Burden and mortality of congenital gastrointestinal anomalies: insights from a nationwide cohort study.

PURPOSE: Improved perioperative care has enhanced survival in children with congenital gastrointestinal conditions and abdominal wall defects (AWD). However, epidemiological and surgical outcomes in developing nations are still scarce. Our aim was to assess the burden and mortality of common congenital gastrointestinal anomalies and AWD in Malaysia, and their influencing factors. METHODS: Using the Global PaedSurg study protocol with permission, we performed a prospective cohort study on children presenting for the first time between October 2021 and April 2022 with these conditions: Esophageal atresia (EA), congenital diaphragmatic hernia (CDH), intestinal atresia, gastroschisis, exomphalos, anorectal malformation (ARM) and Hirschsprung's disease. We compared mortality and 30-day outcome data across different geographical regions in Malaysia. RESULTS: There were 228 patients with 242 study conditions (EA n = 28, CDH n = 36, intestinal atresia n = 49, gastroschisis n = 12, exomphalos n = 8, ARM n = 77, Hirschsprung's disease n = 32). Our mortality rate was 8.8%; 60% of these were CDH patients. Factors significantly associated with mortality were CDH diagnosis, central venous access requirement, higher American Society of Anesthesiologists (ASA) score, blood transfusion and ventilation requirement. CONCLUSION: Diagnosis of CDH is the most important predictor for sepsis on arrival and mortality, therefore measures should be taken for early recognition and aggressive management.

STAT trial: stoma or intestinal anastomosis for necrotizing enterocolitis: a multicentre randomized controlled trial.

PURPOSE: The STAT trial is a multicenter randomized controlled trial in 12 centers worldwide aiming to determine the most effective operation for neonates with necrotizing enterocolitis (NEC) requiring intestinal resection: stoma formation (ST) or primary anastomosis (PA). METHODS: Infants having a primary laparotomy for NEC were randomized intraoperatively to PA or ST if the operating surgeon thought that both were viable treatment options for that patient. The primary outcome (duration of parenteral nutrition [PN]) was evaluated by Cox regression. RESULTS: Eighty patients were recruited from 2010 to 2019. Infants undergoing anastomosis finished PN significantly earlier than patients undergoing stoma (hazard ratio PA vs. ST 2.38, 95% CI 1.36-4.12 p = 0.004). There was no difference in mortality between the two groups (PA 4/35 vs. ST 8/38 p = 0.35) or in the rate of complications requiring further unplanned operations (p = n.s.). Multiple intestinal complications were more frequent in the stoma group compared to the anastomosis group (ST 12/26 vs. PA 5/31, p = 0.02, Fisher's Exact test). CONCLUSION: At laparotomy for NEC, when there is no disease distal to resected intestine, primary anastomosis should be performed as it enhances the recovery from NEC, reduces the risk of multiple intestinal complications and does not increase adverse outcomes.

Intradyadic Correlation Between Parent-reported and Child-reported Quality of Life in Patients With Anorectal Malformation and Hirschsprung's Disease in Comparison to Healthy Controls.

BACKGROUND: Quality of life (QOL) is an important clinical endpoint in paediatric chronic conditions. How parent-proxy reports differ from child self-reported QOL in patients with anorectal malformation (ARM) and Hirschsprung's disease (HD) has not been well examined to date. This study evaluates agreement between parent-proxy and child-reported QOL scores in ARM and HD patients compared to healthy controls. METHODS: We recruited ARM and HD patients aged 5-17 years and their parents at four tertiary referral centres between December 2020 to February 2023 who had corrective surgery done >12 months prior. Healthy controls were age-matched and gender-matched. They completed the Pediatric Quality of Life Inventory™ (PedsQL™) Generic Core Scales and General Well-Being (GWB) Scale. The questionnaires were administered in parallel parent-proxy-report and child self-report formats. Appropriate statistical analysis was performed with p < 0.05 significance. Data are reported as median (interquartile range). Ethical approval was obtained. RESULTS: There were 65 ARM, 54 HD and 83 controls. There were no significant differences between parent-reported scores and child-reported scores overall in the Total, Psychosocial Health and Physical Health components of Core Scales for ARM, HD and controls. However, parent-reported scores were significantly higher than child-reported scores overall in ARM, HD and controls in the GWB Scale. CONCLUSION: Our findings show that parent-rated and child-rated overall QOL was similar in Core Scales for ARM, HD, and controls. However, parents overestimated child's overall GWB for ARM, HD and controls. This highlights the importance of capturing the perspectives of both parents and children to inform strategies to improve patient care. LEVEL OF EVIDENCE: Level III.

A prospective multicentre study evaluating the performance of the modified simple biliary atresia scoring system in predicting biliary atresia.

PURPOSE: Early diagnosis of biliary atresia (BA) is critical for best outcomes, but is challenged by overlapping clinical manifestations with other causes of obstructive jaundice in neonates. We evaluate the performance of the modified Simple BA Scoring System (SBASS) in diagnosing BA. METHODS: We performed a prospective, cross-sectional study on infants with cholestatic jaundice (June 2021-December 2022). Modified SBASS scoring was applied and compared to the eventual diagnosis (as per intraoperative cholangiogram (IOC) and liver histopathology). The score (0-6), consists of gall bladder length < 1.6 cm (+ 1), presence of triangular cord sign (+ 1), conjugated bilirubin:total bilirubin ratio > 0.7(+ 2), gamma-glutamyl transferase (GGT) ≥ 200 U/L (+ 2). RESULTS: 73 were included: Fifty-two (71%) had BA. In the non-BA group, 6 (28%) had percutaneous cholangiography (PTC) while 15 (72%) had intraoperative cholangiogram (IOC). At a cut-off of 3, the modified SBASS showed sensitivity of 96.2%, specificity of 61.9% and overall accuracy of 86.3% in diagnosing BA. Area under receiver operating characteristic curve was 0.901. GGT had the highest sensitivity (94.2%), while triangular cord sign showed the highest specificity at 95.2%. CONCLUSION: The SBASS provides a bedside, non-invasive scoring system for exclusion of BA in infantile cholestatic jaundice and reduces the likelihood of negative surgical explorations.

A multi-center cross-sectional comparison of parent-reported quality of life and bowel function between anorectal malformation and Hirschsprung's disease patients with versus those without Down syndrome.

PURPOSE: Down syndrome (DS) is a common abnormality associated with anorectal malformation (ARM) and Hirschsprung's disease (HD). However, quality of life (QOL) in ARM and HD patients with DS is under-researched. This study compares parent-reported QOL and bowel function in ARM and HD patients with DS to those without. METHODS: Between December 2020 to February 2023, parents of ARM and HD patients with and without DS aged 3-17 years who had undergone surgery > 12 months prior at four tertiary referral centers were recruited. We used the Pediatric Quality of Life Inventory™ (PedsQL™) Generic Core Scales, General Well-Being (GWB) Scale and Family Impact (FI) Module questionnaires, and the Rintala bowel function score (BFS). RESULTS: There were 101 ARM, 9 (8.9%) of whom had DS; and 87 HD, of whom 6 (6.9%) had DS. Parent-reported Core scores in ARM and HD with DS were comparable to those without DS. However, ARM and HD with DS had worse scores in the FI Module and bowel function than those without DS. CONCLUSION: Although parent-reported QOL in ARM and HD with DS is similar to those without DS, family impact and BFS are worse. Our findings are limited by small sample size in proportion of DS patients.

Experiences of youth growing up with anorectal malformation or Hirschsprung's disease: a multicenter qualitative in-depth interview study.

PURPOSE: Patients with anorectal malformation (ARM) and Hirschsprung's disease (HD) live with long-term impact of these diseases even into adulthood. We aimed to explore the physical, social and emotional impact of these diseases in adolescents and young adults to develop best practices for transition care. METHODS: We conducted one-on-one in-depth interviews with ARM and HD patients aged ≥ 11 years who had undergone surgery at four tertiary referral centers. All interviews were audio-recorded and transcribed verbatim. We analyzed transcripts for recurring themes, and data were collected until data saturation was reached. Three researchers independently coded the transcripts for major themes using thematic analysis approach. RESULTS: We interviewed 16 participants (11 males) between October 2022 and April 2023. Ages ranged from 11 to 26 years. Five major themes emerged: (1) personal impact (subthemes: physical, emotional and mental health, social, school), (2) impact on family, (3) perceptions of their future (subthemes: relationships, career, state of health), (4) sources of support (subthemes: family, peers, partner), and (5) transition care (subthemes: concerns, expectations). Only females expressed concerns regarding future fertility. CONCLUSION: This study highlights the evolving problems faced by adolescents and young adults with ARM and HD, especially gender-specific concerns. Our findings can inform efforts to provide individualized care.

Anorectal malformation and Hirschsprung's disease: a cross-sectional multicentre comparison of quality of life and bowel function to a healthy population.

PURPOSE: Children with anorectal malformation (ARM) and Hirschsprung's disease (HD) often experience bowel symptoms into adulthood, despite definitive surgery. This study evaluates the quality of life (QOL) and bowel functional outcome of children treated for ARM and HD in comparison to healthy controls. METHODS: Between December 2020 and February 2023, we recruited patients with ARM and HD aged 3-17 years at four tertiary referral centres, who had primary corrective surgery done >12 months prior. Healthy controls were age-matched and sex-matched. All participants completed the Pediatric Quality of Life Inventory Generic Core Scales 4.0, General Well-Being (GWB) Scale 3.0 and Family Impact (FI) Module 2.0 Questionnaires. Bowel Function Score (BFS) Questionnaires were also administered. We also performed subgroup analysis according to age categories. Appropriate statistical analysis was performed with p<0.05 significance. Ethical approval was obtained. RESULTS: There were 306 participants: 101 ARM, 87 HD, 118 controls. Patients with ARM and HD had significantly worse Core and FI Scores compared with controls overall and in all age categories. In the GWB Scale, only ARM and HD adolescents (13-17 years) had worse scores than controls. ARM and HD had significantly worse BFSs compared with controls overall and in all age categories. There was significant positive correlation between BFS and Core Scores, GWB Scores and FI Scores. CONCLUSION: Patients with ARM and HD had worse QOL than controls. Lower GWB Scores in adolescents suggests targeted interventions are necessary. Bowel function influences QOL, indicating the need for continuous support into adulthood.

Parent-Reported Health-Related Quality of Life Outcomes and Impact on Family of Congenital Diaphragmatic Hernia Survivors After Repair: A Cross-Sectional Comparison to Healthy Controls.

BACKGROUND: Congenital diaphragmatic hernia (CDH) survivors often experience long-term CDH-associated morbidities, including musculoskeletal, gastrointestinal and respiratory issues. This study evaluates parent-reported health-related quality of life (HRQOL) and family impact of the disease. METHODS: Electronic medical records (EMR) were reviewed and phone surveys performed with parents of CDH survivors who underwent repair at our institution from 2010 to 2019. They completed the following Pediatric Quality of Life Inventory™ (PedsQL™) questionnaires: Generic Core Scales 4.0 (parent-proxy report) and Family Impact (FI) Module 2.0. Age-matched and gender-matched healthy controls from an existing database were used for comparison. Subgroup analysis of CDH patients alone was also performed. Appropriate statistical analysis was used with p < 0.05 significance. Data are reported as median (range). Ethical approval was obtained. RESULTS: Of 76 CDH survivors, 45 parents (59 %) consented for study participation. Patients and controls were aged 6 (3-12) years; 51 % were male. In Core Scales, there were significant differences between the groups in the overall scores (p = 0.003) and the psychosocial health sub-scores (p = 0.004), but no difference in the physical health domain scores. In the Family Impact Module, there were no significant differences between the groups in overall scores, in parent HRQOL and in family functioning sub-scores. However, CDH patients with learning disabilities had significantly worse Family Impact Module overall scores compared to CDH patients without learning disabilities (p = 0.04). CONCLUSION: The overall HRQOL in children with CDH survivors is worse compared to controls, but impact on family appears similar. We highlight the need for long-term follow-up of CDH patients, especially those with learning disabilities. Healthcare providers should formulate tailored care plans to address patient and caregiver needs. TYPE OF STUDY: Prospective Study. LEVEL OF EVIDENCE: Level III.

Comparing Consistency and Usability of Common Bowel Function Scoring Systems in Anorectal Malformation Patients.

BACKGROUND: Assessment of postoperative bowel function in anorectal malformation (ARM) patients is crucial for benchmarking outcomes. We compared existing bowel function scoring systems in various aspects in patients with ARM. METHODS: With ethical approval, this was a cross-sectional study involving 5 paediatric surgery referral centres in Malaysia, comparing the Kelly, Japanese Study Group of Anorectal Anomalies (JSGA), Holschneider and Krickenbeck bowel function questionnaires. We recruited patients aged 4-17 years, who had completed definitive surgery & stoma closure (where relevant) > 12 months prior to participation. We standardised outcomes of each scoring system into categories ('good', 'fair', 'poor' and 'very poor') to facilitate comparison. Parents & patients were surveyed and asked to rate the ease of understanding of each questionnaire. The difference in protocol scores rated between parents and patients were compared. Association of each bowel function scoring protocol with type of anomaly was assessed. Statistical significance was p < 0.05. RESULTS: Thirty-nine parents (21 mothers, 18 fathers) and 23 patients were included in this study. Fair agreement was found between Kelly and Krickenbeck protocols (κ = 0.343; p < 0.001), between JSGA constipation and Holschneider protocols (κ = 0.276; p = 0.002); JSGA constipation and Krickenbeck protocols (κ = 0.256; p = 0.004); and between Holschneider and Krickenbeck protocols (κ = 0.273; p = 0.003). Only the Kelly protocol showed significant correlation between parents and patients' answers (ρ = 0.459, p = 0.028). Krickenbeck demonstrated the best negative correlation of patients' scores with ARM types (ρ = -0.401, p = 0.001). The Kelly protocol ranked highest when comparing ease of understanding. CONCLUSION: All the questionnaires appeared comparable in assessing postoperative faecal continence in ARM patients. The Kelly questionnaire performed best in 3 key areas of assessment. LEVEL OF EVIDENCE: Level III Cross-Sectional Study.

Knowledge, attitude, and practices of operating theatre staff towards environmentally sustainable practices in the operating theatres.

BACKGROUND: Successful implementation of environmentally sustainable practices in the operating theatre (OT) requires stakeholder engagement. We evaluate the knowledge, attitudes, and practices of OT users in our institution towards sustainable practices in the OT. METHODS: A survey was conducted among OT users in August 2022. Respondents completed a 44-question anonymised online survey covering sustainability in (1) knowledge, (2) attitude, (3) practice, and (4) proposed changes to current practices. Points were assigned to knowledge (15 points) and attitude (40 points) sections. Practice was evaluated based on proportion of measures practiced. Appropriate statistical tests were used, with significance p < 0.05. Data are presented as mean ± standard deviation (SD) or proportion (%). RESULTS: Among 149 respondents were doctors (n = 76), non-doctors (n = 45), and medical students (n = 28). Doctors scored highest in knowledge of sustainability (8.58 ± 1.83) compared to non-doctors and medical students (7.62 ± 1.75, 8.39 ± 1.87). Positive attitudes towards sustainability correlated with years of experience (p < 0.01). Non-doctors were more likely to practice sustainable measures, versus doctors (61 vs 52%, p < 0.01). Most (69%) respondents were unwilling to adopt any practice changes. The least popular measure was replacement of standard hand scrubbing with alcohol-based hand rub, considered unsafe by 74% of respondents. CONCLUSION: Despite positive attitudes towards sustainable measures, there remains wariness of practice changes, which should be addressed by educational campaigns.

Sociodemographic factors affecting paediatric surgical training in Malaysia: Gender matters.

BACKGROUND: A shortage of specialist paediatric surgeons in Malaysia led to establishment of a national postgraduate training programme in 2004. We aimed to identify sociodemographic factors impacting training experience, and to define pressure points during training to inform targeted trainee support strategies. METHODS: We conducted an anonymized online survey in June 2021 on all programme graduates. Participants were asked for sociodemographic data, both current and during training. Likert scale responses were required for questions regarding adequacy of support received for family, health and personal issues during training. A free text response question soliciting suggestions for programme improvement was included. Data are reported as median (range). Chi-square/Fisher's exact tests for categorical variables and Mann-Whitney U tests for continuous variables were used, with p<0.05 significance. RESULTS: Of 53 eligible participants, 52 (98%) responded, 24 (46%) were female. Marital status was similar between genders at entry, but female trainees were more likely to be unmarried on exit (p = 0.001), and less likely to have children while training (p = 0.017). Of the 6 female and 18 male trainees who had children while training, women were more likely to take parental leave (p = 0.01). The majority felt advice given regarding parental leave and managing training while having children were poor. In thematic analysis of free text answers, lack of hands-on experience was the most common concern. CONCLUSION: Factors related to marriage and parenthood significantly associate with gender amongst trainees in Malaysia despite both genders being well represented. Concerns regarding adequacy of hands-on training highlight the need for educational innovations such as simulation models. LEVEL OF STUDY: Level III.

Laparoscopic versus Open Incarcerated Inguinal Hernia Repair in Children: A Systematic Review and Meta-Analysis.

BACKGROUND: Laparoscopic hernia repair (LH) is reported to have superior outcomes in pediatric inguinal hernia repair, but its advantages in incarcerated inguinal hernia (IIH) are not defined. We compare the outcomes of LH versus open hernia repair (OH) for pediatric IIH. METHODS: We performed a systematic review on all published analyses of LH versus OH for IIH. We identified studies published in 2000 to 2018 from Medline, PubMed, Embase, Google Scholar, and Cochrane databases. We included only studies that compared both surgical techniques on children aged 18 years or younger. Search terms were variations of "incarcerated inguinal hernia," "hernia repair," "laparoscopy," and "child." We categorized complications as major (testicular atrophy, ascending testis, recurrence, iatrogenic visceral injury) and minor (wound infection). Heterogeneity was assessed using I2; meta-analyses were performed using random- or fixed-effects models as appropriate. Weighted mean differences (WMDs) or odds ratios (ORs), with their corresponding 95% confidence intervals (CIs), were used for analysis of continuous and dichotomous variables, respectively. Significance level was at p-value less than 0.05. RESULTS: Our initial search yielded 549 unique citations. Eight retrospective cohort (RC) studies (584 patients) were included in the final analysis (339 LH, 245 OH). Overall, major complications (eight RC; n = 584; OR = 0.38; 95% CI: 0.17-0.88; p = 0.02) were more common in OH. When each complication was assessed individually, there were no differences between groups. The length of hospital stay in the LH group was shorter than in the OH group (five RC; n = 418; WMD = - 1.39; 95% CI, -2.56 to -0.22; p = 0.02). CONCLUSION: Laparoscopic repair for IIH is associated with less major complications and shorter hospital stay, but data are limited due to the absence of randomized controlled trials.

Anal canal and sphincter function in children with Hirschsprung disease after definitive surgery.

INTRODUCTION: Anorectal manometry may be useful to objectively evaluate anorectal function following definitive pullthrough for Hirschsprung Disease (HD) but there is little published data. Our study aims to investigate anorectal manometry findings and their association with bowel function. METHODOLOGY: This was a prospective observational study. Convenience sampling method was used to recruit all HD patients who had definitive pullthrough from January 2019 to December2020 in our institution. High-resolution anorectal manometry (HRAM) was used to record anal resting pressure (ARP), length of high-pressure zone (HPZ), and presence/absence of recto-anal inhibitory reflex (RAIR). The Paediatric Incontinence/Constipation Scoring System (PICSS) was scored for all participants. PICSS is a validated questionnaire with scores mapped to an age-specific normogram to denote constipation, incontinence, and their combinations. Non-parametric and chi-square tests at significance p<0.05 were conducted to examine the relationship between PICSS categories and manometry findings. Ethical approval was obtained. RESULTS: There were 32 participants (30 boys). Median age at participation was 26.5 months (range: 13.8-156). Twenty-four (75%) had transanal pullthrough, 8(25%) underwent Duhamel procedure. PICSS scored 10(31.3%) as normal, 8(25%) as constipation, 10(31.3%) as incontinent, and 4(12.5%) as mixed. RAIR was present in 12 patients (37.5%). HPZ, maximum ARP, mean ARP were comparable across all PICSS groups without statistically significant differences. Presence of RAIR was not significantly associated with any PICSS groups (p = 0.13). CONCLUSION: Bowel function does not appear to be significantly associated with HRAM findings after definitive pullthrough for HD, but our study is limited by small sample size. RAIR was present in 37.5% patients after pullthrough. LEVEL OF EVIDENCE: Level II.

Management of acute testicular pain in children: changing trends with improvements in scrotal ultrasonography over 18 years.

Introduction: Doppler scrotal ultrasonography (US) is the modality of choice in diagnosing testicular torsion. We aimed to evaluate the performance of scrotal US in diagnosing testicular torsion over the past 18 years in our institution and determine the factors contributing to the length of wait times for it. Methods: A retrospective review was conducted of boys who presented with acute scrotal pain from 2014 to 2015. US reports, operative findings, final diagnosis and key time points of the patients' journey (time to emergency department consultation, time to admission, time to US and time to operating theatre [OT]) were collected. US performance results were compared with those observed in a historical cohort from 1998 to 2004. Wait times were compared between operated and non-operated patients. Results: Data from 519 boys with a mean age of 9.15 years was collected. Of these, 438 (84.4%) boys had undergone initial scrotal US; of these scrotal US cases, 28 were surgically explored, with 23 confirmed to have torsion. Another five cases were explored without prior US, and all were confirmed to have torsion. Performance analysis of US showed a sensitivity of 100% and a specificity of 98.8%. There was no significant difference between wait times of operated and non-operated patients. Time to US (P < 0.0001, r = 0.96) and time to OT (P < 0.0001, r = 0.64) correlated significantly with the total time from presentation to surgery. Conclusion: There has been an improvement in the diagnostic performance of scrotal US for testicular torsion over the past 18 years. Quality improvement programmes targeted at reducing wait times for patients presenting with acute scrotum should target time to US and time to OT.

Utility of postoperative anorectal manometry in children with anorectal malformation: a systematic review.

Children with anorectal malformation (ARM) often continue to have disturbances in bowel function long after reconstructive surgery. Anorectal manometry may be utilized to evaluate bowel function in these children. We aimed to describe the reported protocols and manometric findings in children with ARM post-reconstructive surgery and to investigate the correlation between manometric evaluation and bowel functional outcome. PubMed, EMBASE, and Google Scholar databases were searched from 1980 to 2021. Data were reviewed and extracted independently by two authors, in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Included studies were English articles reporting postoperative assessment of children (≤ 18 years) with ARM using anorectal manometry. From 128 articles obtained in the initial search, five retrospective cohort studies and one prospective study fulfilled inclusion criteria. The rectoanal inhibitory reflex and mean anal resting pressure were parameters most often reported to correlate with postoperative bowel function. The least reported parameters among the studies were high-pressure zone, rectal volume, and rectal sensation. Anorectal manometry could be an objective method providing important information for personalized management of postoperative ARM patients with bowel function issues, but lack of standardized protocols limits a comprehensive analysis of their utility.

Effectiveness of table salt versus copper sulphate in treating umbilical granuloma: A pilot randomized controlled trial.

BACKGROUND: Umbilical granuloma is a common infantile condition which usually responds to non operative management. Copper sulphate (CuSO4) is often used as chemical cauterization but can cause superficial skin burns. An alternative is table salt (NaCl), which osmotically dehydrates wet granulation tissue causing necrosis. We aimed to compare the effectiveness of NaCl versus CuSO4 in treating umbilical granuloma. METHOD: We performed a multi centerrandomized controlled trial involving three regional pediatricsurgical units. We included children who presented with umbilical granuloma from December 2018 to May 2020. Children who received treatment prior to index visit were excluded. They were randomly allocated to receive NaCl (twice/day application for 5 days by caregiver) or CuSO4 (single application by clinician). Demographic data, compliance in the NaCl group by pill counting method, treatment outcomes, and complications were recorded. Treatment success was defined as complete lesion resolution. Partial or no response was considered treatment failure. Subsequent treatment then reverted to the respective center's routine management. RESULT: We recruited 70 participants with 6 dropouts (2 defaulters, 1 vitellointestinal duct, 3 urachal remnants), leaving 64 subjects for final analysis: 31 NaCl, 33 CuSO4. Compliance rate of 77.4% was recorded for NaCl, with 6 (20%) 'poor compliance' participants stopping therapy before completion owing to complete resolution. NaCl group had a significantly higher complete resolution rate (90.4%) compared to CuSO4 (69.7%), p = 0.040. No NaCl participant developed complications versus 9% (n = 3) in CuSO4 (periumbilical superficial skin burn). CONCLUSION: Table salt is an ideal treatment choice for umbilical granuloma as it is effective, safe, and readily available. LEVEL OF EVIDENCE: II.

Intra-abdominal hypertension in neonates following congenital diaphragmatic hernia repair: Correlation with early postoperative respiratory and gastrointestinal outcomes.

BACKGROUND: Increased intra-abdominal pressure (IAP) is seen in patients after congenital diaphragmatic hernia (CDH) repair owing to reduction of thoracic contents into the relatively smaller abdominal cavity. In infants, IAP ≥11 mmHg is considered intra-abdominal hypertension (IAH). We aim to determine the incidence of IAH and its relationship with duration of ventilatory support, and gastrointestinal function post CDH repair. METHODS: We prospectively recruited all neonates who had CDH repair in four hospitals in Malaysia from June 2018 to October 2020. Intra vesical pressure was used as a proxy for IAP and was measured for 5 consecutive days post surgery. The daily median value was used for analysis. We categorized IAP as <11 mmHg (no IAH), 11-15 mmHg (IAH), and >15 mmHg (severe IAH). Incidence of IAH, its effects on the duration of ventilatory support, and gastrointestinal function were studied. RESULTS: There were 24 neonates included in this study. They were operated between day 1 and 6 of life (median: 4 days old). IAH was detected within the first 3 days post surgery, with 83% occurring on day one. Those requiring ventilatory support for more than 3 days contributed the largest proportion of IAH (n = 17, 71%). There was strong correlation between days of IAH and duration of ventilation (p < 0.001, r = 0.70). There was moderate correlation between days of IAH and duration taken to achieve full enteral feeding (p < 0.005, r = 0.70). CONCLUSION: IAP measurement is a safe and useful adjunct in post CDH monitoring and in predicting ventilatory support requirements and the time needed to establish feeding.

Early experience with universal preoperative and pre-procedural screening for COVID-19 in low-risk pediatric surgical patients requiring general anesthesia.

PURPOSE: The COVID-19 pandemic has placed extraordinary demands on healthcare services worldwide. Some have reported increased viral transmission to healthcare workers during aerosol-generating procedures such as intubation. We report our experience with universal preoperative and preprocedural screening for COVID-19 in children requiring general anaesthesia with low risk of having the infection. METHODS: This was a data review involving children aged < 18 years undergoing procedures under general anaesthesia in our institution from 18th March to 31st May 2020 and deemed low risk for COVID 19 infection, as defined by our institutional protocol. Confirmation of COVID-19 was by real time reverse-transcription polymerase chain reaction with confirmation by nucleic acid sequencing. All patients were followed up 14 days post-swab. RESULTS: Of the 66 children (median age 4.5 years, range 0-16.8) eligible for the study, 39 (60%) were male and infants (1-12 months) formed the largest group (n = 24, 36%). None were positive for COVID-19. On 14 day follow-up, none had symptoms related to COVID-19. CONCLUSION: Our study shows that low risk asymptomatic children with no history of contact with COVID-19 patients test negative on universal screening. Larger studies are required to ascertain the role of screening prior to procedures done under general anaesthesia.

Assess, adapt and act: a paediatric surgery division's initial approach in a rapidly evolving pandemic.

PURPOSE: The COVID-19 pandemic has placed an unprecedented test on the delivery and management of healthcare services globally. This study describes the adaptive measures taken and evolving roles of the members of the paediatric surgery division in a developing country during this period. METHODS: We adopted multiple adaptive strategies including changes to stratification of surgeries, out-patient services by urgency and hospital alert status, policy writing involving multidisciplinary teams, and redeployment of manpower. Modifications were made to teaching activities and skills training to observe social distancing and mitigate reduced operative learning opportunities. Roles of academic staff were expanded to include non-surgical duties. RESULTS: The planned strategies and changes to pre COVID-19 practices were successful in ensuring minimal disruption to the delivery of essential paediatric surgical services and training. Despite the lack of established guidelines and literature outlining strategies to address the impact of this pandemic on surgical services, most of the initial measures employed were consistent with that of other surgical centres. CONCLUSION: Changes to delivery of surgical services and surgical training warrant a holistic approach and a constant re-evaluation of practices with emergence of new experiences and guidelines.

Parental Experiences While Waiting For Children Undergoing Surgery in Singapore.

PURPOSE: To explore the experiences and needs of parents while waiting for their children undergoing surgery. DESIGNS AND METHODS: A descriptive qualitative study was conducted. A purposive sample of 11 parents who went through their first waiting experiences during their children's surgeries in a Singapore public hospital was recruited. Children younger than or equal to 16 years of age were included. A semi-structured interview guide facilitated the individual face-to-face interviews. Thematic analysis was used. RESULTS: Four themes were identified: "Care and care provision affecting waiting experiences", "Parental concerns and surgery affecting waiting experiences", "Coping strategies used during waiting periods" and "Recommendations to improve waiting experiences". Pre-operative instructions, the professionalism of medical teams, and a lack of timely updates affected parental experiences. Parents expressed their worries. The complexities and types of surgery influenced how they felt. Their concerns included potential complications, surgical outcomes, anesthesia-related side effects, and post-operative care including pain. They spent their waiting times eating, resting, using their smart devices, and coping with a support system. Environmental improvements, more updates, and mobile applications were recommended by the participants. CONCLUSION: For a parent, the wait during his/her child's surgery can be unsettling. Our results give insights into parental waiting experiences and needs during their children's surgeries. PRACTICE IMPLICATIONS: These findings can guide the improvement of the current practise based on our evidence or the implementation of newer technology to provide better waiting experiences for parents during their children's surgeries and to enhance the quality of clients' experiences in the hospital.