Assessment of long-term quality of life, bowel and voiding function outcomes in patients with anorectal malformation at a single UK centre.

AIMS: Assess long-term quality of life (QoL), bowel and voiding function in anorectal malformation (ARM) paediatric patients. METHOD: Retrospective review of ARM patients between 2007 and 2020 was performed. QoL (all patients), bowel and voiding function (> 5 yo) were assessed using the paediatric quality of life inventory (PedsQL), paediatric incontinence and constipation score (PICS) and dysfunctional voiding scoring system (DVSS), respectively. RESULTS: There were 122 patients (49% female, 85 > 5 yo) with ARM. Two had died, four refused, twenty-two were non-contactable, leaving ninety-four patients (65 > 5 yo) included. Mean age was 89 months (19-183), and follow-up was 86 months (13-183). Patients had significantly poorer scores for QoL, bowel and voiding function compared to published healthy controls. 57% had poor bowel function, 32% had poor voiding function and 38% required 'ancillary aids' to facilitate function. Patients using 'ancillary aids' for voiding function had a significantly lower QoL (parent: 62 vs 77; p = 0.01, patient: 66 vs 79; p = 0.05). Bowel continence was worse in those with high vs low ARM (13 vs 20, p = 0.004) and timely vs delayed diagnosis (17 vs 24, p = 0.04). CONCLUSION: Patients with ARM have significantly worse QoL, bowel and voiding function than normal healthy controls. There is a need for long-term monitoring of function and further support for these children. LEVEL OF EVIDENCE: III.

Impact of socioeconomic deprivation on short-term outcomes and long-term overall survival after colorectal resection for cancer.

PURPOSE: The aim of this study was to assess the effects of socioeconomic deprivation on short-term outcomes and long-term overall survival following major resection of colorectal cancer (CRC) at a tertiary hospital in England. METHOD: This was an observational cohort study of patients undergoing resection for colorectal cancer from January 2010 to December 2017. Deprivation was classified into quintiles using the English Indices of Multiple Deprivation 2010. Primary outcome was overall complications (Clavien-Dindo grades 1 to 5). Secondary outcomes were the major complications (Clavien-Dindo 3 to 5), length of hospital stay and overall survival. Outcomes were compared between most affluent group and most deprived group. Multivariate regression models were used to establish the relationship taking into account confounding variables. RESULTS: One thousand eight hundred thirty-five patients were included. Overall and major complication rates were 44.9% and 11.5% respectively in the most affluent, and 54.6% and 15.6% in the most deprived group. Most deprived group was associated with higher overall complications (odds ratio 1.48, 95% CI 1.13-1.95, p = 0.005), higher major complications (odds ratio 1.49, 1.01-2.23, p = 0.048) and longer hospital stay (adjusted ratio 1.15, 1.06-1.25, p < 0.001) when compared with most affluent group. Median follow period was 41 months (interquartile range 20-64.5). Most deprived group had poor overall survival compared with most affluent, but it was not significant at the 5% level (hazard ratio 1.27, 0.99-1.62, p = 0.055). CONCLUSION: Deprivation was associated with higher postoperative complications and longer hospital stay following major resection for CRC. Its relationship with survival was not statistically significant.

Cognitive Function Declines Significantly during Haemodialysis in a Majority of Patients: A Call for Further Research.

INTRODUCTION: Cognitive impairment (CI) is very common condition that occurs in haemodialysis patients and it is associated with reduced functional capacity and mortality. We assessed the change in cognitive function during haemodialysis and associated risk factors. METHODS: All patients ≥50 years, on haemodialysis for ≥3 months, no dementia from 2 dialysis centres were selected. Cognition was assessed before and after a haemodialysis session using parallel versions of the Montreal Cognitive Assessment (MOCA) tool. Multiple regression was used to examine potential confounders. RESULTS: Eight-two patients completed both tests - median age 73 (52-91) years, 59% male, dialysis vintage 41 (3-88) months. Sixty-two (76%) had CI at baseline. Cognition declined over dialysis (MOCA 21 ± 4.8 to 19.1 ± 4.1, p < 0.001) and domains affected were attention, language, abstraction and delayed recall. Age and dialysis vintage were independently associated with decline. CONCLUSION: Cognitive function declines over a haemodialysis session and this has significant clinical implications over health literacy, self-management and tasks like driving. More research is needed to find the cause for this decline in cognition.

Using Microbiology Culture in Pediatric Appendicitis to Risk Stratify Patients: A Cohort Study.

Background: We sought to investigate the value of intra-operative microbiology samples in pediatric appendicitis. Proposed benefits include tailoring post-operative antimicrobial management, risk-stratifying patients, and reducing post-operative intra-abdominal abscess formation. Patients and Methods: All cases of appendicitis managed with appendicectomy in a single center were collected from January 2015 to August 2020. Intra-operative microbiology samples were taken routinely. Post-operative outcomes were analyzed with reference to culture and sensitivity results. Histologic findings were further categorized as normal, simple, or complex. Results: Six hundred seventy-eight children had appendicectomies, and 608 had both microbiology and histology samples taken. Intra-abdominal fluid collection and subsequent intervention rates were 22% and 9%, respectively. There were more collections in those with a culture positive result (p < 0.001), and those growing each of three recognized organisms, Escherichia coli (p < 0.001), Pseudomonas aeruginosa (p = 0.01), and Streptococcus anginosus group (p < 0.001). Intervention rate was higher in the culture-positive result group (p = 0.002) and the Streptococcus anginosus group (p < 0.001). Conclusions: This study shows an increased risk of developing a collection with the isolation of one of three key organisms (Escherichia coli, Pseudomonas aeruginosa, Streptococcus anginosus group). Sersoal swabs are an effective and practical method of gathering information on organisms. Microbiologic yield was correlated to the severity of appendicitis. Isolation of Streptococcus anginosus increases the incidence of collections to 50%. This is useful to empower surgeons to prognosticate patients' potential outcomes based on both intra-operative, and microbiologic findings, and is useful in counseling patients and managing expectations. A prolonged course of antibiotic agents or higher dose may mitigate this risk.

Evaluating the use of laparoscopic-assisted gastrostomy tube feeding in children with epidermolysis bullosa: A single-center retrospective study.

BACKGROUND: Nutritional management of children with epidermolysis bullosa (EB) presents multiple challenges including reduced oral intake compounded by mucosal fragility. Gastrostomy tube feeding is effective in improving nutritional status however there is limited data on the safety and tolerance of this technique in EB children. We aim to review the effectiveness and morbidity of our minimally invasive two-port laparoscopic-assisted gastrostomy (LAG) approach using Seldinger techniques with serial dilatations in children with EB. METHODS: A retrospective, observational cohort study was conducted on all consecutive EB patients who underwent LAG tube insertion between 2009 and 2019. Patient demographics, admission details and 12-month clinical outcomes were reported. RESULTS: 32 EB patients underwent LAG placement. Median age at insertion was 7.3 (IQR ± 6.3) years, with 8 (25.0%) and 3 (9.4%) of patients also undergoing oesophageal dilatation and fundoplication, respectively. Minor complications arose in 58.1% of patients including: peri-stomal overgranulation (25.8%), gastrostomy infection (22.6%), pain (22.6%), mild gastrostomy leakage (16.1%), blockage (9.7%) and device failure (3.2%). 2 patients (6.5%) developed major complications with extensive gastrostomy site leakage. Improvements in growth were reflected in mean height Z-scores (-1.99 to -1.71). Mean weight Z-scores improved in patients aged 0-10 years (-2.30 to -1.61) and mean BMI Z-scores increased in patients more than 10 years (-2.71 to -1.46). No cases of gastrostomy-related mortality were reported. CONCLUSION: LAG is well-tolerated in EB patients with improvements in growth and minimal morbidity 12-months post-gastrostomy insertion. An extended follow-up period is required to ascertain the long-term implications of gastrostomy feeding.

Working Collaboratively: Outcomes of Geriatrician Input in Older Patients Undergoing Emergency Laparotomy in a District General Hospital.

With the increasing median age of survival in the UK, there is an increased burden on the provision of medical and surgical care to the population. The 2010 National Confidential Enquiry into Patient Outcome and Death report, "An Age Old Problem," emphasizes the early involvement of surgical and geriatric consultant input to improve perioperative care in older patients. This study describes the development of a Geriatric Surgical Liaison Service aimed at providing consultant-led geriatrician support to improve the outcomes of older patients undergoing Emergency Laparotomy (EL). The primary outcome is the reduction in length of stay (LOS) compared to baseline data prior to geriatrician involvement. The service was designed to include one clinical session involving a consultant geriatrician and two and a half days with a junior doctor in a week. Data was collected prospectively from February 2018 till July 2018 for surgical patients aged ≥ 70 years, who underwent EL, had an inpatient stay of more than seven days, and who were diagnosed with delirium or incurred inpatient falls (intervention group). Baseline data, prior to geriatrician involvement, were collected retrospectively for EL patients aged ≥ 70 years from December 2015 until May 2016. Length of stay and 30-day mortality were also compared between the two cohorts undergoing EL. A total of 69 patients were included in the intervention group; 45 patients underwent EL and their mean LOS was 17.5 days, which was reduced from 22.5 days prior to geriatrician involvement (n=57). There was no difference in median length of stay and 30-day mortality between the retrospective baseline group and the intervention groups. In the intervention group, 8.5% of patients had a new medical diagnosis and 26.8% of patients were offered follow-ups. Although statistically not significant (p=0.40), a shorter stay in hospital by five days can potentially have a positive impact on patient outcomes by reducing psychosocial, cognitive, and functional deconditioning. This would also improve patient flow, release capacity, and waiting times and would be of benefit to the financially strained National Health Service (NHS). Overall, our study suggests that a collaborative, consultant-led geriatric service can improve the management of older surgical patients by potentially reducing length of stay, identifying high-risk patients, and facilitating early and appropriate specialty input alongside adequate and required outpatient follow-up.

Streptococcus anginosus is associated with postoperative intraabdominal collections in appendicitis.

AIM OF STUDY: Streptococcus anginosus group (SA) (formerly Streptococcus milleri) are pathogens recognised to have a high risk of postoperative collection in appendicitis, although little data exist specifically in children. We performed a retrospective review of all microbiological data from appendicectomies to assess whether there was an association in children. METHODS: A retrospective case note review of patients admitted to a paediatric tertiary centre coded for appendicitis from January 2015 to October 2016 was completed. Initial length of stay (LOS), cumulative hospital days, histology, microbiology, and radiology reports were recorded. The postoperative antibiotic regimen was based on surgeon's choice and not standardised. MAIN RESULTS: 231 children were identified, and 18 were excluded. In the remainder, 169 (78.9%) had positive microbiology cultures, and of these 45 were positive for SA (26.6%). There was no significant variation in monthly incidence (P=0.58). Patients with SA+ve cultures were associated with complicated appendicitis on histology (P=0.01), longer LOS and cumulative hospital days (P=0.001), and increased likelihood of developing postoperative collections (P=0.001). The relative risk of developing a postoperative collection with SA+ve cultures was 2.40. There was no difference in time to presentation, histology, or intervention between SA and non-SA patients who developed collections. All SA cultures were sensitive to penicillin and erythromycin. CONCLUSION: SA cultured from intraoperative serial swabs is associated with an increased risk of developing postoperative collection (2.40). Using this information with standardisation of antimicrobial management may reduce the rate of postoperative complications in paediatric appendicitis. LEVEL OF EVIDENCE: Level II prognosis study.

Targeted Distraction: Spinal Growth in Children With Early-Onset Scoliosis Treated With a Tail-gating Technique for Magnetically Controlled Growing Rods.

STUDY DESIGN: Prospective cohort study OBJECTIVE.: To understand the efficacy of a tail-gating technique (TGT) to mirror the normal spinal growth of children with early-onset scoliosis (EOS) treated with magnetically controlled growing rods (MCGR). SUMMARY OF BACKGROUND DATA: MCGR allow outpatient distraction and guided spinal growth without the need for repeat surgery. Two techniques (maximal and targeted) are currently employed to determine the distraction amount, however the efficacy of each is unknown. This study specifically assesses the ability of targeted distraction to achieve physiological growth. METHODS: We performed a retrospective review of European children treated with MCGR using a TGT and analyzed the post-operative clinical and radiographic outcomes, including the sitting height, standing height, coronal Cobb angle, T1-T12 and T1-S1 height. Furthermore, we compared the post-operative sitting/standing height ratio every 6 months to those reported for normal age- and sex-matched European children. RESULTS: Thirty-five children were included with a mean follow-up of 3.4 years (1.8-5.8 years). All clinical and radiographic parameters significantly (P < 0.05) improved immediately post-operatively and were maintained until final follow-up. The TGT mirrored the normative sitting/standing height ratios for expected spinal growth (Pearson correlation 0.95 for males and 0.90 for females). The mean difference between the reference values for the sitting/standing height ratio and our results was 0.0124 (P < 0.001) for males and 0.0068 (P = 0.010) for females. CONCLUSION: MCGR can reliably improve the coronal deformity in children with EOS while maintaining spinal growth. A TGT to determine the distraction amount at follow-up accurately mirrors the normal growth pattern of age-, sex-, and ethnicity-matched children. However, patients treated with this technique have a statistically significant, but clinically insignificant, shorter than physiologically normal spinal height. LEVEL OF EVIDENCE: 3.

Paper #31: The Oxford 5 year observational study on 35 patients with Magnetically Controlled Growing Rods (MCGR).

MCGR controls scoliosis progression and allows growth. Functional activity also improves generally. Primary infection rates are low. The overall unplanned return to theatre rates are still high but the psychosocial benefits are obvious.

Paper #25: Quantifying the 'Law of Diminishing Returns' in Magnetically Controlled Growing Rods.

The 'law of diminishing returns' can also be observed following serial distraction in MCGR. In comparison to previously published data for CGRS, there is a gradual linear decline as opposed to a rapid initial decline in lengthening. In the older, heavier child a reduced distraction ratio in the concave rod of the MCGR device is noted over time.