Cryptorchidism in Sweden: A Nationwide Study of Prevalence, Operative Management, and Complications.

OBJECTIVES: To review the cumulative prevalence, operative management, and complications of treatment for cryptorchidism in Sweden. STUDY DESIGN: A nationwide observational study from longitudinal register data of all Swedish-born boys 0-18 years of age, diagnosed with cryptorchidism from 2001 to 2014. Primary outcomes were occurrence and age at primary surgery. Secondary outcomes included type of procedure and surgical site infection. RESULTS: Of 20 375 boys diagnosed with cryptorchidism in 2001-2014, 12 766 were surgically treated. The cumulative childhood prevalence was 1.8% (95% CI, 1.5-2.0), with a higher prevalence in boys born prematurely, small for gestational age, or with low birth weight. The median age at treatment decreased from 6.2 years in 2001 to 3.4 years in 2014 (P < .001). Still, 94.1% (95% CI, 92.7-95.6) had surgery after the recommended 1 year of age in 2014. Variations in age at surgery between Swedish counties were great (range, 2.9-5.9 years of age). There were no deaths within 30 days after surgery and the frequency of surgical site infection was low (1.4%; 95% CI, 1.1-1.6). CONCLUSIONS: The cumulative childhood prevalence of cryptorchidism was high, and complications were rare. Few boys underwent surgery in a timely manner according to clinical guidelines, and standards of care varied considerably across the country. Further research and collective actions are needed to improve the detection and management of congenital cryptorchidism.

Prevalence of Mental Health Problems, Associated Factors, and Health-Related Quality of Life in Children with Long-Gap Esophageal Atresia in Sweden.

BACKGROUND: Children with long-gap esophageal atresia (LGEA) face a high risk of digestive and respiratory morbidity, but their mental health outcomes have not been investigated. We aimed to identify the prevalence of mental health problems in children with LGEA, associated factors and health-related quality of life (HRQOL). METHODS: Twenty-six children with LGEA aged 3-17 were recruited nationwide in Sweden. One of their parents and adolescents aged 11-17 completed information on the child's mental health (Strength and Difficulties Questionnaire), generic (PedsQL 4.0) and condition-specific HRQOL (EA-QOL). Parents gave information on current child symptomatology. Mental health level was determined using validated norms; abnormal≥90 percentile/borderline≥80 percentile/normal. Elevated levels were considered borderline/abnormal. Data were analyzed using descriptives, correlation and Mann-Whitney-U test. Significance level was p < 0.05. RESULTS: Twelve children with LGEA aged 3-17 (46%) had elevated scores of ≥1 mental health domain in parent-reports, whereas 2 adolescents (15%) in self-reports. In parent-reports, 31% of the children had elevated levels of peer relationship problems, with associated factors being child sex male (p = 0.037), airway infections (p = 0.002) and disturbed night sleep (p = 0.025). Similarly, 31% showed elevated levels of hyperactivity/inattention, and associated factors were male sex (p = 0.005), asthma (p = 0.028) and disturbed night sleep (p = 0.036). Elevated levels of emotional symptoms, seen in 20%, were related to swallowing difficulties (p = 0.038) and vomiting problems (p = 0.045). Mental health problems correlated negatively with many HRQOL domains (p < 0.05). CONCLUSIONS: Children with LGEA risk mental health difficulties according to parent-reports, especially peer relationship problems and hyperactivity/inattention, with main risk factors being male sex, airway problems and sleep disturbances. This should be considered in follow-up care and research, particularly since their mental health problems may impair HRQOL. LEVELS OF EVIDENCE: Prognosis study, LEVEL II.

Postoperative morbidity and health-related quality of life in children with delayed reconstruction of esophageal atresia: a nationwide Swedish study.

BACKGROUND: In 10-15% of children with esophageal atresia (EA) delayed reconstruction of esophageal atresia (DREA) is necessary due to long-gap EA and/or prematurity/low birth weight. They represent a patient subgroup with high risk of complications. We aimed to evaluate postoperative morbidity and health-related quality of life (HRQOL) in a Swedish national cohort of children with DREA. METHODS: Postoperative morbidity, age-specific generic HRQOL (PedsQL™ 4.0) and condition-specific HRQOL (The EA-QOL questionnaires) in children with DREA were compared with children with EA who had primary anastomosis (PA). Factors associated with the DREA group's HRQOL scores were analyzed using Mann-Whitney U-test and Spearman's rho. Clinical data was extracted from the medical records. Significance level was p < 0.05. RESULTS: Thirty-four out of 45 families of children with DREA were included and 30 returned the questionnaires(n = 8 children aged 2-7 years; n = 22 children aged 8-18 years). Compared to children with PA(42 children aged 2-7 years; 64 children aged 8-18 years), there were no significant differences in most early postoperative complications. At follow-up, symptom prevalence in children aged 2-7 with DREA ranged from 37.5% (heartburn) to 75% (cough). Further digestive and respiratory symptoms were present in ≥ 50%. In children aged 8-18, it ranged from 14.3% (vomiting) to 40.9% (cough), with other digestive and airway symptoms present in 19.0-27.3%. Except for chest tightness (2-7 years), there were no significant differences in symptom prevalence between children with DREA and PA, nor between their generic or condition-specific HRQOL scores (p > 0.05). More children with DREA underwent esophageal dilatations (both age groups), gastrostomy feeding (2-7 years), and antireflux treatment (8-18 years), p < 0.05. Days to hospital discharge after EA repair and a number of associated anomalies showed a strong negative correlation with HRQOL scores (2-7 years). Presence of cough, airway infection, swallowing difficulties and heartburn were associated with lower HRQOL scores (8-18 years), p < 0.05. CONCLUSIONS: Although children with DREA need more treatments, they are not a risk group for postoperative morbidity and impaired HRQOL compared with children with PA. However, those with a long initial hospital stay, several associated anomalies and digestive or respiratory symptoms risk worse HRQOL. This is important information for clinical practice, families and patient stakeholders.

Resolution of hydronephrosis after pyeloplasty in children.

BACKGROUND: There is still a lack of knowledge regarding the natural course of resolution of hydronephrosis after pyeloplasty, and no consensus exists on how resolution of hydronephrosis is defined or when resolution is expected to occur. OBJECTIVE: To determine when resolution of hydronephrosis occurs following pyeloplasty, by type of obstruction and by surgical approach. METHODS: This retrospective study included 125 children age <15 years treated with pyeloplasty and followed for two years with repeated ultrasound and MAG3 scan. Children with single kidneys, bilateral disease, and without hydronephrosis were excluded. Children with re-interventions were excluded in the evaluation of hydronephrosis but not in terms of success rate. Outcomes time to resolution of hydronephrosis (Anterior-Posterior diameter (APD) <10 mm or >50% reduction of APD) and 2-year success rate. Exposure was surgical approach and type of obstruction (intrinsic/extrinsic). Survival analysis was performed, adjusting for age, gender, year, laterality, preoperative renal function on MAG3, calyces dilatation and APD in the multivariable analysis. RESULTS: At 12 months and 24 months follow-up, 90% and 93% had reached resolution, respectively. All children with persistent dilatation had improved drainage and stable or improved function on MAG3. There was no difference in time to resolution of hydronephrosis between open versus robotic-assisted laparoscopic surgery (adjusted HR 0.90, [0.54-1.52], p = 0.70), nor between different types of obstruction (aHR 0.84 [0.53-1.34], p = 0.47). Eight children had re-intervention, all identified within 3 months after primary surgery, and four had a postoperative drop on MAG3, giving a total success rate of 91% (121/135). DISCUSSION: The vast majority of cases resolve and do so within 12 months from surgery. Since the improvement of hydronephrosis seems small between the first and second year after surgery, the value of follow-up beyond 12 months could be questioned. Based on the present study and previous literature we would recommend that children with persisting dilatation should continue their follow-up with ultrasound beyond 12 months. Children with complete resolution of their hydronephrosis at 12 months do not likely benefit from further follow-up. The same follow-up protocol should be applied, regardless of whether the obstruction is intrinsic or extrinsic in nature, or the surgery is performed with open or robotic-assisted approach. Overall, the definition of resolution of hydronephrosis varies in the literature and have impact on the results and may compromise comparisons. CONCLUSION: Surgical approach or type of obstruction does not seem to affect time to resolution of hydronephrosis after pyeloplasty in children. Follow-up with ultrasound beyond 12 months does not seem to benefit children with complete resolution.

A Nationwide Cohort Study of Outcome after Pediatric Appendicitis.

INTRODUCTION: Children with appendicitis often present with complicated disease. The aim of this study was to describe the clinical management of pediatric appendicitis, and to report how disease severity and operative modality are associated with short- and long-term risks of adverse outcome. MATERIALS AND METHODS: A nationwide retrospective cohort study of all Swedish children (<18 years) diagnosed with appendicitis, 2001 to 2014 (n = 38,939). Primary and secondary outcomes were length of stay, surgical site infections, readmissions, 30-day mortality, and long-term risk of surgery for small bowel obstruction (SBO). Implications of complicated disease and operative modality were assessed with adjustment for age, gender, and trends over time. RESULTS: Complicated appendicitis was associated with longer hospital stay (4 vs. 2 days, p < 0.001), increased risk of surgical site infection (5.9 vs. 2.3%, adjusted odds ratio [aOR]: 2.64 [95% confidence interval, CI: 2.18-3.18], p < 0.001), readmission (5.5 vs. 1.2, aOR: 4.74 [95% CI: 4.08-5.53], p < 0.001), as well as long-term risk of surgery for SBO (0.7 vs. 0.2%, adjusted hazard ratio [aHR]: 3.89 [95% CI: 2.61-5.78], p < 0.001). Intended laparoscopic approach was associated with reduced risk of surgical site infections (2.3 vs. 3.1%, aOR: 0.74 [95% CI: 0.62-0.89], p = 0.001), but no overall reduction in risk for SBO; however, successful laparoscopic appendectomy was associated with less SBO during follow-up compared with open appendectomy (aHR: 0.27 [95% CI: 0.11-0.63], p = 0.002). CONCLUSION: Children treated for complicated appendicitis are at risk of substantial short- and long-term morbidities. Fewer surgical site infections were seen after intended laparoscopic appendectomy, compared with open appendectomy, also when converted procedures were accounted for.

How boys and testicles wander to surgery: a nationwide cohort study of surgical delay in Sweden.

BACKGROUND: Early orchidopexy is recommended for cryptorchidism and the surgery is increasingly centralised. The objectives were to determine the incidence, risk factors and if distance to treating hospital impacted on timely treatment of cryptorchidism. METHODS: In this observational study, all boys born in Sweden from 2001 to 2014 were followed in national registers to determine the incidence of cryptorchidism by levels of birth-related risk factors and social determinants. Travel time to hospital was used as the primary exposure in multivariable survival analysis, with age at surgery as main outcome. RESULTS: Of 748 678 boys at risk for cryptorchidism, 7351 were treated and evaluated for timing of surgery (cumulative childhood incidence 1.4%, 95% CI 1.3% to 1.5%). The incidence was clearly associated with prematurity and overdue pregnancy (HR for <32 weeks 2.77 (95% CI 2.39 to 3.21); 32-36 weeks HR 1.36 (95% CI 1.24 to 1.49); >41 weeks HR 1.19 (95% CI 1.10 to 1.29)), low birth weight (<1000 g HR 3.94 (95% CI 3.15 to 4.92); 1000-1499 g HR 3.70 (95% CI 3.07 to 4.46); 1500-2500 g HR 1.69 (95% CI 1.52 to 1.88)) and intrauterine growth restriction (small for gestational age HR 2.38 (95% CI 2.14 to 2.65); large for gestational age HR 1.26 (95% CI 1.13 to 1.42)), but not with smoking or maternal age. Each 30 min increase in travel time was associated with a reduced probability of timely treatment (HR for being treated by age 3 adjusted for risk factors and socioeconomic determinants: 0.91 (95% CI 0.88 to 0.95)). Lower income and financial support were also associated with treatment delays (adjusted HR for lowest income quintile 0.82 (95% CI 0.72 to 0.93) and for families with financial support 0.85 (95% CI 0.73 to 0.97)). CONCLUSIONS: Travel distance to treating hospital was associated with delayed treatment. 'Not all those who wander are lost', but these findings suggest a trade-off between centralisation benefits and barriers of geography also in elective paediatric surgery.

Association of IgE-Mediated Allergy With Risk of Complicated Appendicitis in a Pediatric Population.

Importance: Childhood appendicitis is commonly complicated by gangrene and perforation, yet the causes of complicated appendicitis and how to avoid it remain unknown. Objective: To investigate whether children with IgE-mediated allergy have a lower risk of complicated appendicitis. Design, Setting, and Participants: This retrospective cohort study included all consecutive patients younger than 15 years (hereinafter referred to as children) who underwent appendectomy for acute appendicitis at a tertiary pediatric surgery center in Sweden between January 1, 2007, through July 31, 2017. Children were stratified between those with and without IgE-mediated allergies. Main Outcome and Measures: Risk of complicated appendicitis with gangrene or perforation, with occurrence of IgE-mediated allergy as an independent variable and adjusted for age, sex, primary health care contacts, seasonal antigenic exposure, allergy medications, appendicolith, and duration of symptoms. Results: Of 605 included children (63.0% boys; median age, 10 years; interquartile range, 7-12 years), 102 (16.9%) had IgE-mediated allergy and 503 (83.1%) had no allergy. Complicated appendicitis occurred in 20 children with IgE-mediated allergy (19.6%) compared with 236 with no allergy (46.9%; adjusted odds ratio, 0.33; 95% CI, 0.18-0.59). No significant allergy effect modification by sex, seasonal antigenic exposure, or allergy medication was found. Children with IgE-mediated allergy had a shorter hospital stay (median, 2 days for both groups; interquartile range, 1-2 days vs 1-5 days; P = .004). Conclusions and Relevance: In this study, children with IgE-mediated allergy had a lower risk of complicated appendicitis. The findings suggest that immunologic disposition modifies the clinical pattern of appendiceal disease. This theory introduces novel opportunities for understanding of the pathogenesis and clinical decision making for one of childhood's most common surgical emergencies.