Preoperative computed tomography scanning for abdominal neuroblastomas is superior to magnetic resonance imaging for safe surgical planning.

BACKGROUND: Cross-sectional imaging is required to assess disease prior to surgery for neuroblastoma (NBL), and both magnetic resonance imaging (MRI) and computed tomography (CT) scan are considered acceptable. We had concerns that MRI was underestimating disease extent, so from early 2016 we have systematically used MRI and CT before all abdominal NBL resections. The aim of this retrospective study was to establish which imaging modality is more accurate in determining disease extent, particularly after chemotherapy. METHODS: Abdominal MRI and CT scans for all children with abdominal NBL referred for surgery from January 2016 to February 2018 were retrospectively reviewed to evaluate the extent of disease and the presence of imaging-defined risk factors (IDRFs). RESULTS: Thirty-one patients were eligible for consideration of surgery post disease reassessment with MRI/MIBG. Twenty-four of 31 children were included. CT was performed a median of 15 (range, 1-47) days after MRI. MRI underestimated IDRFs compared with CT in 13 of 24 patients (54%). Seventeen of 24 patients underwent surgery, and operative findings had 100% correlation with CT imaging. Notably, there were fundamental changes in management post CT in 6 of 24 patients (25%). CT did not underestimate disease compared with MRI in any patient. CONCLUSION: MRI underestimated the extent of the disease in half of our patients considered for NBL resection. This may be due in part to tumor fibrosis, calcification, and chemotherapy. Preoperative CT scan is the best imaging modality to identify all IDRFs after chemotherapy to ensure safe surgery.

The value of contrast studies in the evaluation of bowel strictures after necrotising enterocolitis.

PURPOSE: Strictures of the bowel are a frequent complication post-necrotising enterocolitis (NEC). Contrast studies are routinely performed prior to stoma closure following NEC. The aim of this study was to evaluate the ability of these studies to detect strictures and also directly compare them to operative and histological findings. METHODS: Two hundred and fourteen neonates who had a diagnosis of NEC (Bell stage 2 or greater) in a single unit (2007-2011) were analysed. Their case notes, radiology, and histology were reviewed. RESULTS: One hundred and sixteen neonates underwent an emergency laparotomy and 77 had stomas fashioned. Sixty-six patients had a contrast study prior to stoma closure (distal loopogram 18, contrast enema 37, both studies 11). Colonic strictures were reported in 18 patients and small bowel strictures were reported in two patients. Fourteen of these colonic strictures were confirmed at operation and on histology but three colonic strictures were missed on contrast studies; one patient had had both contrast studies and the other two only a distal loopogram. Two small bowel strictures reported were confirmed and an additional small bowel stricture missed on distal loopogram was also detected at the time of operation. The incidence of post-op strictures was 19 out of 68 patients (27.9 %) and 16 (84.2 %) of these strictures were found in the colon. Contrast enemas had a much higher sensitivity for detecting post-NEC colonic strictures than distal loopograms; 93 versus 50 %, respectively; however, they are more likely to give a false positive result and therefore their specificity is lower; 88 versus 95 %, respectively. CONCLUSION: Colon is the commonest site for post-NEC stricture and contrast enema is the study of choice for detecting these strictures prior to stoma closure.

A randomised, single blinded trial, assessing the effect of a two week preoperative very low calorie diet on laparoscopic cholecystectomy in obese patients.

BACKGROUND: Laparoscopic cholecystectomy (LC) can be technically challenging in the obese. The primary aim of the trial was to establish whether following a Very Low Calorie Diet (VLCD) for two weeks pre-operatively reduces operation time. Secondary outcomes included perceived operative difficulty and length of hospital stay. METHODS: A single-blinded, randomized controlled trial of consecutive patients with symptomatic gallstones and BMI >30 kg/m(2) 46 patients were randomized to a VLCD or normal diet for two weeks prior to LC. Food diaries were used to document dietary intake. The primary outcome measure was operation time. Secondary outcomes were length of stay, weight change operative complications, day case rates and perceived difficulty of operation. RESULTS: The VLCD was well tolerated and had significantly greater preoperative weight loss (3.48 kg vs. 0.98 kg; p < 0.0001). Median operative time was significantly reduced by 6 min in the VLCD group (25 vs. 31 min; p = 0.0096). There were no differences in post-operative complications, length of stay, or day case rates between the groups. Dissection of Calot's triangle was deemed significantly easier in the VLCD group. CONCLUSION: A two week VLCD prior to elective laparoscopic cholecystectomy in obese patients is safe, well tolerated and was shown to significantly reduce pre-operative weight and operative time. ISRCTN: 61630192. http://www.isrctn.com/ISRCTN61630192 Trial registration.

Incarcerated inguinal hernia management in children: 'a comparison of the open and laparoscopic approach'.

PURPOSE: To compare the outcomes of management of incarcerated inguinal hernia by open versus laparoscopic approach. METHODS: This is a retrospective analysis of incarcerated inguinal hernina in a paediatric surgery centre involving four consultants. Manual reduction was attempted in all and failure was managed by emergency surgery. RESULTS: The laparoscopy group had 27 patients. Four patients failed manual reduction and underwent emergency laparoscopic surgery. Three of them had small bowel strangulation which was reduced laparoscopically. The strangulated bowel was dusky in colour initially but changed to normal colour subsequently under vision. The fourth patient required appendectomy for strangulated appendix. One patient had concomitant repair of umbilical hernia and one patient had laparoscopic pyloromyotomy at the same time. One patient had testicular atrophy, one had hydrocoele and one had recurrence of hernia on the asymptomatic side. The open surgery group had 45 patients. Eleven patients had failed manual reduction requiring emergency surgery, of these two required resection and anastomosis of small intestine. One patient in this group had concomitant repair of undescended testis. There was no recurrence in this group, one had testicular atrophy and seven had metachronous hernia. CONCLUSIONS: Both open herniotomy and laparoscopic repair offer safe surgery with comparable outcomes for incarcerated inguinal hernia in children. Laparoscopic approach and hernioscopy at the time of open approach appear to show the advantage of repairing the contralateral patent processus vaginalis at the same time and avoiding metachronous inguinal hernia.

Popliteal node visualization during standard pedal lymphoscintigraphy for a swollen limb indicates impaired lymph drainage.

OBJECTIVE: The objective of our study was to examine the frequency and significance of visualization of popliteal nodes during lymphoscintigraphy for the investigation of lower extremity swelling. MATERIALS AND METHODS: Technetium-99m-labeled nanocolloid was injected subcutaneously in the first web spaces of both feet of 204 consecutive patients (69 males, 135 females; age range, 11-79 years) undergoing routine, clinically indicated lymphoscintigraphy; imaging was performed 5, 45, and 150 minutes after injection. The patients were asked not to undertake any vigorous exercise between the injection and completion of imaging. RESULTS: No popliteal nodes were visualized in 29 patients in whom there was no evidence of lymphedema on clinical or lymphoscintigraphic examination (group 1). Unilateral or bilateral popliteal nodes were visualized in 10 of 39 patients (25.6%) with clinical evidence of lymphedema but normal lymphoscintigraphy findings (group 2) (p < 0.005 vs group 1). In 136 patients with clinical evidence of lymphedema and abnormal lymphoscintigraphy findings (group 3), unilateral or bilateral popliteal nodes were visualized in 59 (43.4%) (p < 0.0001 vs group 1). Popliteal nodes were visualized in 40 of 73 limbs with "dermal backflow" (54.8%) and 42 of 335 limbs without dermal backflow (12.5%) (p < 0.0001). CONCLUSION: Popliteal node visualization after subcutaneous foot web space injection is an important sign of abnormal lymphatic function in patients with clinical lymphedema of the lower extremities.

Varicosities in an adolescent girl on laparoscopy: an unusual presentation of May-Thurner syndrome.

May-Thurner syndrome is a rare clinical entity involving venous obstruction of the left lower extremity. May-Thurner syndrome most commonly presents with deep vein thrombosis. We describe an unusual presentation of a girl with a dragging abdominal pain mimicking the symptoms of a varicocele. Diagnosis can be made with MR venogram. There are many different treatment options but if compression of the vein is minimal conservative management is possible.

Sacrococcygeal teratoma with intraspinal extension: A case series and review of literature.

BACKGROUND: Sacrococcygeal teratoma (SCT) is the most common teratoma in neonates and arises from the coccyx. SCT with intraspinal invasion is extremely rare and only reported in a few cases. METHODS: 37 patients with SCT were identified at our institution between 2000 and 2018. Three of these patients had SCT with intraspinal extension. A literature review for intraspinal extension associated with SCT, including mode of diagnosis, presentation, surgical approach and neurological sequelae, between 1993 and 2018 was also conducted. RESULTS: The authors report three cases of infants who were antenatally and/or postnatally diagnosed with a sacrococcygeal teratoma extending into the spinal canal. We illustrate the challenges of accurate diagnosis and therapeutic management. Postnatal magnet resonance imaging (MRI) was the best method to define spinal anatomy and extension of the tumors prior to surgery. Management with a multidisciplinary team approach including neuroradiology, neurosurgery and general surgery was used in our two most recent patients. The literature review yielded 6 cases of SCT with intraspinal extension. CONCLUSION: Intraspinal extension in SCT is rare but should be excluded at birth before attempting any resection. In case of positive spinal invasion on Ultrasonography (US), MRI is essential to plan for surgery and possible laminectomy to be able to perform a radical resection of this congenital tumor. We recommend this multidisciplinary approach. LEVEL OF EVIDENCE: Level IV.

Renal scarring is the most significant predictor of breakthrough febrile urinary tract infection in patients with simplex and duplex primary vesico-ureteral reflux.

INTRODUCTION: The association of high-grade vesico-ureteral reflux (VUR) with renal dysplasia and/or scarring is well-established, and the combination of these factors has been shown to decrease the likelihood of VUR resolution. Other VUR parameters have similarly been shown to be associated with VUR non-resolution, including VUR grade and timing at cystography, associated urinary tract anatomical abnormalities, and bladder dysfunction. OBJECTIVE: To establish independent risk factors that can predict symptomatic persistence of VUR. DESIGN: This was a single-centre study (2011-2017) including consecutive prospectively collected patients with primary VUR on voiding cystourethrogram (VCUG). Patients with dilating VUR also underwent renography (dimercaptosuccinic acid [DMSA] or 99m-technetium mercaptoacetyltriglycine [99mTc-MAG3]). All patients were initially managed medically with antibiotic prophylaxis. Primary outcome was febrile culture-positive breakthrough urinary tract infection (BT-UTI). Demographic parameters, as well as VUR grade, VUR timing at cystography, presence of ureteral anomaly, VUR index (VURx), and differential renal function (DRF) or scarring were analysed to determine independent predictors. RESULTS: A total of 61 patients (41 male, of whom 7 circumcised at presentation) were studied. VUR was diagnosed following investigation of prenatal hydronephrosis in 37 patients (62%) and following a febrile UTI in 22 (37%). Median [range] follow-up period was 38 [12-84] months. Data from a total of 77 refluxing renal units (RUs) were used for analysis. Analysis of VCUG data demonstrated that high VURx might be a potential significant predictor of breakthrough UTI (RR: 1.7, 95% CI: 1.1-2.7, p < 0.05 vs low VURx) but this was not the case for individual VURx components. Renography data showed increased risk of breakthrough UTI in patients with renal scarring (relative risk (RR): 5.1, 95% confidence interval (CI: 2.0-10.7, p < 0.0001 vs no renal scarring), but not in patients with reduced DRF. Multivariate regression analysis revealed that renal scarring was the only significant risk factor for breakthrough UTI. VUR patients with renal scarring were three times more likely to develop breakthrough UTI (odds ratio (OR): 3.3, 95% CI: 1.4-7.4, p < 0.01). DISCUSSION: Multiple factors have been shown to be significant predictors of radiological VUR resolution. Univariate analysis of these factors suggests that only scarring on DMSA and VURx are significant predictors of symptomatic non-resolution. On multivariate analysis, scarring on DMSA was the only significant predictive variable. This information will be useful in targeting investigation and treatment in susceptible patients and when counselling families. CONCLUSION: Renal scarring is the most significant risk factor for breakthrough UTI in primary VUR patients and could be used to determine those at risk of symptomatic VUR persistence.

Self-expanding esophageal stents for the management of benign refractory esophageal strictures in children: A systematic review and review of outcomes at a single center.

BACKGROUND: This study aimed to evaluate our outcomes and complication rate following placement of self-expanding esophageal stents in children for the management of refractory esophageal strictures and comparing these to the existing literature. METHODS: Outcomes following placement of stents in consecutive patients under 18 years at a single center from 2003 to 2018 were reviewed. A PRISMA-guided systematic review was conducted identifying studies with 5 or more children evaluating self-expanding stents published from 1975 to 2018. Endpoints for both the retrospective and systematic reviews were the requirement for further intervention and stent-associated complications. RESULTS: 25 patients received 65 stents. There were 12 caustic injury-related strictures (48%), 9 anastomotic strictures (36%), and 4 esophagitis-related strictures (16%). Four patients were lost to follow-up. 19/21 patients (90%) required further intervention, and 8/21 (38%) had esophageal replacement. Nine studies, all case series, were included in the systematic review. 97 patients received 160 stents for esophageal strictures and/or perforation. 36 out of 69 patients (52%) with strictures required no further treatment post-stenting, and 22/29 (76%) of esophageal perforations closed with stenting. CONCLUSIONS: Esophageal stents may have a role as a bridge to definitive surgery and for the management of esophageal leaks, but complete stricture resolution post-stenting is unlikely. TYPE OF STUDY: Treatment Study (Case Series with no Comparison Group) LEVEL OF EVIDENCE: Level IV.

Laparoscopic nephrectomy for Wilms' tumor: Can we expand on the current SIOP criteria?

INTRODUCTION: Wilms' tumor now has a good overall prognosis with open radical nephrectomy having been the mainstay of surgical treatment. Recently laparoscopic nephrectomy (LN) has been growing in popularity. The aim of our study was to review our indications and outcomes for laparoscopic resections for Wilms' tumor and compare indications with International Society of Paediatric Oncology (SIOP) criteria for LN. MATERIAL AND METHODS: Patient demographics, preoperative management, surgical data, respect of SIOP criteria, complications, disease outcome, and follow-up were recorded on consecutive children who underwent nephrectomy for Wilms' tumor. RESULTS AND DISCUSSION: Fifty-four consecutive children with Wilms' tumor underwent a nephrectomy; 20 had a LN (Table). Nine of 20 (45%) patients who had LN did not meet SIOP criteria for LN. No patients had an intraoperative tumor rupture and one patient had positive margins because of preoperative rupture. There were two conversions: one caused by difficulty accessing the renal hilum and the other caused by difficulty maintaining oxygen saturations. There was one local recurrence. CONCLUSION: SIOP criteria are conservative and safe. Indications can be extended for teams experienced in surgical oncology and laparoscopy after agreement at a multidisciplinary meeting (MDM).

Pneumoperitoneum in the Setting of Pneumatosis Intestinalis in Children: Is Surgery Always Indicated?

Aim Pneumatosis intestinalis (PI) is a condition in which multiple gas-filled cysts form within the wall of the gastrointestinal tract in either the subserosa or submucosa. The presence of pneumoperitoneum in the presence of PI can present a therapeutic dilemma. The aim of our study was to review our experience and management of this condition. Methods A single-center retrospective study of consecutive children (> 1 year) presenting with a pneumoperitoneum and evidence of PI (2009-2015). Demographics, case notes, microbiology, and imaging were reviewed. Results Seven patients were identified (four males; age range 5-14 years). Four children had global developmental delay and were percutaneous endoscopic gastrostomy or jejunostomy fed, one was immunocompromised (acute lymphoblastic leukemia). The others had encephalitis and eosinophilic gastroenteritis. One patient proceeded to an exploratory laparotomy; no perforation was identified, pneumatosis of the colon was observed, and a loop ileostomy was formed. The remaining six were managed conservatively and made nil by mouth with intravenous antibiotics commenced. Five of the six had a computed tomography (CT) scan which revealed PI and free air with no other worrying signs. One died from nongastrointestinal causes, while the remaining five had feeds reintroduced uneventfully. Conclusion Free air in the setting of PI may represent rupture of the gas cysts and not always transmural perforation. Surgery may not always be indicated and conservative management may suffice. A CT scan can be useful for excluding other intra-abdominal pathological findings and continued clinical assessment is essential.

A cross sectional study of colonic diverticulosis in the London Bangladeshi population.

BACKGROUND: Diverticular disease is the most common morphological abnormality of the colon and the fifth most important gastrointestinal disease in terms of cost in the Western world. Tower Hamlets is the poorest borough in London containing a large Bangladeshi community. We observed that emergency admissions with complications of colonic diverticulosis were minimal in the Bangladeshi community. The objective was to compare the background prevalence of colonic diverticulosis in Bangladeshis with other ethnicities in patients undergoing colonoscopy at a single centre in Tower Hamlets. METHODS: Four thousand four hundred and fifty-four consecutive colonoscopy reports over a 2-year period were retrospectively analysed. Patients under 40 years of age and repeat colonoscopies were excluded, leaving 3151 patients (mean age: 63 years; 48% male). Demographics including ethnicity and medical background were retrieved from the electronic patient record system and findings correlated with the prevalence of other 'Western' diseases in the cohort. RESULTS: Six hundred and thirty out of 3151 (20%) colonoscopies were performed on Bangladeshis. The prevalence of colonic diverticulosis was significantly lower in Bangladeshis (17/630: 2.7%) than Caucasians (673/1869: 36%), Indians/Pakistanis (16/161: 9.9%), Oriental (15/44: 34%) and Black (90/369: 24.4%) patient groups (χ(2) p < 0.0001 for all comparisons). The prevalence of classical sigmoid diverticulosis in the Bangladeshi cohort was only 1.0%, despite significantly more Bangladeshi patients undergoing colonoscopy for abdominal pain (p < 0.0001, χ(2)) and diarrhoea (p < 0.0034, χ(2)). There was also a significantly greater incidence of type 2 diabetes mellitus and ischaemic heart disease (p < 0.0001, χ(2)) in Bangladeshi patients. CONCLUSIONS: There is a negligible prevalence of colonic diverticulosis in the Bangladeshi population of London who undergo colonoscopy. This is in spite of a high incidence of type 2 diabetes and ischaemic heart disease. The effect of diet and genetics on the prevalence of colonic diverticulosis in Bangladeshis is not known and merits further investigation.

Lymphatic dysfunction in the apparently clinically normal contralateral limbs of patients with unilateral lower limb swelling.

PURPOSE: To determine how often lymphatic dysfunction is bilateral when, clinically, lymphedema appears unilateral. METHODS: Lymphoscintigraphy was performed after subcutaneous Tc-99m-nanocolloid injection in the first webspaces of both feet. The percentage of injected radioactivity accumulating in the ilioinguinal regions was recorded in dedicated images separately acquired at 60 and 180 minutes after injection. RESULTS: Within a consecutive series of 204 patients, 74 had unilateral clinical lymphedema of whom 68 had abnormal scintigraphy. Of these 68 patients, 46 had unilateral abnormal scintigraphy affecting the clinically abnormal limb, but 20 patients had bilateral abnormal scintigraphy and 2 had unilateral abnormal scintigraphy in the clinically unaffected limb. Thus, 32% (22/68) of patients in whom clinical lymphedema appeared to be unilateral, nevertheless, had abnormal scintigraphy in the clinically normal limb. Twenty-nine patients had no clinical evidence of lymphedema in either limb and were scintigraphically normal bilaterally. Mean ilioinguinal nodal accumulation at 180 minutes in the 44 limbs of 22 of these clinically and scintigraphically normal patients (dedicated ilioinguinal imaging was not performed in all patients) was 13.1% (standard deviation, 8.8%), higher (P = 0.02) than the mean value of 9.3% (standard deviation, 5.0%) in the clinically and scintigraphically normal contralateral limbs of 39 patients with unilateral clinical lymphedema. CONCLUSIONS: In the presence of unilateral lymphedema, the contralateral limb is often also abnormal. On lymphoscintigraphy, therefore, care should be taken before diagnosing unilateral lymphatic dysfunction. Quantification should be included in routine lymphoscintigraphy, as reduced ilioinguinal nodal accumulation may be the only apparent abnormality.

Acute scrotal pain in boys at a single paediatric centre with a questionnaire to assess patient awareness of the acute scrotum.

Paediatric surgeons commonly evaluate acute scrotal pain. Previous peer review articles have suggested that boys should be educated to ensure early medical assessment thereby avoiding potential testicular loss. In this study we sought to ascertain a contemporary view of educational awareness of testicular pain in boys presenting to our service. A prospective 11 month study of boys attending our unit with acute scrotal pain was undertaken. Additionally, 30 consecutive patients completed a standardised questionnaire to ascertain their educational awareness of testicular pain. A total of 84 boys were referred to our service for evaluation of acute scrotal pain; 36 required operative interventions. Nine patients (25%) had testicular torsion; 19 patients (52.8%) had torted appendages; 6 patients (16.7%) had epididymitis and 2 patients (5.5%) had alternative diagnoses. There was one case of testicular loss in the older age group. Most boys were unaware of testicular problems but felt an education regarding scrotal problems would be useful. Our study shows that an unawareness of testicular pain exists in both children and their carers. We envisage that including basic educational aspects into the school curriculum may help avoid possible testicular loss in the future.

Dynamic contrast-enhanced texture analysis of the liver: initial assessment in colorectal cancer.

PURPOSE: To undertake an initial assessment of the potential utility of dynamic contrast-enhanced texture analysis (DCE-TA) of the liver in patients with colorectal cancer. MATERIALS AND METHODS: TA comprised measurement of mean gray-level intensity, entropy, and uniformity with and without selective-scale filtration using a band-pass filter to highlight different spatial frequencies reflecting fine, medium, and coarse textures. An initial phantom study assessed the sensitivity of each texture qualifier to computed tomography (CT) acquisition parameters. Texture was analyzed in DCE-CT series from 27 colorectal cancer patients having apparently normal hepatic morphology (node-negative: n = 8, node-positive: n = 19). Averaged changes in hepatic texture induced by contrast material were assessed qualitatively and quantitatively by using kinetic modeling to calculate hepatic perfusion indices following fine, medium, and coarse image filtration. RESULTS: All texture qualifiers were less sensitive to changes in CT acquisition parameters than measurement of CT attenuation. Temporal changes in hepatic texture were qualitatively different from changes in enhancement. Statistically significant differences between node-negative and node-positive patients were observed for at least 1 time period for measurements of hepatic enhancement and for all texture parameters. The differences were most statistically significant and occurred over the greatest number of time periods for fine texture quantified as mean gray-level intensity (5 time periods, minimum P value: 0.006) followed by fine texture quantified as entropy (4 time points, minimum P value: 0.006). There was no difference in hepatic perfusion indices for the 2 groups. CONCLUSIONS: DCE-TA is a potentially useful adjunct to DCE-CT warranting further investigation.