessment Battery for Children. RESULTS: Sixty-seven EA adolescents median 16 (13-20) years participated. The prevalence of significant scoliosis (≥ 20º) was 12% (8/67) whereas 22% (15/67) had mild scoliosis (10-19º). Vertebral anomalies occurred in 18/67 (27%), eight of them (44%) had scoliosis. The majority of adolescents (15/23) with scoliosis did not have vertebral anomalies. Musculoskeletal abnormalities were detected in 22-78%. Balance problems occurred three times more frequently than expected (44% vs. 15%, p = 0.004). Submaximal exercise capacity was significantly reduced compared to reference values (p < 0.001). Scoliosis ≥ 20º was related to reduced physical activity (p = 0.008), and musculoskeletal abnormalities to reduced physical activity and impaired motor skills (p = 0.042 and p < 0.038, respectively). CONCLUSIONS: Significant scoliosis was diagnosed in 12% of the EA adolescents and related to reduced physical activity. Musculoskeletal abnormalities identified in more than half of the patients, were related to reduced physical activity and impaired motor skills, and exercise capacity was significantly below reference group. EA patients with and without vertebral anomalies need health-promoting guidance to prevent impaired motor skills and consequences of reduced physical activity. LEVEL OF EVIDENCE: Prognostic Study, Level II.

Sexual well-being and penile appearance in adolescents operated for distal hypospadias in childhood.

BACKGROUND: The importance of patient-reported outcomes (PRO) in hypospadias is increasing. However, more knowledge is needed concerning genital self-perception on appearance and function in adolescents. The complication rates for distal hypospadias is different from that for severe hypospadias, and expected outcomes related to sexual well-being and cosmetics may also differ. OBJECTIVE: To investigate 16-year-olds' self-reported outcomes on penile appearance, sexual well-being, and voiding function in distal hypospadias, and compare with that of healthy male adolescents and a surgeon's view. STUDY DESIGN: Sixteen-year-old patients operated for distal hypospadias were included in this cross-sectional study and compared to a group of healthy adolescents. The assessment tools included the adolescents' self-perception on genital appearance and function measured by Pediatric Penile Perception Score (PPPS) and their responses to a structured interview. We also included information on clinical data from the electronic medical records, together with a physical examination and an uroflowmetry. RESULTS: Seventy patients and 61 healthy adolescents participated. Patients and the comparison group reported no differences on sexual well-being. The patients were satisfied with penile appearance, however their overall PPPS was significantly lower (8.9), compared to the comparison group (9.6, p = 0.03). Thirty-nine percent of patients had complications leading to re-interventions and reported lower scores on genital self-perception on appearance and function compared to those who had not re-interventions. Voiding function was normal. The surgeon's score on appearance was comparable to the patients' score. DISCUSSION: A key finding in our study is the patients' high satisfaction on sexual well-being, which was similar to healthy adolescents. The patients were also satisfied with penile appearance but scored significantly lower than the comparison group. Surgeons and patients had comparable scores on appearance; however, they seemed to emphasize different aspects of appearance. Our results on penile appearance and sexual well-being are comparable to those of other studies on distal hypospadias. In our study, re-interventions were associated with more negative genital self-perception on appearance and function, similar to findings in other studies. CONCLUSION: Our results show overall positive satisfaction on sexual well-being, voiding function and penile appearance despite less satisfaction on penile appearance when compared with the comparison group. Satisfaction was reported to be good also in patients experiencing re-interventions.

Clinical Variables as Indicative Factors for Endoscopy in Adolescents with Esophageal Atresia.

INTRODUCTION: Gastro-esophageal reflux disease (GERD) occurs frequently in patients operated for esophageal atresia (EA). Longstanding esophagitis may lead to dysphagia, strictures, columnar metaplasia, and dysplasia with an increased risk of adenocarcinoma. Are clinical factors and non-invasive assessments reliable indicators for follow-up with endoscopy? MATERIAL AND METHOD: A follow-up study with inclusion of EA adolescents in Norway born between 1996 and 2002 was conducted. Clinical assessment with pH monitoring, endoscopy with biopsies, along with interviews and questionnaires regarding gastroesophageal reflux disease (GERD) and dysphagia were performed. RESULTS: We examined 68 EA adolescents. 62% reported GERD by interview, 22% by questionnaire. 85% reported dysphagia by interview, 71% by questionnaire. 24-hour pH monitoring detected pathological reflux index (RI) (>7%) in 7/59 (12%). By endoscopy with biopsy 62 (92%) had histologic esophagitis, of whom 3 (4%) had severe esophagitis. Gastric metaplasia was diagnosed in twelve (18%) adolescents, intestinal metaplasia in only one (1.5%). None had dysplasia or carcinoma. Dysphagia and GERD were statistically correlated to esophagitis and metaplasia, but none of the questionnaires or interviews alone were good screening instruments with high combined sensitivity and specificity. A compound variable made by simply taking the mean of rescaled RI and dysphagia by interview showed to be the best predictor of metaplasia (85% sensitivity, 67% specificity). CONCLUSION: The questionnaires and interviews used in the present study were not good screening instruments alone. However, combining dysphagia score by interview and RI may be helpful in assessing which patients need endoscopy with biopsy at each individual follow-up examination. LEVEL OF EVIDENCE: Level II prognostic study.

Maternal psychological distress and parenting stress after gastrostomy placement in children.

OBJECTIVES: The aim of the study was to evaluate stress in mothers of children with feeding problems before and after gastrostomy placement, and to identify changes in child health and variables affecting maternal stress. METHODS: Psychological distress and parenting stress in 34 mothers of children referred for gastrostomy were assessed using general health questionnaire (GHQ) (overall psychological distress), impact of event scale (IES) (intrusive stress related to child's feeding problems), and parenting stress index (PSI) (stress related to parenting) before, 6, and 18 months after placement of a gastrostomy. Information of child health and long-term gastrostomy complications were recorded. A semistructured interview constructed for the present study explored maternal preoperative expectations and child's quality of life. RESULTS: Insertion of a gastrostomy did not significantly influence vomiting or the number of children with a low weight-for-height percentile. All of the children experienced peristomal complications. Despite this, mothers' overall psychological distress was significantly reduced after 6 and 18 months, and the majority of mothers (85%) reported that their preoperative expectations were fulfilled and that the child's quality of life was improved after gastrostomy placement. Maternal concerns for the child's feeding problems, measured as intrusive stress, had effect on maternal overall psychological distress. CONCLUSIONS: Despite frequent stomal complications the gastrostomy significantly reduced the mothers' psychological distress and improved the child's quality of life as reported by the mother.

Parenting stress and emotional wellbeing in mothers and fathers of preschool children.

AIMS: The aims of the study were to compare parenting stress and emotional wellbeing in mothers and fathers of preschool children, to look for predictors of different aspects of parenting stress in mothers and fathers, and to discriminate parenting stress from psychological distress and anxiety. METHODS: We studied 256 mothers and 204 fathers of children aged 1-7 years. The Swedish Parenthood Stress Questionnaire (SPSQ) assesses stress related to parenting. Emotional wellbeing was defined by the General Health Questionnaire-28 (GHQ-28) and the State Anxiety Inventory (STAI-X1) that measures psychological distress and anxiety, respectively. RESULTS: Fathers reported significantly more social isolation than mothers (P < 0.001). On all other parameters mothers, had higher scores, representing more stress and less wellbeing than fathers. Anxiety and psychological stress were strong predictors of parental stress in both mothers and fathers. Furthermore, maternal parental stress was predicted by birth of subsequent children and younger child age. Higher educational attainment predicted increased role restriction in fathers and more health problems in mothers. A principal component analysis (PCA) of the SPSQ, GHQ-28, and STAI-X1 showed that all endpoints of the analysis are positively correlated. CONCLUSIONS: Fathers reported significantly more social isolation, but less role restriction, incompetence and state anxiety than mothers. The SPSQ together with GHQ-28 and STAI-X1 allow a targeted screening aimed at contrasting parents who experience reduced emotional wellbeing with those who struggle with stress directly related to their parenting role.

High satisfaction on genital self-perception and sexual function in healthy Norwegian male adolescents.

BACKGROUND: Genital self-perception and self-reported outcome on sexual function represent important information in studies focusing on male adolescents born with a genital malformation. Normal data from an age-matched control group are essential for comparison and more knowledge is needed concerning age after puberty and before entering adulthood. OBJECTIVE: To investigate the self-reported outcome on genital perception and sexual outcome of healthy male adolescents aged 16 and 17 years. STUDY DESIGN: Sixty-one individuals were included in this cross-sectional study. The assessment tools included the adolescents' self-report on genital perception and sexual function measured by the Pediatric Penile Perception Score (PPPS) and their responses to a semi-structured interview. In addition, we added information on mental health and psychosocial functioning measured by the Strengths and Difficulties Questionnaire, and health-related quality of life (HRQoL) measured by the Pediatric Quality of Life Inventory. Body satisfaction and self-esteem were also measured by the Global Self-Worth and Physical Appearance subscales of the revised version of the Self-Perception Profile for Adolescents (SPPA). RESULTS: Of the 73 individuals invited, a total of 61 participated. The adolescents reported high satisfaction on genital self-perception and sexual function with a score close to 10 on the overall PPPS score (maximum overall score is 12). Participants who were dissatisfied with their genitals reported penile length, alongside foreskin, as their main concern. More than 90% reported satisfaction on sexual function, concerning erection, masturbation, ejaculation, and orgasm. Results showed a higher score on body satisfaction, self-esteem, mental health and psychosocial functioning and a lower score on HRQoL compared to the normative Norwegian data. The small numbers of individuals that scored more negatively on genital self-perception and sexual function also scored more negatively in all items studied. DISCUSSION: A key finding in our study was their high satisfaction on the overall PPPS score and reported sexual function. The results are comparable to other studies related to healthy male adolescents and the sample studied deviate little from a representative Norwegian sample. A comparison group of age-matched adolescents from the normative population is important to determine long-term outcomes on genital appearance and sexual function of patients born with a genital malformation and operated on in early childhood. Limitations of this study are the small sample-size and the lack of information on non-participants. CONCLUSIONS: Our results show generally positive genital self-perception and sexual function in a healthy group of Norwegian male adolescents, aged 16 and 17.

Impaired motor performance in adolescents with esophageal atresia.

AIMS: The study prospectively assessed motor development from infancy to adolescence in patients with esophageal atresia (EA). METHODS: At one year of age motor performance was evaluated with the Psychomotor Developmental Index (PDI) of the Bayley Scales of Infant Development, Second Edition (BSID-II), and as adolescents reevaluated with Motor Assessment Battery for Children, Second Edition (MABC-2). Associations to clinical factors were assessed. RESULTS: 23 EA patients were followed from infancy to adolescence. The median total PDI score in infancy was 102 (56-118) and the corresponding mean z-score was -0.006 (SD 0.995) and not significantly different from the reference values (p = 0.48). The median total MABC-2 score in adolescence was 75 (32-93) and the corresponding mean z-score -0.43 (SD 0.998) which is significantly below normal (p = 0.03). Children with impaired motor function in adolescence underwent significantly more rethoracotomies than those with normal motor performance (p = 0.037); whereas the two groups did not differ with respect to other clinical characteristics. CONCLUSION: From infancy to adolescence the motor performance in the group of EA patients deteriorated from within normal range to significantly impaired compared to reference values. Interdisciplinary follow-up programs from infancy to adolescence with close monitoring for motor function is necessary to detect motor impairments.

Long-term parental psychological distress among parents of children with a malformation--a prospective longitudinal study.

We previously reported that prenatal diagnosis of malformations is associated with increased parental psychological distress after birth compared to distress in parents with postnatal diagnosis. We have now extended our earlier study to include a long-term follow-up of mothers and fathers 9 years after birth. Psychological responses were measured by General Health Questionnaire (GHQ-28), State Anxiety Inventory (STAI-X1), and Impact of Event Scale (IES) in 118 mothers and 100 fathers of 124 children with malformations 0-7 days (T1), 6 weeks (T2), 6 months (T3), and 9 years postpartum (T4). At T4 we observed no significant differences in psychological responses comparing parents with and without prenatal foreknowledge of their child's malformation. At T4 30.2% and 27.8% of the parents reported clinically important psychological distress and clinically important state anxiety, respectively. Intrusive stress decreased from T1 to T3, but increased significantly from T3 to T4. At T4 25.6% of the parents reported severe intrusive stress, with a higher proportion among mothers than fathers (32.8% vs. 17.2%, P = 0.029). In the multivariate analysis, unemployment predicted clinically important psychological distress at T4, whereas, clinically important state anxiety at T4 was predicted by low educational level. This study shows that prenatal diagnosis is associated with significantly increased psychological distress in the acute postnatal phase. However, there was no long-term increase in psychological distress among parents with prenatal foreknowledge of their child's malformation. The significantly increased intrusive stress at 9-year follow-up might reflect long-term challenges related to having a child with a malformation.

Underlying correlation structures of parental stress, general health and anxiety.

A partial least square regression (PLSR) was performed on the Swedish Parenthood Stress Questionnaire (SPSQ) sum score and subscales on incompetence, role restriction, social isolation, spouse relationship and health problems, using 42 items from the General Health Questionnaire (GHQ) and 20 items from the State Anxiety Inventory (STAI-X1). The dataset contained 227 fathers and 301 mothers of children aged 1.0-6.6 years from a population-based study on parental psychological distress in the general Norwegian population, and all items correlated positively with SPSQ. Subscales on spouse relationship, incompetence, social isolation and role restriction related to items on state anxiety and depression. The SPSQ subscale on health problems related to GHQ items on somatic symptoms and social dysfunction. The STAI-X1 item "not feeling rested" had a particularly important effect on parental stress. Underlying correlation structures between parental stress and items from STAI-X1 and GHQ were explored, but only the SPSQ sum score could be acceptably predicted. PLSR as a statistical methodology was found useful for health and psychometric data.

Short-term parent reported recovery following open and laparoscopic fundoplication.

BACKGROUND: It is assumed that children recover faster after laparoscopic (LF) than after open fundoplication (OF). As this has not been confirmed in any randomized study (RCT), we have in a subsection of a larger RCT compared parent reported recovery of children after LF and OF. METHODS: Postoperative symptoms, use of analgesics, overall well-being, and time to return to school/day-care were recorded in a subsection of children enrolled in a RCT comparing LF and OF. Ethical approval and parental consent were obtained. RESULTS: Fifty-five children (LF: n = 27, OF: n = 28) of the 88 enrolled in the RCT, were included in the short term follow up on parent reported recovery. Caregivers were interviewed median 28 days [interquartile range (IQR) 22-36] postoperatively. There was no significant difference regarding improvement in overall well-being (LF: 63%, OF: 68%, p = 0.70), new-onset dysphagia (LF: 30%, OF: 18%, p = 0.08), use of analgesics (LF: 15%, OF: 14%, p = 1.00), or time to return to school/day-care (LF: median 7 days [IQR 5-14] vs. OF: 12 days [IQR 7-15], p = 0.35). CONCLUSION: We could not demonstrate faster recovery after LF than after OF. Most children had returned to school/day-care after 2 weeks and had improved overall well-being 1 month after surgery. TYPE OF STUDY: Randomized controlled trial. LEVEL OF EVIDENCE: Level II.

Utility of ERCP in neonatal and infant cholestasis.

BACKGROUND AND STUDY AIMS: In neonates and infants with biliary obstruction, the diagnosis is important to establish early. Despite the use of several noninvasive imaging modalities, a definite diagnosis of biliary atresia (BA) or other pancreaticobiliary disorders may be difficult to ascertain. In this paper, we report our experience with endoscopic retrograde cholangiopancreaticography (ERCP) in the clinical situation of neonatal and infant jaundice. PATIENTS AND METHODS: Between 1999 and 2006, we performed 23 ERCP procedures in 22 neonates and infants with the provisional diagnosis of biliary obstruction where other imaging was inconclusive. The mean age was 2.4 months and the mean weight was 4.8 kg. A pediatric videoendoscope with an outer diameter of 7.5 mm was used in all patients. RESULTS: ERCP was successful in 20 of 23 patients. BA was suggested in 6 patients, all subsequently verified by surgery. Detailed visualization of biliary structures important for planning of treatment was performed in children with choledochal cysts and spontaneous biliary perforation. Cannulation of the ampulla failed in 3 patients, of whom 1 had BA, 1 a choledochal stone, and 1 bile plug syndrome. Only 1 therapeutic ERCP was performed in a child with a stone completely obstructing the ampulla. The only complications were 1 asymptomatic case of hyperamylasemia and 1 of mild cholangitis successfully treated with antibiotics. CONCLUSIONS: ERCP is feasible and safe in the workup of neonatal cholestasis where other imaging modalities are inconclusive. Despite the expanding role of magnetic resonance cholangiography, ERCP may still have a role in the multidisciplinary workup of these patients.

Low incidence of enterocolitis and colonic mucosal inflammation in Norwegian patients with Hirschsprung's disease.

BACKGROUND: Hirschsprung's disease (HD) may be associated with inflammation in the colon. Further, the etiology of Hirschsprung-associated enterocolitis (HEC) is unclear. To learn more about these features, we examined our cohort of HD patients during a period of 6 years for inflammation in their colonic mucosa as well as for signs of HEC. MATERIALS AND METHODS: Rectal suction biopsies and operative full thickness aganglionic and ganglionic colonic specimens from 36 patients were examined. Signs of inflammation were recorded in hematoxylin/eosin/saffron (HES)-stained sections and with fluorescence conjugated polyclonal antibodies to IgA and IgG applied on serial sections. The suction biopsies were also evaluated for the presence of mucus inspissation and crypt dilatation. Clinical signs of HEC were recorded from medical files of the same 36 patients. RESULTS: HES-staining revealed that seven patients had inflammation in the suction biopsies; these patients were significantly older than the patients without inflammation. Slight mucus inspissation was identified in suction biopsies of five out of 33 patients, but crypt abscesses or ulcerations were not found in any specimens. Virtually all very young patients (<3 months) had slight crypt dilatation. We identified inflammation in resected colonic segments from 17 out of 36 patients. Thirteen of these 17 had a diverting colostomy, and only one out of 14 patients with colostomy had no inflammation. Inflammatory changes were similar in ganglionic and aganglionic bowel. By immunofluorescence (IF) staining, inflammation was found in resected colonic segments from five patients. Four of these had a colostomy. HEC was diagnosed in three patients, and inflammation detected in resected specimens from only one of these three. CONCLUSIONS: We have not been able to identify particular characteristics in the colonic or rectal mucosa that are linked to development of HEC. Inflammation in the resected specimen was mainly found in patients with a diverting colostomy, and then in both ganglionic and aganglionic colon.