Transition and reversal: long-term experience of the MACE procedure in children.

PURPOSE: Analysis of outcomes and follow-up of children who underwent the Malone antegrade continence enema (MACE) procedure in a UK tertiary paediatric surgery unit. METHODS: Children who underwent a MACE procedure from 1998 to 2020 were identified. Demographic and clinical data were obtained from contemporaneous records. Outcomes were categorised as full (success), partial or failure. RESULTS: Ninety-five children were identified for inclusion (chronic idiopathic constipation (CIC, 59), anorectal malformations (ARM, 23) and Hirschsprung's disease (HD, 13)). Mean age at surgery was 9.4 years (3-19 years) and mean follow-up time was 6 years (0.3-16.8 years). Outcomes were successful in 69% of CIC patients, 78% in ARM and 69% in HD. Twenty (21%) underwent MACE reversal after developing independent continence, with a significant difference between groups (CIC 19%, ARM 9%, HD 54%, p = 0.0047). 50% of patients > 16 years old were transitioned to adult services. CONCLUSION: We report a success rate of 72% for MACE procedures in our unit, with a significant difference in reversal rate between diagnostic groups. Long term, a fifth of patients no longer required their MACE. When these patients reach adolescence, those who require ongoing support outside of the paediatric surgery setting should be safely transitioned to adult services.

Does decentralisation of surgical management improve outcomes for paediatric testicular torsion?

INTRODUCTION: In testicular torsion (TT), delayed emergency scrotal exploration (ESE) increases the risk of orchidectomy. Transfer of a patient with suspected TT from a district general hospital (DGH) to a paediatric surgical centre (PSC) delays ESE and potentially puts them at increased risk of testicular loss. Prior to 1st January 2017, all boys under aged <16 years presenting to a DGH within the East Midlands Clinical Network (EMCN) would be referred to the PSC. From this date, it was agreed within the EMCN that boys aged ≥5 years with suspected TT presenting to a network DGH would be managed locally, barring exceptional circumstances. Boys aged <5 years would be referred to the PSC for management. AIM: This study aimed to assess the impact of decentralisation of ESE for suspected TT on orchidectomy rates in the EMCN. METHODS: All patients who underwent ESE under the care of paediatric surgery in the PSC, and all patients <16 years old who underwent ESE in 4 EMCN DGHs between January 2017 and December 2019 were identified. Neonatal cases and inpatient referrals were excluded. Comparison was made with published data on ESE performed in the PSC over the 9 years 2008-2016 prior to decentralisation. RESULTS: In the 9 years prior to decentralisation, there were 110 cases of TT in the PSC. In the subsequent 3 years, there were 40 in the PSC and 37 in the DGHs. The orchidectomy rate of boys with TT presenting to DGHs and undergoing exploration locally (16%, 6/37) contrasts with the rate in those transferred from DGHs to the PSC for exploration (58%, 15/26). The difference is highly significant (p = 0.00059, RR 0.28 [95% CI 0.13-0.63]) and indicates that in the EMCN, avoiding hospital transfer and performing ESE at the presenting DGH reduces the risk of orchidectomy by 72%. CONCLUSION: Decentralisation of the provision of ESE in boys with TT has resulted in a significantly lower orchidectomy rate in boys undergoing ESE in the presenting hospital than when transferred to the PSC. This study reinforces existing literature that demonstrates the effect of delayed ESE on orchidectomy rate, and supports the recommendations of national guidelines in the UK that transfer of boys to a PSC for ESE should only occur in exceptional circumstances.

Outcomes following emergency fixation of torted and non-torted testes.

INTRODUCTION: Scrotal exploration is a frequently performed emergency procedure in children. It is a subject of debate as to whether and how a non-torted testis should be fixed, with a wide variation in practice across the UK. This study aims to ascertain whether the method of testicular fixation (if any) impacts on patient outcomes. METHODS: A review of all emergency scrotal explorations performed in children under the age of 18 between 2008 and 2018 in a tertiary Paediatric Surgery unit was undertaken. Patients were categorised by initial fixation method, chi squared analysis was used to compare complication and reoperation rates. RESULTS: 522 boys were taken to theatre, 424 had a unilateral procedure and 98 had bilateral; after 35 orchidectomies, 585 testes were left in situ. The most frequent diagnosis at operation was torted testicular appendage (n = 278, 53%), followed by testicular torsion (n = 79, 15%). The number of testes by category of fixation were: 72 no documented fixation, 130 dartos pouch only, 34 absorbable sutures, 346 non-absorbable sutures and 3 unspecified sutures. There was no difference in the reattendance rate between groups after outliers were removed (p = 0.72). Thirty-seven patients experienced complications, most commonly ongoing pain. Nine patients required an ipsilateral reoperation, 25 underwent a contralateral operation at a later date. The complication rate appeared to be higher in the no fixation group compared to the dartos (p = 0.02) and sutured groups (p = 0.048). Testes in the no fixation group had a higher reoperation rate compared to the sutured group (p = 0.002). CONCLUSIONS: The present study is a detailed analysis of a wide variety of emergency testicular fixation methods in a large cohort, including the routine fixation of non-torted testes. Whilst there appears to be a benefit to using sutured or dartos fixation, this merits cautious interpretation. It is likely that influences on complications and reoperations are multifactorial and cannot be attributed solely to the method of testicular fixation. Adoption of a standardised approach to emergency fixation of testes within or across institutions may be a potential avenue for future studies.

Effect of Surgical Specialty on Management of Adnexal Masses in Children and Adolescents: An 8-Year Single-Center Review.

STUDY OBJECTIVE: Children with adnexal masses might be managed by pediatric surgeons, urologists or gynecologists, with the potential for different management strategies between specialties. In this study we compared ovarian conservation rates and surgical approach for adnexal masses in children and adolescents managed either by pediatric surgeons/urologists or gynecologists at a tertiary care institution. DESIGN: Retrospective cohort review. SETTING: Tertiary pediatric and adult university hospital. PARTICIPANTS: Patients younger than 18 years of age with an adnexal mass managed surgically with removal of histologically confirmed ovarian or fallopian tube tissue from 2008 to 2015. INTERVENTIONS: Laparoscopic or open procedure for adnexal mass. MAIN OUTCOME MEASURES: The primary outcome was rate of ovarian conservation relative to surgical specialty. The secondary outcome was surgical approach relative to surgical specialty. RESULTS: Forty-eight patients underwent surgery for adnexal masses; 26 (54%) under pediatric surgery/urology and 22 (46%) under gynecology care. Laparoscopy was performed in 5 (19%) pediatric and 19 (86%) gynecology cases (P = .000006). Of 24 patients older than 12 years of age with a benign tumor, 10 (42%) underwent procedures resulting in loss of an ovary with or without fallopian tube; 8 of these (80%) were under pediatric care. Of the remaining 14 (58%) who underwent ovarian conserving surgery, 12 (80%) were under gynecology care (P = .0027). CONCLUSION: Patients with a benign tumor were significantly more likely to undergo ovary-preserving surgery under gynecology care than under pediatric surgery/urology care. A multidisciplinary team approach involving gynecology and pediatric surgical specialties would be valuable in assessing the merits of ablative or conservative surgery in each case.

Intradetrusor injection of botulinum toxin A in children: a 10-year single centre experience.

PURPOSE: We evaluated the efficacy and safety outcomes of endoscopic intradetrusor botulinum toxin A (BTA) injections for the treatment of children with neuropathic bladder (NB) and non-neuropathic bladder (NNB) with or without detrusor overactivity in a single centre with a retrospective analysis. METHODS: For the period 2006-2015, children who received BTA in our hospital were analysed. They were divided into group 1, those with underlying NB and group 2, those without a clear neuropathic cause of symptoms (NNB). Data are given as percentages or medians (interquartile range). RESULTS: Over the study period, 52 children (28 boys, 54%) received BTA, 28 in group 1 (54%; 17 (61%) boys) and 24 in group 2 (46%; 11 (46%) boys). Age at first injection was 11.8 (9.5-14.4) years. After initial injection, 40 (77%) reported symptomatic improvement, 17 (43%) becoming dry. There was no significant difference in response to initial injection between groups (p = 0.11). Duration of improvement after first injection was 7 (5.8-14) months. Twenty-five (48%) had further injections, of whom 3 (12%) were initial non-responders. Ongoing improvement was reported in 20 (80%), 11 (44%) of whom were dry. There was no significant difference in overall response to injections between groups (p = 0.11). Of the 11 non-responders, none (0/3) improved after subsequent injection and 3 (27%) subsequently underwent major urological surgery. Of the 40 who responded, 2 (5%) underwent major surgery. CONCLUSION: BTA injection produced symptomatic improvement in 77% of our study population, with no significant differences in response between NB and NNB groups. In 95% of those who improved, major urinary tract procedures were avoided during the period studied. None of the initial non-responders improved after subsequent BTA injection. BTA injection is effective and reliable in the management of children with NB and NNB refractory to medical therapy.

Does Laparoscopic Sleeve Gastrectomy Improve Depression, Stress and Eating Behaviour? A 4-Year Follow-up Study.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is a restrictive bariatric surgery procedure and currently the second most performed technique worldwide. Follow-up data on depression, stress and eating behaviour are scarce. The aim of this longitudinal study was to investigate the medium-term effects of LSG on mental health and eating behaviour and their influence on weight loss by using a comprehensive interview-based assessment. METHODS: Seventy-five individuals, who had undergone LSG at a university hospital, were included in the study. Symptoms of disordered eating were assessed using a structured clinical interview (eating disorder examination) and the Three-Factor Eating Questionnaire with depressive symptoms and stress assessed via the Patient Health Questionnaire. RESULTS: Mean interval from LSG to follow-up (FU) examination was 48 ± 13.3 months. The total body weight loss was 24.2 ± 12.0 %. Depressive symptom scores improved from pre-operative to FU (9 [IQR 5-14] vs. 6 [IQR 2-10], p = 0.002) as did stress scores (8.7 ± 4.6 vs. 6.3 ± 4.7, p = 0.001). At FU, 11 % of patients reported loss-of-control eating and 39 % grazing, paralleled by increased body mass index, stress and depressive symptoms. Prior to LSG, nine patients fulfilled the diagnostic criteria of binge eating disorder but only one at FU. CONCLUSIONS: Post-surgical mental health appears to be highly relevant in terms of weight loss maintenance. It is likely that the surgical outcome could be positively influenced if patients at risk of developing mental health issues or eating disorders were identified and monitored in order to offer targeted interventions.

Challenges in the management of bilateral single-system ectopic ureters in male infants.

OBJECTIVE: To describe our experience of managing bilateral single-system ectopic ureters in boys. METHODS: We discuss difficulties in diagnosis, importance of appropriate preoperative imaging, and the individualized surgical management for this rare congenital malformation. RESULTS: The first patient aged 3 months presented with urosepsis-subsequent imaging demonstrated bilateral single-system ectopic ureters, which were reimplanted at age 7 months. The second case was an antenatal diagnosis of bilateral hydronephrosis. Postnatal imaging identified bilateral ectopic single-system ureters. A suprapubic catheter was inserted to ensure optimal bladder drainage. He underwent a Cohen reimplantation at age 7 months because of recurrent urinary tract infections. The third patient was born with a duodenal atresia (repaired in the neonatal period) and a complex anorectal malformation, including a pouch colon with a colourethral fistula, a dilated, ectopic left ureter, and a hypoplastic urethra. He was initially managed with a colostomy and suprapubic catheter. At age 14 months, he underwent a left nephrouretectomy for a nonfunctioning kidney and posterior sagittal anorectoplasty. The right ureter was noted to be ectopic at this time and was reimplanted. CONCLUSION: Our series highlights the many challenges for diagnosis and management in boys with this condition because of the diverse presentation and need for appropriate preoperative imaging. Treatment is by bilateral ureteric reimplantation at an appropriate age.

The testicular regression syndrome--do remnants require routine excision?

AIM: Excision of testicular remnants is debatable in the scenario where hypoplastic vas and vessels can be seen entering a closed internal ring during laparoscopy for impalpable testes. We aimed to establish how frequently excised remnants have identifiable testicular tissue and, hence, malignant potential. METHODS: This study is a retrospective review of all excised testicular remnants in children with impalpable testis. Specimens that were excised for indications other than testicular regression syndrome were excluded. Pathology reports of excised specimens were reviewed, and the presence of multiple histologic features was noted. Histologic confirmation of testicular/paratesticular tissue required the presence of 1 or more of the following: seminiferous tubules, germ cells, Sertoli cells, Leydig cells, vas deferens, or epididymal structures. Malignancy potential was defined by the presence of germ cells or seminiferous tubules. All patients with seminiferous tubules were further examined by a single histopathologist. RESULTS: A total of 208 testicular remnants from 206 children were excised over the 11-year period (1999-2009). Histologic evidence confirmed excision of testicular/paratesticular tissue in 180 cases (87%). Seminiferous tubules were noted in 27 (15%), and germ cells were present in 19 (11%) cases. CONCLUSION: Viable germ cells were found in 11% of examined remnants, which, in our opinion, justifies their removal.