An International Consensus Survey among Pediatric Surgeons on the Role of Appendectomy in Malrotation.

Introduction: Ladd's procedure, originally described in 1936 for the treatment of malrotation, does not traditionally include appendectomy as a standard step. We conducted a multinational survey to investigate the current consensus on the role of appendectomy in Ladd's procedure. Methodology: An anonymous online survey was distributed to pediatric surgeons worldwide. The survey collected demographic data and explored surgical preferences related to the management of malrotation. Open-ended questions were used to assess the opinions regarding the necessity of appendectomy, decision-making factors, and complications associated with appendectomy during Ladd's procedure. Results: A total of 343 responses were received from 46 countries. Of the respondents, 319 (93%) were consultants and 24 (7%) were residents/trainees. When asked about the choice between open and laparoscopic Ladd's procedure, 292 (85%) preferred open surgery. Overall, 184 (53%) respondents favored appendectomy in both open and laparoscopic Ladd's procedure. Furthermore, 172 (50%) surgeons advocated for appendectomy in all malrotation cases, citing concerns about potential future appendicitis. While differences existed between all comparisons, none of them reached statistical significance. The factors influencing the decision to preserve the appendix included the risk of postoperative complications and the potential future use of the appendix as a surgical conduit. The surgical complications following appendectomy included surgical site infections in 14 (33%) patients, adhesive obstruction in 13 (31%) patients, intrabdominal abscesses in 10 (24%) patients, and fecal fistulas in 5 (12%) patients. Conclusion: The majority of surgeons aim to perform appendectomy in all malrotation cases, considering the potential risks and benefits of this approach. These findings offer valuable insights for clinical practice and may inform future guidelines and decision-making algorithms.

Non-operative treatment for simple acute appendicitis (NOTA) in children during the COVID-19 era: new lessons from the pandemic.

Coronavirus (COVID-19) was a pandemic disease that was affecting our medical and surgical daily practice badly. The surgical management of acute appendicitis was the gold standard, but new studies suggest the safety of antibiotic treatment alone. Non-operative treatment for simple acute appendicitis (NOTA) avoids surgery, the risks of general anesthesia, and long hospital stays. It also decreases the risk of exposure to coronavirus. We aimed to study the cost-effectiveness and outcome of NOTA during the COVID-19 pandemic and compared it to single-incision pediatric endo-surgery appendectomy (SIPESA). A prospective cohort study for NOTA of patients from 6 to 12 years old in the COVID-19 pandemic period from April 1st, 2020, to April 30th, 2021, patients were divided into two groups: Group S was managed by SIPESA, and Group N was managed by NOTA. Family education and assurance with detailed explanation were done for early detection of any complications, and we continue monitoring the patients until their complete recovery. Group S had 24 cases (40%), mean age 9.3 years. Group N had 36 cases (60%), mean age 9.1 years. Six cases (17%) in group N were converted to surgical management in the first 6 months of the study. The mean cost dropped from $2736/day to $400/day. The mean psychological stress for the children improved from 4.4 in April to 2 in September. The mean follow-up was 3.5 months. NOTA is a feasible, cost-effective approach, and we recommend it, as we have learned this lesson during the COVID-19 pandemic days.

Overview of complications associated with epidermolysis bullosa: A multicenter retrospective clinical analysis of 152 cases.

BACKGROUND/PURPOSE: Epidermolysis bullosa (EB) is a rare disease of skin and mucosa which may causes surgical complications. We review these in a large patient cohort from Saudi Arabia. METHODS: A retrospective study was conducted at 21 centers between 2003 and 2020. Demographic data and information on EB type [Simplex (EBA), Dystrophic (DEB) and Junctional (JEB)]. The dataset included clinical features, operations, surgical complications, and treatment. RESULTS: There were 152 (63 male) children with EB [EBS n = 93 (61.2%); DEB n = 30 (19.7%); JEB n = 25 (16.4%), and Kindler syndrome n = 4, (2.6%)]. Children with JEB and DEB tended to have a higher frequency of skin and musculoskeletal system complications (skin cancer, pseudosyndactyly and recurrent skin infection). Esophageal strictures were mostly seen in DEB (n = 19, 63%) and to a lesser extent in EBS (n = 20, 21%) and JEB (n = 4, 16%). Pyloric atresia was uncommon (n = 4) and limited to those with JEB. Percutaneous gastrostomy for feeding support was used in all types. Ankyloglossia was common but often recurred (76%) after division. Circumcision was usually safe and complication-free in male children except in those with severe JEB. Phimosis was reported in 10% of uncircumcised patients. CONCLUSIONS: Our series showed that surgeons play a key role in the management of some complications associated with EB. It is also important to be aware of the particular sub-type as this can predict the natural history and likely response to treatment. LEVEL OF EVIDENCE: 2.

The Outcome of Pediatric Esophageal Strictures Managed with Endoscopic Balloon Dilation in Saudi Arabia.

Background: Esophageal strictures can affect nutrition of infants and children impairing their weight gain. To our knowledge, this is the first article evaluating and comparing between the two methods of dilation in terms of outcome and one of few, if any, to assess both weight and height to evaluate the nutritional outcomes following dilation. To determine the safety, efficacy, and long-term effects of endoscopic dilation in managing pediatric esophageal strictures by assessing the clinical and nutritional outcomes. Methods: A retrospective study of 137 patients with esophageal strictures who underwent either endoscopic balloon dilatation or Savary dilatation, or both. Outcome parameters measured include the number of dilatations, nutritional status, and if symptoms had been relieved. Results: The most frequent cause of esophageal strictures was post-tracheoesophageal fistula repair (n = 51, 37.2%), and the majority were lower third strictures (n = 47, 34.3%). However, 8 cases (5.8%) had failed the dilation procedure. Savary dilatation had the highest number of complications. Overall, success rate was 79.6%. Higher success rate was for cases dilated by endoscopic balloon dilation (EBD) (n = 47, 90.4%). There was a statistically significant correlation between the success rate and the method of dilatation (P = .042). Statistically significant increment of weight was recorded for lower strictures (P = .001). Conclusion: EBD was associated with the highest success rate. Endoscopic dilatations are safe and efficient in managing pediatric esophageal strictures with improvement in both clinical and nutritional outcomes.

Is It Safe for Trainees to Perform Single-Incision Pediatric Endosurgery Splenectomy?

INTRODUCTION: Few centers worldwide have advanced single-incision pediatric endosurgery (SIPES) splenectomy. The safety and feasibility of SIPES performed by trainees were not assessed before. SIPES splenectomy is a demanding technique that needs high level of skills. This is the largest series of 39 SIPES splenectomies performed by 14 trainees in one single center. AIMS: To assess the safety, feasibility, and technical challenges of SIPES splenectomy performed by trainees and to compare it with other published series. MATERIALS AND METHODS: Retrospective study of all patients operated with SIPES splenectomy for 7 years. SIPES port was inserted through 1.5 cm umbilical incision. One type of port and straight regular instruments were used in all cases. RESULTS: Forty-nine patients underwent SIPES splenectomy. Eighty percent was done by our trainees. Six cholecystectomies were done simultaneously. Forty-five patients with sickle cell disease, two with thalassemia, one spherocytosis, and one Fanconi's anemia. Mean operative time (MOT) for splenectomy was 182 minutes (130-190) and 251 minutes for splenectomy with cholecystectomy (230-270) depending on severity of adhesions and size of the spleen; P value <.001. Two conversions have to be opened due to bleeding. There is neither wound infection nor incisional hernia up to date. CONCLUSION: SIPES splenectomy is safe and feasible when performed by surgical trainees without adding any morbidity to the patient. Learning curve can quickly improve with more exposure of trainee to different SIPES procedures and hands-on workshops. More than one procedure could be done at the same time. It has excellent cosmesis and almost invisible scar.

Is mitrofanoff a more socially accepted clean intermittent catheterization (CIC) route for children and their families?

AIM: We aimed to examine the social impact of clean intermittent catheterization (CIC) on children with a neurogenic bladder and to compare the impact of urethral CIC with Mitrofanoff catheterization. METHODS: Questionnaires containing 29 questions about the social impact of CIC on the children and their families were administered with their parents or caregivers of 50 children (34 boys and 16 girls) using CIC. The mean (standard deviation [SD]) age of the children was 9.6 (4.32) years and duration on CIC was 6.1 (3.97) years. RESULTS: Seventeen children were using Mitrofanoff catheterization (group I) and 33 children urethral catheterization (group II). Of the respondents, 54% respondents reported that their children accept the use of CIC, 30% respondents reported that they do not like it, and 16% respondents reported that they always refuse and resist it. There was no difference in the level of acceptance between the two groups. Both groups reported that children were social (90%) and had close friends (88%). However, 50% felt that CIC affected mood, with 30% of the children displaying bad temper. Mitrofanoff catheterization was associated with fewer episodes of frequent urinary tract infection (p = 0.004) and greater adherence. All children from group I, who were older than 6 years, were attending school compared with 78% from group II. School performance was significantly better in group I (p = 0.022). CONCLUSION: There was acceptance of CIC by most children but Mitrofanoff catheterization seemed to have a lower social impact in terms of school performance, adherence to therapy, and complications.

Supradiaphragmatic accessory liver: a rare cause of respiratory distress in a neonate.

The authors describe a case of supradiaphragmatic accessory liver seen on prenatal ultrasound examinations, mimicking fetal hydrothorax and causing life-threatening respiratory failure after birth. The accessory liver with a transdiaphragmatic pedicle to the caudate lobe of the normal liver was found at throracotomy after failure to expand the lung by chest drainage. The "hydrothorax" turned out to be multilocular mesothelial cyst collection surrounding the ectopic liver. This is the first report of the development of a thoracic accessory liver followed by obstetric ultrasound examinations.

Abdominal cystic mass in infancy--in utero perforated Meckel's diverticulum?

Meckel's diverticulum occurs in 2% of the population. Of these, 4% may present as intestinal bleeding, intussusception, diverticulitis, volvulus, or perforation at any age, including neonates. We describe a 3-month-old baby whose giant Meckel's diverticulum had probably perforated in utero, leading to the formation of a large intra-abdominal pseudocyst.

Prenatal ultrasound screening of the urinary tract is useful.

Fetal uropathies can be identified by obstetric ultrasound (US) examination, permitting treatment before their clinical manifestation. To evaluate the justification for prenatal US screening for urinary-tract malformations (UTM), the outcome of occult UTMs in 23,000 babies born in our hospital between 1992 and 1998 was examined retrospectively. A prenatal US examination was performed on 19,400 newborns; 128 (0.7%) had an abnormal urinary tract, leading to surgery in 38 cases. The overall incidence of UTMs requiring either medical or surgical therapy was 0.2% (45:19,400); 3,600 pregnancies were not screened by prenatal US. To date, 7 of the newborns have presented with urosepsis (2 with renal impairment) and 2 additional case of posterior urethral valves were identified by routine postnatal US. The incidence of significant UTMs was similar in both groups, but complications occurred in the unscreened group. Prenatal US to detect occult UTMs is thus beneficial, fulfilling the criteria for a population-screening test. We recommend postnatal US urinary-tract screening for newborns with no prenatal US examination.