Comparison of perioperative surgical outcomes following total robotic and total laparoscopic Roux-en Y hepaticojejunostomy for choledochal cyst in paediatric population: a preliminary report from a tertiary referral centre.

PURPOSE: There is a paucity of data regarding the comparison of robotic and laparoscopic hepaticojejunostomy (HJ) for the treatment of paediatric choledochal cysts. Thus, our primary objective was a comparison of early complications namely post-operative bleeding, anastomotic leak, intestinal obstruction and the need for reoperation in both techniques. Our secondary objectives included a comparison of the mean time for surgery and HJ, conversion of procedure to open, intraoperative blood loss, late complications like cholangitis, stricture and post-operative outcomes like time to start oral feeds and length of post-operative stay. METHODS: A retrospective data analysis of all children who underwent laparoscopic and robotic choledochal cyst excision with Roux-en-Y HJ from 2008 to 2021 was performed. RESULTS: Ninety patients were classified into Group R (robotic HJ), n = 20 and Group L (laparoscopic HJ), n = 70. Post-operative complications were comparable amongst groups R and L (2 vs 6; p = 1 and 1 vs 2, p = 0.53, respectively). Intraoperative blood loss was significantly less in group R (54.8 ± 13.5 ml vs 64.1 ± 17.3 ml; p = 0.0280). The mean time to complete HJ was significantly less in group R (58 ± 12 min vs 71 ± 11 min; p < 0.001) while the mean time to complete surgery was significantly more in Group R (284 ± 14 min vs 195 ± 18 min; p < 0.001). CONCLUSION: Our preliminary research report suggests overall comparable early complications in both groups.

Comparative analysis of off-road vehicle crashes in children: motorcycles versus quad bikes.

OBJECTIVE: To characterise and compare off-road motorcycle and quad bike crashes in children in New South Wales (NSW), Australia. METHODS: A retrospective, cross-sectional study was performed of children aged 0-16 years, admitted to hospitals in NSW, from 2001 to 2018 following an injury sustained in an off-road motorcycle or quad bike crash, using linked hospital admissions, mortality and census data.Motorcycle and quad bike injuries were compared regarding: demographics; incidence; body region injured and type of injury; injury severity based on the survival risk ratio; length of stay and mortality. RESULTS: There were 6624 crashes resulting in hospitalisation; 5156 involving motorcycles (77.8%) and 1468 involving quad bikes (22.2%). There were 10 fatalities (6 from motorcycles and 4 from quad bikes). The rates of injury declined over the study period for motorcycles, but not for quad bikes.Motorcycle riders were more likely than quad bike riders to have lower limb injuries (OR 1.49, p<0.001) but less likely to have head/neck (OR 0.616, p<0.001), abdominal (OR 0.778, p=0.007) and thoracic (OR 0.745, p=0.003) injuries. Quad bike crashes resulted in higher injury severity (mean International Classification Injury Severity Score 0.975 vs 0.977, p=0.03) and longer hospital stay (mean 2.42 days vs 2.09 days, p=0.01). CONCLUSIONS: There are significant differences between quad bike and motorcycle crashes in injury type and affected body region. While quad bike injuries in children were more severe, there were almost four times more hospitalisations from motorcycles overall. The overall larger burden of motorcycle crashes suggests a greater focus of injury prevention countermeasures for two-wheeled riders is needed.

Open Versus Ultrasound Guided Tunneled Central Venous Access in children: A Randomized Controlled Study.

BACKGROUND: The purpose of this study was to compare open insertion to ultrasound guided percutaneous insertion of central access catheters performed in a tertiary pediatric hospital in terms of its safety and complication rates. METHODS: This was an ethics approved prospective randomized trial of children under 16 y of age. Procedure was performed by surgeons with varying experience with percutaneous and open insertion. Primary outcome studied was complications-immediate and late. Secondary outcomes were time taken to complete procedure, conversion rates, duration of line use. RESULTS: A total of 108 patients were analyzed. Sixty-four were male. Right internal jugular vein was accessed in 97. Eighty-one lines were double lumen, 23 implantable access devices, and the rest were single lumen catheters. More than one needle puncture was needed in 22% of the cases but there were no conversions in the ultrasound group. Twelve patients needed more than one insertion to achieve optimal position of the tip. Eleven patients had immediate and late complications. Percutaneous lines lasted 45 d longer though this was not statistically significant. Operating time was 20.6% shorter with percutaneous access. Post-removal measurement of vein size by ultrasound demonstrated significant decrease in size in the open group. CONCLUSIONS: Ultrasound guided percutaneous insertion was safe. The study also demonstrated a decrease in operating times, preservation of vein size, and no increase in complication rates in the US group when performed by operators of varying expertise.

Observational study of falls in children from windows and balconies: What has changed?

AIM: To describe patterns of injury from window and balcony falls in children presenting to a tertiary paediatric trauma centre in New South Wales. METHODS: A retrospective review of cases of children <15 years who had sustained injuries in a fall from a building, identified from the trauma database between 1998 and 2019. RESULTS: A total of 381 falls from windows and balconies were recorded over the 22-year study period. There were 218 falls from windows (57%) and 163 from balconies. The majority (64%) were children under 4 years of age. The male to female ratio was 2:1. While many children sustained simple abrasions, contusions and lacerations, 17% sustained injuries with an injury severity scores of ≥12. There were four deaths. CONCLUSIONS: This study identified that children falling from buildings remains a problem in Australia. Although many injuries were minor, severe injuries and fatalities continue to occur.

Paediatric off-road vehicle injury in rural and regional Australia.

OBJECTIVE: Off-road riding of quad bikes and motorcycles is common among children across rural and remote Australia, but is a significant source of injury and hospitalisation. An in-depth analysis of paediatric off-road vehicle crashes was undertaken to inform injury prevention countermeasures by characterising injury patterns and sources of injury. DESIGN: This is a prospective in-depth case series. PARTICIPANTS: Participants are children aged 16 and under who have been hospitalised due to injury sustained from the use of an off-road motorcycle or quad bike in New South Wales, Australia. INTERVENTIONS: Crash investigation techniques (medical data, structured interview, vehicle and crash site inspection) were used to ascertain details of the crash event, protective gear, injury information and contributory factors. RESULTS: Thirty children were recruited, 27 boys and 3 girls, ranging in age from 4 to 16 years, having crashed on off-road motorcycles (n = 27) or quads (n = 3). Most (73.3%) were participating in unstructured social riding. A total of 67 separate injuries were observed, with overall Injury Severity Scores between 1 and 35. There were high rates of wearing helmets and motorcycle-specific garments. The most commonly injured areas were the upper and lower extremities. The most common sources of injury were from impacting the ground, obstacles/other riders or the vehicle. CONCLUSION: This study demonstrates the patterns of riding and injury in rural paediatric off-road vehicle riders, occurring despite high rates of helmet/protective gear use. This underscores the need for investigation into the injury mitigation and fit properties of protective gear and the inherent risks for physically and developmentally maturing children.

The Predictors for Positive Yield Abdominal Computed Tomography in Pediatric Abdominal Trauma.

OBJECTIVES: Abdominal computed tomography (ACT) use in the initial evaluation of pediatric abdominal trauma is liberal in most instances. The aim of this study was to identify the predictors for a positive yield ACT scan in this population. METHODS: A prospective, cohort, single-center observational study was conducted at Children's Hospital at Westmead, New South Wales, from January 2008 to June 2015 on 240 pediatric abdominal trauma patients who had abdominal computed tomography. Clinical, laboratory, imaging, and interventional variables were explored with univariate and multivariate analyses among children who sustained abdominal trauma. RESULTS: Of 240 patients, positive ACT scans were found in 161 patients (67%), 112 patients (47%) had intra-abdominal injury, and 20 patients (8%) required invasive therapeutic interventions. Mortality rate was 1.7% (4 patients) due to nonabdominal causes. Multivariate analyses revealed that increasing age (odds ratio [OR], 1.12; 95% confidence interval [CI], 1.02-1.24; P = 0.024), high injury severity score (OR, 1.14; 95% CI, 1.07-1.21; P < 0.001), abnormal abdominal examination (OR, 5.95; 95% CI, 2.08-17.01; P = 0.001), elevated alanine aminotransferase greater than 125 IU/L (OR, 46.28; 95% CI, 2.81-762.49; P = 0.007), abnormal pelvic radiograph (OR, 14.03; 95% CI, 2.39-82.28; P = 0.003), presence of gross hematuria (OR, 4.14; 95% CI, 1.04-18.23; P = 0.044), low initial hematocrit level (less than 30%) (OR, 8.51; 95% CI, 1.14-63.70; P = 0.037), and positive focused assessment with sonography for trauma (OR, 2.61; 95% CI, 1.01-7.28; P = 0.048) remained significantly associated with abnormal ACT scan. In contrast, those who required scanning of other body region(s) were less likely to have abnormal ACT scan (OR, 0.34; 95% CI, 0.14-0.86; P =0.022). CONCLUSIONS: Integrating the abdominal examination findings, relevant laboratory values, and focused assessment with sonography for trauma results with the physicians' suspicion may aid in stratifying patients for ACT scan. Further efforts should be made to decrease number of normal ACT scans; yet not to increase the number of delayed or missed injures with its inherent morbidity and mortality.

Traumatic Abdominal Wall Hernias Following High-Velocity Trauma in Children.

Traumatic abdominal wall hernias following blunt high-velocity trauma are uncommon in children and can result in concurrent abdominal visceral injuries. We present one such case of a 9 year-old boy requiring a trauma laparotomy to repair visceral injuries following a motor vehicle accident.

Radiation exposure in infants with oesophageal atresia and tracheo-oesophageal fistula.

PURPOSE: Oesophageal atresia and tracheo-oesophageal atresia require surgical repair in early infancy. These children have significant disease-related morbidity requiring frequent radiological examinations resulting in an increased malignancy risk. METHODS: A single-centre, retrospective review was performed of radiation exposure in children with OA/TOF born 2011-2015. Medical records were reviewed to determine the number and type of imaging studies involving ionising radiation exposure enabling the calculation of the estimated effective dose per child over the first year of life. RESULTS: Forty-nine children were included. Each child underwent a median of 19 (IQR 11.5-35) imaging studies, which were primarily plain radiography (median = 14, IQR 7-26.5). The overall median estimated effective dose per patient was 4.7 (IQR 3.0-9.4) mSv, with the majority of radiation exposure resulting from fluoroscopic imaging (median 3.3 mSv, IQR 2.2-6.0). 'Routine' postoperative oesophagrams showed no leak in 35/36 (97%) with the remaining study showing an insignificant leak that did not alter management. CONCLUSIONS: Careful consideration should be given to the use of imaging in OA/TOF to minimise morbidity in these vulnerable infants. Oesophagrams in children without the symptoms of anastomotic leak or stricture should be discontinued. Standardisation of monitoring protocols with regard to radiation exposure should be considered.

Complexity of gastroschisis predicts outcome: epidemiology and experience in an Australian tertiary centre.

BACKGROUND: Gastroschisis is a congenital anomaly of the fetal abdominal wall, usually to the right side of umbilical insertion. It is often detected by routine antenatal ultrasound. Significant maternal and pediatric resources are utilised in the care of women and infants with gastroschisis. Increasing rates of gastroschisis worldwide have led institutions to review local data and investigate outcomes. A collaborative project was developed to review local epidemiology and investigate antenatal and neonatal factors influencing hospital length of stay (LOS) and total parental nutrition (TPN) in infants born with gastroschisis. METHODS: We performed a five-year review of infants born with gastroschisis (2011-2015) at a major Australian centre. Complex gastroschisis was defined as involvement of stenosis, atresia, ischemia, volvulus or perforation and closed or vanishing gastroschisis. We extracted data from files and databases at the two participating hospitals, a major maternal fetal medicine centre and the affiliated children's hospital. RESULTS: There were 56 infants antenatally diagnosed with gastroschisis with no terminations, one stillbirth (2%) and one infant with 'vanishing' gastroschisis. The mean maternal age was 23.9 years (range, 15-39 years). The mean gestation at delivery was 36 weeks (range, 25-39+ 3 weeks). Of the 55 neonates who received surgical management, 62% had primary closure. The median LOS was 33 (IQR, 23-45) days and the median duration of TPN was 26 (IQR, 17-36) days. Longer days on TPN (median 35 vs 16 days, P = 0.03) was associated with antenatal finding of multiple dilated bowel loops. Postnatal diagnosis of complex gastroschisis was made in 16% of cases and was associated with both longer LOS (median 89 vs 30 days, P = 0.003) and days on TPN (median 46 vs 21 days, P = 0.009). CONCLUSION: Complex gastroschisis was associated with greater days on TPN and LOS. We found no late-gestation stillbirths and a low overall rate of 1.8%, suggesting the risk for stillbirth associated with gastroschisis is lower than previously documented. This information may assist counselling families. Improved data collection worldwide may reveal causative factors and enable antenatal outcome predictors.

Aganglionosis with the absence of hypertrophied nerve fibres predicts disease proximal to rectosigmoid colon.

PURPOSE: The gold standard for the diagnosis of Hirschsprung's disease (HSCR) is the pathologic evaluation of a rectal biopsy that demonstrates the absence of ganglion cells and nerve fibre hypertrophy. However, it has been frequently reported that hypertrophic nerves may not be present in some variants like long-segment HSCR, total colonic aganglionosis, premature and very young infants. The aim of this study was to determine this association. METHODS: We performed a retrospective review of the HSCR database at our tertiary care children's hospital from 2000 to 2013. In order to analyse the relationship between the diameter of the nerve fibres and the level of aganglionosis, we classified the patient sample into two groups-fibres ≤40 and >40 µm. The groups were statistically compared with P < 0.05 being significant. RESULTS: Rectal biopsies of 92 patients confirmed as HSCR with definitive operation performed at the same institution were reviewed. The mean nerve diameter was 50.1 µm (range 20-87.5 µm). Nerve fibre diameter ≤40 µm was predictive of transition zone above the sigmoid colon. A specificity of 77.3 % and a likelihood ratio of 2.03 supported this perception. No correlation was noted between nerve fibre diameter and gestational age at birth, birth weight or age at biopsy. CONCLUSION: The absence of nerve fibre hypertrophy in the presence of aganglionosis on rectal biopsy specimens is predictive of long-segment HSCR.

The Safety and Efficacy of Early Enteral Nutrition After Paediatric Enterostomy Closure - The EPOC Study.

INTRODUCTION: Keeping children nil by mouth until return of bowel function after intestinal anastomosis surgery is said to reduce complications. Fasting may extend up to five days, risking malnourishment and usage of parenteral nutrition. This study aims to establish the efficacy and safety of early enteral nutrition in children undergoing intestinal stoma closure. METHODOLOGY: A retrospective cohort study of children aged three months to 16 years who underwent an intestinal stoma closure between 1/1/2019 and 31/12/2021 at two tertiary paediatric hospitals was undertaken. Children fed clear fluids within 24 h (EEN) were compared to those commencing feeds later (LEN). The primary outcome was length of post-operative stay (LOS) and secondary outcomes included: time to feeds; time to stool; and complications. RESULTS: Of the 129 children that underwent a stoma closure, 69 met inclusion criteria: 35 (51 %) in the LEN group and 34 (49 %) in the EEN group. Children in the EEN group had a significantly shorter LOS (92.6 h vs 121.7 h, p = 0.0045). Early feeding was also associated with a significantly decreased time to free fluids (p < 0.001) and full enteral intake (p = 0.007). There was no significant intergroup difference in complications. CONCLUSION: Commencing feeding within 24 h of stoma closure is efficacious and safe, with clear reductions in LOS, time to full feeds and time to stool, and no increase in complications. Further research is required to extrapolate these findings to other populations. LEVEL OF EVIDENCE: III.

Neonatologist-performed point-of-care abdominal ultrasound: What have we learned so far?

This review describes the sonographic appearances of the neonatal bowel in Necrotising enterocolitis. It compares these findings to those seen in midgut-Volvulus, obstructive intestinal conditions such as milk-curd obstruction, and slow gut motility in preterm infants on continuous positive airway pressure (CPAP)-CPAP belly syndrome. Point-of-care bowel ultrasound is also helpful in ruling out severe and active intestinal conditions, reassuring clinicians when the diagnosis is unclear in a non-specific clinical presentation where NEC cannot be excluded. As NEC is a severe disease, it is often over-diagnosed, mainly due to a lack of reliable biomarkers and clinical presentation similar to sepsis in neonates. Thus, the assessment of the bowel in real-time would allow clinicians to determine the timing of re-initiation of feeds and would also be reassuring based on specific typical bowel characteristics visualised on the ultrasound.

Development of a rapid process for purification of Bowman-Birk and Kunitz inhibitors from legume seeds, and evaluation of their biophysical, insecticidal, and antimicrobial properties.

Bowman-Birk inhibitor (BBI ~10 kDa) and Kunitz inhibitor (KI ~20 kDa) are serine protease/proteinase inhibitor(s) [PI(s)] ubiquitously found in several Leguminous plant species with insecticidal and therapeutic properties. Due to narrow molecular mass differences, the separation of these inhibitors from a single seed variety is tedious. The present study is aimed to develop a rapid protocol (<24 h) for purifying BBI and KI from legume seeds using mild trichloroacetic acid (TCA) extraction followed by trypsin-affinity chromatography. The mature seeds of Vigna radiata and Cajanus platycarpus are used as a model to purify BBI and KI using this protocol. The BBI and KI purified from the seeds of V. radiata are labeled as VrBBI & VrKI, and C. platycarpus are labeled as CpBBI & CpKI, respectively. These PIs are confirmed by immunodetection and MALDI-TOF studies and further characterized for their structural (CD & fluorescence spectroscopy) and functional properties (temperature & DTT stability). BBI(s) purified using the above process are effective in the management of castor semi-looper 'Achaea janata', while KI(s) are effective in the management of pod borer 'Helicoverpa armigera'. Besides, both BBI(s) and KI(s) have significant potential in controlling the growth of methicillin-sensitive 'Staphylococcus aureus', a gram-positive pathogenic bacterium.

Predicting morbidity and mortality in Australian paediatric trauma with the Paediatric Age-Adjusted Shock Index and Glasgow Coma Scale.

BACKGROUND: Paediatric age-adjusted shock index (SIPA) has emerged as a predictor of morbidity and mortality in trauma. Poor sensitivity and low generalisability demonstrated in previous studies have limited its use. We evaluate the use of SIPA in the general Australian paediatric trauma population and the combination of SIPA with GCS. METHODS: All patients from January 2015 to August 2020 at a major Australian paediatric trauma centre were reviewed. Pre-arrival SIPA (pSIPA) and arrival SIPA (aSIPA) were calculated. If SIPA was elevated or the Glasgow Coma Scale ≤ 13, SIPA with mental state (SIPAms) was marked positive for pre-arrival (pSIPAms) and arrival (aSIPAms) respectively. RESULTS/DISCUSSION: Data from 480 patients were analysed. pSIPA and aSIPA poorly predicted outcomes of morbidity. Only aSIPA predicted mortality. However, both pre-arrival and arrival SIPAms variables predict mortality, major trauma (ISS≥12), hospital LOS, need for ICU admission, and major surgery. Furthermore, median ISS and lactate were significantly higher in positive pSIPA, aSIPA, pSIPAms, and aSIPAms groups than negative. aSIPAms has a sensitivity of 76% and specificity of 70% for major trauma. CONCLUSION: Broad inclusion criteria reduce SIPA's ability to predict morbidity. Combining it with GCS improves this and is most valuable when calculated at arrival. In addition, the score is more reliable for major trauma (ISS≥12). Future studies should evaluate the use of SIPAms in activation criteria.

Features and outcomes of neonatal neuroblastoma.

PURPOSE: Neonatal neuroblastoma (NNBL) is a rare tumour with few reported cases in the literature. The prognosis of NNBL is unclear with reported survival between 76 and 91%. The growing use of ante-natal ultrasound (USS) in recent years has resulted in an increasing incidence of NNBL. The purpose of this study is to review our experience with incidence, clinical features and outcome of NNBL in those children diagnosed ante-natally compared to those diagnosed post-natally. METHODS: Twelve cases of NNBL were detected ante-natally or in the neonatal period (0-28 days) from a cohort of 120 children diagnosed with neuroblastoma (10%) over a 10-year period at the study institutions. Review of these 12 children forms the basis of this report. RESULTS: Ante-natal diagnosis (ADNB) was made in six children (50%) and post-natal diagnosis (PDNB) in six (50%). Tumour site in both cohorts were predominantly adrenal and tumour staging was similar in both groups. There was no difference in outcome in ADNB compared to PDNB with overall 100% survival for the entire group. CONCLUSIONS: NNBL is a subset of neuroblastoma with apparent excellent outcome irrespective of the time of diagnosis. Clinical features and outcomes of ADNB are no different to PDNB.

Trampoline trauma in children: is it preventable?

OBJECTIVES: Trampoline injuries represent a preventable cause of injury in children. This study identified the characteristics of children injured while using trampolines who presented to a pediatric trauma center in Sydney, Australia. METHODS: The Pediatric Trauma Database at our institution was reviewed to identify children with trampoline-related injuries between January 1999 and June 2008. Data collected included age, sex, Injury Severity Score, anatomical region injured, type of injury, mechanism of injury, site of injury and surface fallen onto, level of supervision, treatment, and hospital length of stay. RESULTS: Over the 9.5-year review period, 383 children presented with trampoline-related injuries: 193 (50.4%) were female. Just over a quarter (n = 106, 27.7%) were treated and discharged the same day. The remaining patients accounted for 725 hospital bed days with a mean length of stay of 2.3 days. The most common area of the body injured was the upper limb (n = 246, 64.2%), with a fall from the trampoline to the ground being the most frequent mechanism of injury (n = 257, 67.1%). The majority (n = 345, 90.1%) of children were injured in their home or at the home of a friend or relative. Surgery was required in 236 (61.6%), with closed reduction of an upper limb fracture being the most common procedure (n = 107, 27.9%). CONCLUSIONS: Trampoline-related injuries remain common in children. Implementation of current guidelines and the introduction of innovative trampoline designs should reduce the risk of this injury in children.

Traumatic duodenal injuries in children: a single-centre study.

BACKGROUND: Traumatic duodenal injuries in children are rare, and few studies have documented duodenal injuries in children, especially in Australasia. This study assessed the mechanism, investigations, management and outcomes of children (aged <16 years) with duodenal injuries. METHODS: Retrospective review was conducted over a 16-year period from a single paediatric trauma centre. RESULTS: Sixteen cases of duodenal injuries were identified: 15 cases of blunt duodenal injury and only one case of penetrating injury. Motor vehicular accidents were the most common cause of injury, followed by auto-pedestrian injuries and handlebar injuries. Only grade I and II injuries were identified. Computed tomography aided diagnosis in all cases of blunt duodenal injuries, especially given the variable nature of symptoms. Eight patients underwent laparotomy, of whom five required duodenal repair. Three patients underwent primary repair with omental patch, one patient underwent primary repair with gastrostomy and one patient underwent two-layered repair with t-tube duodenostomy. There were no delays in operative management within 24 h and no complications identified. CONCLUSION: In comparison to other paediatric trauma centres worldwide, the majority of duodenal injuries were low grade and attributed to blunt trauma. Computed tomography aided diagnosis in all cases of blunt duodenal injury. Primary repair of duodenal injuries was possible in the majority of cases requiring operative repair.

Surgeon Performed Ultrasound for Diagnosis of Intussusception - A Pilot Study.

Aim: To study the diagnostic accuracy of surgeon performed ultrasound (SPU) in the diagnosis of children presenting with clinical suspicion of intussusception to a tertiary paediatric facility in NSW, Australia. Methods: Children under the age of 16 presenting to the emergency department with clinical features suggestive of intussusception were recruited. After obtaining consent SPU was performed by a Paediatric surgeon. All patients subsequently had an ultrasound performed in radiology department (RPU) on which management was based. Diagnosis and images of SPU were reviewed by an independent radiologist blinded to results of the formal study. Results: Of 7 children enrolled 5 were male. Age ranged from 3 months to 7 years (mean 2.64, SD 2.282), weight from 5.2kgs to 25.2kgs (mean 13.69, SD 6.721). Five out of the 7 children presented during day hours i.e. 8a.m.-5 p.m. (mean 12.72, SD 4.049). Mean time to SPU was 6.3 hours (SD7.1) and RPU was 8.3 hours (SD 7.6). SPU was earlier by 2 hours and correlation between SPU and RPU was 100 percent. Conclusion: SPU for intussusception can be performed early and accurately. Surgeons should train and use ultrasound as a reliable tool in evaluating the child with suspected intussusception.