Endoscopic injection for primary vesicoureteric reflux: Predictors of resolution and long term efficacy.

AIM: We investigated the efficacy of endoscopic-Deflux-injection in treating primary-vesicoureteric-reflux (VUR) and identified factors to predict resolution. MATERIALS AND METHODS: Records of children treated with Deflux for primary-VUR from 1995 to 2016 were reviewed, and outcomes were investigated. RESULTS: Eighty-eight ureters (35 bilateral, 18 unilateral) in 53 children underwent 124 injections. Thirty-five (66%) patients had single injection (13 unilateral, 22 bilateral). Fifteen (28%), two (37%), and one (2%) patients had two, three, and four injections, respectively. Overall success rate by ureters was 57% after single injection. Complete resolution occurred in 65% of ureters with VUR below grade III, 63% of grade III, 40% of grade IV, and 70% of grade V VUR. Four patients had reimplantation. The median follow up duration was 60months (range 20-216months). Univariate analysis showed that lower VUR grade (p=0.03) and absent renal scars (p=0.04) were statistically significant predictors of resolution. In multivariate analysis, absent renal scars were statistically significant (p=0.01). CONCLUSION: We demonstrated efficacy of endoscopic-Deflux-injection as the first line treatment for primary-VUR. Absent renal scar and lower VUR grade were statistically significant predictors of resolution after single injection. TYPE OF STUDY: Case-Control / Retrospective Comparative Study. LEVEL OF EVIDENCE: Level III.

Pneumovesical Ureteric Reimplantation in Pediatric Patients: An Intermediate Term Result.

INTRODUCTION: Pneumovesical ureteric reimplantation has gained increasing popularity for the treatment of vesicoureteric reflux (VUR) and vesicoureteric junction obstruction (VUJO) in pediatric patients. In this study we reviewed our experience at an intermediate term basis. METHODS: A retrospective review of all patients with pneumovesical ureteric reimplantation performed in a tertiary referral center between 2005 and 2015 was carried out. Patients' demographics, operative measures, and postoperative outcomes were recorded. RESULTS: Thirty-one patients were identified during the study period. Twenty-three patients had VUR and 8 patients had VUJO. A total of 42 ureteric reimplantation procedures were carried out. The mean age at operation was 6.1 years old. The mean operative time was 221 minutes. On average the length of hospital stay was 7.4 days. Four patients required conversion to open approach. Four patients had low-grade residual VUR after the operation and all of them were treated conservatively. There was no major complication or mortality. CONCLUSION: Pneumovesical ureteric reimplantation is safe and effective for pediatric patients. Intermediate term result confirmed its reliability and low recurrence rate. It has good potential to become the preferred approach of choice in the future.

Outcomes of Re-Intervention for Laparoscopic Transperitoneal Pyeloplasty in Children.

BACKGROUND: There is no consensus for the management of failed laparoscopic pyeloplasty in pediatric surgical patients, and only limited publications are available. We evaluated here the clinical outcomes of re-intervention for failed laparoscopic transperitoneal pyeloplasty in infants and children. MATERIALS AND METHODS: Retrospective review of all children who had undergone laparoscopic transperitoneal dismembered Anderson-Hynes pyeloplasty for ureteropelvic junction obstruction from 2002 to 2013 was performed. Patients' demographics, indications, operative details, and outcomes for primary operation as well as re-intervention were studied. RESULTS: There were 42 patients with a median age of 20 months (range, 3-192 months) and a median body weight of 12 kg (range, 6-56 kg) who underwent a total of 46 laparoscopic transperitoneal pyeloplasties during the study period. The median operative time and blood loss were 193 minutes (range, 115-480 minutes) and trace amount (range, trace amount to 400 mL), respectively. No conversion was reported. Ten cases (22%) required re-intervention. No statistically significant risk factor for failed pyeloplasty was identified. Indications for re-intervention included deterioration of differential renal function (n = 6), progressive hydronephrosis (n = 1), urinary ascites (n = 2), and urosepsis (n = 1). Median time of re-intervention was 6.5 ± 38 months postpyeloplasty. Re-intervention was categorized into the redo pyeloplasty group (n = 6) and the urinary diversion group (n = 4) (insertion of double-J ureteral stent or endopyelotomy) with success rates of 50% and 25%, respectively. Among the redo pyeloplasty group, 3 patients underwent redo laparoscopic pyeloplasty, and all of them had drainage restored with a median improvement in differential renal function of 11%. The mean follow-up duration was 77 ± 38 months. CONCLUSIONS: Laparoscopic transperitoneal pyeloplasty is safe and feasible in children. Redo pyeloplasty is a more favorable re-intervention compared with urinary diversion in our series. Redo laparoscopic pyeloplasty has been shown to improve differential renal function.

Use of robotic-assisted laparoscopic Mitrofanoff appendicovesicostomy in a paediatric patient: problem encountered.

This report is of robotic-assisted laparoscopic Mitrofanoff appendicovesicostomy in a 12-year-old patient with detrusor underactivity and hereditary sensory neuropathy. The whole operation was performed in 555 minutes with no open conversion. The patient experienced one episode of stomal stenosis, which required dilatation. At 3-year follow-up, the patient had both stomal and urinary continence. This is a safe and effective procedure to create a means of urinary catheterisation with avoidance of a large unsightly scar and comparable clinical outcome to an open procedure.

Childhood intussusception: 17-year experience at a tertiary referral centre in Hong Kong.

OBJECTIVES: To review all paediatric patients with intussusception over the last 17 years. DESIGN: Retrospective case series. SETTING: A tertiary centre in Hong Kong. PATIENTS: Children who presented with intussusception from January 1997 to December 2014 were reviewed. MAIN OUTCOME MEASURES: The duration of symptoms, successful treatment modalities, complication rate, and length of hospital stay were studied. RESULTS: A total of 173 children (108 male, 65 female) presented to our hospital with intussusception during the study period. Their median age at presentation was 12.5 months (range, 2 months to 16 years) and the mean duration of symptoms was 2.3 (standard deviation, 1.8) days. Vomiting was the most common symptom (76.3%) followed by abdominal pain (46.2%), per rectal bleeding or red currant jelly stool (40.5%), and a palpable abdominal mass (39.3%). Overall, 160 patients proceeded to pneumatic or hydrostatic reduction, among whom 127 (79.4%) were successful. Three (1.9%) patients had bowel perforation during the procedure. Early recurrence of intussusception occurred in four (3.1%) patients with non-operative reduction. No recurrence was reported in the operative group. The presence of a palpable abdominal mass was a risk factor for operative treatment (relative risk=2.0; 95% confidence interval, 1.8-2.2). Analysis of our results suggested that duration of symptoms did not affect the success rate of non-operative reduction. CONCLUSIONS: Non-operative reduction has a high success rate and low complication rate, but the presence of a palpable abdominal mass is a risk factor for failure. Operative intervention should not be delayed in those patients who encounter difficult or doubtful non-operative reduction.

A light bulb moment: an unusual cause of foreign body aspiration in children.

A 15-month-old girl developed persistent cough with no associated history of foreign body aspiration. Chest X-ray showed a U-shaped radiopaque foreign body, which was initially thought to be a hairpin, in the right main bronchus. Rigid bronchoscopy was performed and the foreign body turned out to be a light-emitting diode (LED) bulb. In this article, we report our experience of LED bulb aspiration in children, with the view to raise the awareness of clinicians about this potentially life-threatening emergency.

Thoracoscopic bullectomy for primary spontaneous pneumothorax in pediatric patients.

INTRODUCTION: Primary spontaneous pneumothorax is a condition that carries significant morbidities and mortalities if not managed properly. Thoracotomy with bullectomy has been the treatment of choice for persistent air leak or recurrence after initial chest drain insertion. With the advancement in minimal invasive surgery, the thoracoscopic approach can dramatically reduce the complications of open thoracotomy. We review our experience in managing spontaneous pneumothorax in children using thoracoscopy. MATERIALS AND METHODS: The medical records of all patients who were discharged with the diagnosis of spontaneous pneumothorax from 1997 to 2007 were reviewed. The demographic data and management were noted. For those patients who underwent thoracoscopic surgery, the intra-operative findings, post-operative outcomes and complications were compared. RESULTS: A total of 15 patients with spontaneous pneumothorax were identified. They all received chest drain insertion as the primary treatment modality. Nine patients, with mean age 16.1 +/- 0.9 years, failed the initial management and subsequently received thoracoscopic surgery with a mean interval of 7.6 +/- 2.5 days after initial chest drain insertion. Among these patients, bullae were found in seven patients (two patients had more than one bulla). The bullae were excised with mean operative time being 63.9 +/- 25.2 min. No conversion to thoracotomy was reported. All patients received paracetamol as pain control and there was no associated complication. No recurrence was found at follow-up till now. CONCLUSION: This study confirms that the presence of bulla is commonly seen in patients with spontaneous pneumothorax who fail initial management. Thoracoscopic bullectomy, a safe and effective operation, should be offered to this group of patients.

Deflux injection for the treatment of vesicoureteric reflux in children--a single centre's experience.

BACKGROUND: Vesicoureteric reflux (VUR) is a common condition that may lead to end-staged renal failure. Treatment options include long term prophylactic antibiotics or surgical intervention. Recently, endoscopic treatment by a subureteral injection of Deflux has gained popularity. Our centre has introduced this treatment modality since 2002. METHODS: The medical records of 42 patients (15 male and 27 female) who received Deflux injections for treatment of VUR from 2002 to 2007 were reviewed. All the patients were followed up with voiding cystourethrograms at 3 months after the procedure. RESULTS: The median age at operation was 72.59 months (range, 8 to 216 months). Unilateral involvement was found in 20 patients while 22 patients had bilateral involvement. Of the 64 ureters, VUR were grade II to V in six (9.4%), 31 (48.4%), 20 (31.2%) and seven (10.9%) patients respectively. Resolution of reflux, defined as grade 0 to I, after one injection was seen in six (100%), 20 (64.5%), and 16 (80%) ureters from grade II to IV respectively. Only one patient with grade V reflux achieved complete resolution after a single injection. Of the 21 ureters which had residual reflux, three were lost from follow up and 18 (ten grade III, two grade IV and six grade V) received a second injection and eventually 12 ureters achieved resolution. Thus, the overall success rate was 67.2% after a single injection and 85.9% after two injections. No procedure-related complications was reported. CONCLUSION: Injections of Deflux is an effective treatment for VUR. A significant reduction in disease severity was seen in patients with grade II to IV disease after a single injection. Most patients with grade V disease needed more than one injection before achieving complete resolution. With this high success rate, we recommend the use of endoscopic Deflux injection as the first line treatment for children with vesicoureteric reflux disease.

Abdominal compartment syndrome after open biopsy in a child with bilateral Wilms' tumour.

Although Wilms' tumour is one of the most common solid malignancies in children, bilateral disease is rare. We report a child with bilateral Wilms' tumour who developed abdominal compartment syndrome after an open biopsy.

Impact of prenatal diagnosis on choledochal cysts and the benefits of early excision.

AIM: To evaluate the clinical outcomes of patients with prenatally diagnosed choledochal cysts compared with those diagnosed after birth and the optimal timing of definitive treatment. METHODS: Retrospective review of all patients who underwent primary choledochal cyst excision and Roux-en-Y hepaticojejunostomy from 1996 to 2006 at a single institution. RESULTS: A total of 45 patients were included. Ten (22.2%) of the patients had prior prenatal diagnosis. The mean age at operation for this group was 4.4 months and mean follow up was 55.9 months. There was no operative complication or late morbidity. For the post-natal diagnosis group, the mean age at operation was 5.7 years (P < 0.000) and mean follow up period was 69 months. The most common presentation in this group was abdominal pain (31.4%), followed by pancreatitis (28.6%) and symptoms of cholestasis (25.7%). Early post-operative morbidities occurred in two (5.7%) patients. On long-term follow up, two (5.7%) further patients in the post-natal group developed complications. CONCLUSION: Prenatal diagnosis of choledochal cysts results in earlier definitive surgery. More adverse complications were seen in those who had surgery at an older age. We therefore recommend early excision of choledochal cysts.

Evaluation of a standardized protocol in the use of steroids after Kasai operation.

Although the Kasai operation is still the treatment of choice for infants with biliary atresia, the long-term success rate, as defined by survival without transplantation, is only about 25-40%. It has been proposed that post-operative inflammatory changes affect the bile flow and eventually lead to cholangitis and liver failure. Recent case reports have suggested that the administration of steroids post-operatively can improve outcomes. Since 2004, our unit has adopted a strict protocol for the use of post-operative steroids for patients who undergo Kasai operation. The aim of this study is to access the early outcomes of these patients. A retrospective analysis was carried out for all patients who received Kasai operation between 1996 and 2006. For the treatment group, patients all received prednisolone at 4 mg/kg 1 week after operation as guided by protocol. The demographics and outcomes, including post operative bilirubin level, episodes of cholangitic attack, the need for early liver transplantation (transplant within 1 year of Kasai), and transplantation-free survival, were noted. Statistical analysis was done using Fisher's exact test and unpaired t-test when appropriate. A value of P < 0.05 was considered to be statistically significant. Kasai operation was performed in 30 patients (11 boys and 19 girls) during the study period. Thirteen patients received post-operative prednisolone according to protocol. The average age at operation and the mean preoperative bilirubin levels for the steroid and non-steroid group were not significantly different. A normal post-operative bilirubin (defined as bilirubin level less than 20 mumol/L) was achieved at 6 months in 7 (53.9%) patients who received steroid and 8 (47.0%) patients who did not (P = 0.71). A statistically significant reduction in the post-operative bilirubin level was also seen at 3 and 6 months in the steroid group. Early liver transplantation was required in 5 (38.5%) patients with steroid and 5 (29.4%) patients without it (P = 0.60). No significant difference in terms of cholangitic attack was observed. There was also no steroid-associated complication reported. We conclude that lower post-operative bilirubin level can be achieved with the routine use of prednisolone. However, there is no statistical improvement in terms of early liver transplantation and cholangitis. This may be attributed to the small sample size of our study population. Based on this pilot study, a multi-centre randomized trial is needed.

Trends in the prevalence of Helicobacter pylori in symptomatic children in the era of eradication.

PURPOSE: Helicobacter pylori infection is common in Asia and is associated with dyspepsia, peptic ulcer, and gastric cancer. Eradication of the organism remains an important goal. Here, we looked at the trends in the prevalence of H pylori in symptomatic children over an 8-year period to assess the impact of an aggressive eradication program. METHOD: A retrospective review was carried out between 1997 and 2004. All children with a history of dyspepsia or acute gastrointestinal bleeding were included and underwent gastroscopy. Three antral biopsies were taken during endoscopy and sent for histological analysis. Positivity of H pylori was treated aggressively with quadruple therapy under protocol. The demographic data, the histological findings, and the H pylori status were recorded. RESULTS: There were a total of 159 patients (71 males, 88 females) who underwent gastroscopy in this period. One hundred nineteen patients showed histological evidence of gastritis, and the positive rate of H pylori was 25.6%. The overall prevalence has not decreased (33.3% in 1997, 27.7% in 2004). Increasing age, however, was associated significantly with the higher risk of H pylori infection. CONCLUSION: H pylori has a high prevalence in Chinese children with increasing age. Eradication efforts seem to be unsuccessful in the reduction of prevalence. We hypothesize that this may be owing to cross-infection at meal times from sharing chopsticks.

The use of positron emission tomography in detecting hepatoblastoma recurrence--a cautionary tale.

PURPOSE: The use of positron emission tomography (PET) with [18F] fluorodeoxyglucose (FDG) in the detection of recurrences has been well established in many tumor types. Here the authors present their experience using this modality in the evaluation of posttreatment hepatoblastoma patients. METHODS: The authors conducted a retrospective review on patients with hepatoblastoma diagnosed from 1996 to 2003. FDG-PET imaging was performed together with measurement of alpha-fetal protein (AFP) during posttreatment follow-up. RESULTS: Sixteen patients (8 boys and 8 girls) were identified in this series. The mean age was 23.5 months (range, 5 months to 4 years). Three posttreatment patients had PET results suggestive of tumor recurrence. One of these patients had normal AFP level and suspected recurrence in the caudate lobe. Radiologic-guided biopsy was performed 3 times, and there was no evidence of tumor. The other 2 patients underwent further liver resections because of mildly raised AFP levels. The histology of these showed regenerative liver tissue only with no hepatoblastoma recurrence. CONCLUSIONS: Although PET has been gaining popularity as a tool in the detection of tumor recurrences worldwide, it has been shown in this series that PET may not be useful in hepatoblastoma patients, and caution must be taken in the interpretation of positive results.

Effective antibiotic regime for postoperative acute cholangitis in biliary atresia--an evolving scene.

PURPOSE: The prompt use of empirical antibiotics is vital in managing post-Kasai cholangitis. The authors published findings of their clinical trial in 1991 and established the use of cefoperazone, with a response rate of 88.9%. Here its clinical use since its introduction is reviewed and the trend in its efficacy is assessed. METHODS: A retrospective review was carried out between 1997 and 2003. All episodes of acute cholangitis in patients who underwent Kasai procedure were recorded. Cholangitis was defined as unexplained fever with derangement of liver enzymes. Cefoperazone was started empirically according to the established protocol, and the response to treatment was analyzed. RESULTS: There were 19 patients with a total of 49 episodes of cholangitis. Cefoperazone was used as the first-line empirical antibiotic in 40 of these episodes. Only 30 showed successful response (75%). For the 10 unresponsive episodes, meropenem was used as second-line antibiotic with complete response in all. CONCLUSIONS: The efficacy of cefoperazone in the treatment of post-Kasai cholangitis has decreased over the last years. This suggests a need for a more effective first-line empirical antibiotic. From this review, meropenem seems to be a suitable candidate, and a future prospective clinical trial is warranted.