Post-discharge follow-up of congenital duodenal obstruction patients: a systematic review.

PURPOSE: Long-term follow-up of congenital duodenal obstruction patients often falls on care providers with little experience of this condition. We performed a systematic review of the long-term outcomes of duodenal obstruction and provide a summary of sequelae care providers should anticipate. METHODS: In 2022, after registering with PROSPERA, Medline (Ovid), EMBASE, PSYCHINFO, CNAHL and SCOPUS databases were searched using the title keyword 'intestinal atresia'. Abstracts were filtered for inclusion if they included the duodenum. Papers of filtered abstracts were included if they reported post-discharge outcomes. Methodological Index for Non-Randomized Studies was used to grade the papers. RESULTS: Of the 1068 abstracts were screened, 32 papers were reviewed. Eleven studies were included. Thirty additional papers were included after reviewing references, for a total of 41 papers. The average MINORS was 7/16. CONCLUSION: There is good evidence that children with congenital duodenal obstruction do well in terms of survival, growth and general well-being. Associated cardiac, musculoskeletal and renal anomalies should be ruled-out. Care providers should be aware of anastomotic dysfunction, blind loop syndrome, bowel obstruction and reflux. Reflux may be asymptomatic. Laparoscopic repair does not change long-term outcomes, and associated Trisomy 21 worsens neurodevelopmental outcomes.

Preventing severe necrotizing enterocolitis: Propensity score analysis of interventions associated with surgical NEC or NEC-associated death.

PURPOSE: To determine what modifiable interventions used in the neonatal intensive care unit (NICU) are associated with severe necrotizing enterocolitis (NEC) requiring surgical intervention. METHODS: A retrospective review of patients treated for NEC at a tertiary hospital from 1991 to 2016 was performed. Patient characteristics were used to calculate propensity scores for likelihood of exposure to seven interventions: enteral feeds, use of glucocorticoids, nonsteroidal anti-inflammatory drugs (NSAIDs), antacids, antibiotics, or umbilical arterial (UAC) and venous catheters (UVC). Conditional logistic regression was used to compare the odds of having surgical NEC if exposed to each treatment. RESULTS: We included 195 NEC patients: 69 severe NEC managed with surgery and 126 non-severe NEC managed medically. After propensity score matching based on birth characteristics, exposure to glucocorticoids (OR 5.21, 95%CI: 1.62, 16.70), NSAIDs (OR 4.87, 95%CI: 1.67, 14.17), UVC (OR 2.53 (95%CI: 1.19, 5.73), and UAC (OR 4.91, 95%CI: 2.12, 11.37) were associated with surgical NEC in separate conditional logistic regression analyses. Including these treatments in a second round of propensity matching and conditional logistic regression revealed that glucocorticoids (OR 2.99, 95%CI: 1.01, 8.88), NSAIDs (OR 3.97, 95%CI: 1.41, 11.19), UVC (OR 3.07, 95%CI: 1.46, 6.48), and UAC (OR 5.10, 95%CI: 2.10, 12.36) were still associated with surgical NEC. CONCLUSION: After controlling for birth confounders and common NICU supportive interventions, use of glucocorticoids, NSAIDs and umbilical catheters independently increased the odds of developing severe NEC requiring surgical intervention. LEVEL-OF-EVIDENCE RATING: Case-control, Level III evidence.

Follow-up of children who undergo an uncomplicated surgical procedure: A caregiver survey to determine satisfaction, family impact, and preferences for alternate follow-up.

BACKGROUND: Historically most surgical patients returned to clinic for an in-person postoperative follow-up. However, returning to hospital impacts the family in many ways. We hypothesized that in-person follow-up is not necessary after an uncomplicated procedure, and that caregivers would prefer an alternate follow-up. METHODS: We surveyed caregivers of children less than 17 years of age who underwent a simple appendectomy, pyloromyotomy, cholecystectomy, or repair of an inguinal or umbilical hernia. With REB approval and caregiver consent, surveys were completed in-person during clinic visits and by telephone for alternate follow-up plans. RESULTS: Despite interruptions due to COVID-19, 24 surveys were completed (clinic visit group N = 7, alternate plan group N = 17). Thirteen families resided in Winnipeg. The majority rated their overall satisfaction with follow-up as good-excellent (6/7 clinic group, 17/17 alternate group). The most frequent impacts to attend clinic were time off work (18/24), parking (17/24), gas costs (17/24), time from school (13/24) and childcare arrangements (12/24). The median estimated cost to attend clinic was 142 CAD$. Most families preferred an alternate plan (18/24) (i.e. call surgeon only if concerned, follow-up with their primary care provider or attend virtually). Only 4 children having an alternate follow-up plan required medical treatment for minor issues. DISCUSSION: We conclude there is significant impact on families to attend a post-operative in-person clinic visit. Although all respondents rated their satisfaction highly, the majority preferred the option of an alternate plan. Surgeons should consider offering families alternate follow-up after an uncomplicated procedure.

Educational outcomes in school age children with a history of isolated Hirschsprung disease are equivalent to their peers.

PURPOSE: The aim of this study was to assess real-world educational outcomes and developmental disorders in patients with a history of Hirschsprung disease compared to an age-matched control group. METHODS: With ethics approval (H2016:014) a retrospective cohort study of all children diagnosed with Hirschsprung disease at a single centre from 1992 to 2017 was performed. A 10:1 date-of-birth matched control cohort was constructed from a population-based directory. The educational outcomes were compared using the following measures: Early Developmental Instrument, Grades 3, 7, and 8 assessments, Grade 9 completion, Grade 9 performance, and high school graduation. Fisher's exact tests were used to compare the odds of failure between cases to controls. Only children who reached 4 years of age were included. RESULTS: A total of 75 cases with Hirschsprung disease patients were identified. Patients with Hirschsprung disease were at increased risk of failing to meet expectations on the Early Development Instrument. After entering elementary school, Hirschsprung patients were at no greater risk than their peers of failing to meet expectations on standardized testing or failing to graduate from high school. CONCLUSION: Using real-world measures of academic success as a surrogate for neurodevelopmental status, our study demonstrates that patients with a history of Hirschsprung disease demonstrated poor neurodevelopmental performance in pre-school, but the educational achievements of patients did not differ from controls once they started school. These promising data can be used to mitigate preconceived notions that patients with Hirschsprung disease require special education, which may be isolating and psychosocially damaging.

The prevalence of hearing loss in children with congenital diaphragmatic hernia: A longitudinal population-based study.

BACKGROUND: The true prevalence of hearing loss among children with congenital diaphragmatic hernia (CDH) is unknown, with some studies reporting rates up to 60%. PURPOSE: The purpose of this study was to determine the prevalence of hearing loss among children with CDH and compare it to age-matched controls. METHODS: We used population-based datasets to compare the number of hearing loss diagnoses in children younger than 10 years-of-age born between 1992 and 2009 with CDH to date-of-birth matched controls without CDH. Factors associated with CDH disease severity were analyzed to determine their effect on the prevalence of hearing loss. A sensitivity analysis was performed to determine if selection bias of improved care over the course of the study affected hearing loss in CDH patients. The prevalences of hearing loss were compared using Fisher's exact tests and statistical significance was defined as p < 0.05. RESULTS: A total of 529 children, 38 CDH cases and their 491 date-of-birth matched controls, met the inclusion criteria. Hearing loss was found in 7 children with CDH (18.4%) compared to 26 (5.3%) controls; the risk ratio (RR) of hearing loss was 3.48 (95%CI = 1.61-7.49, p = 0.006). There was no association between CDH disease severity and hearing loss. CONCLUSIONS: CDH is associated with hearing loss compared to the general population. Our results suggest that congenital factors may contribute to hearing loss in CDH more than perinatal exposures. LEVEL OF EVIDENCE: 3.

High-frequency vs. conventional ventilation at the time of CDH repair is not associated with higher mortality and oxygen dependency: a retrospective cohort study.

PURPOSE: The VICI-trial reported that in patients with congenital diaphragmatic hernia (CDH), mortality or bronchopulmonary dysplasia (BPD) were equivalent using conventional mechanical ventilation (CMV) and high-frequency oscillatory ventilation. The purpose of this study was to determine if the mode of ventilation at the time of CDH repair affected mortality or oxygen dependence at 28 days. METHODS: We performed a retrospective cohort study of infants born wih CDH from 1991 to 2015. A generalized linear model was applied to the data using a propensity score analysis. RESULTS: Eighty patients met the inclusion criteria; at the time of surgery 39 (48.8%) patients were on HFV and 41 (51.3%) patients were on CMV. In the HFV group, 16 (47.1%) patients remained oxygen dependent and there were 5 (12.8%) deaths at 28 days. In the CMV group, 5 (12.2%) patients remained oxygen dependent at 28 days but none had died. The base model demonstrated that the HFV group had increased rates of oxygen dependence [OR = 6.40 (2.13, 22.2), p = 0.002]. However, after propensity score analysis, we found no difference between HFV and CMV. CONCLUSION: Our study suggests that in infants with CDH, there is no significant difference between HFV and CMV in oxygen dependency or death.

Impact of distance on postoperative follow-up in patients of pediatric surgery: a retrospective review.

Objective: Centralization of medical services in Canada has resulted in patients travelling long distances for healthcare, which may compromise their health. We hypothesized that children living farther from a children's hospital were offered and attended fewer follow-up appointments. Methods: We reviewed children less than 17 years of age referred to the general surgery clinic at a tertiary children's hospital during a 2-year period who underwent surgery. Descriptive statistics were performed. Results: We identified 723 patients. The majority were male (61%) with a median age of 7 years (range 18 days to16 years) and were from the major urban center (MUC) (56.3%). The median distance travelled to hospital for MUC patients was 8.9 km (range 0.9-22 km) vs 119.5 km (range 20.3-1950 km) for non-MUC patients. MUC children were offered more follow-up appointments (72.7% vs 60.8%, p<0.05). No significant differences existed in follow-up attendance rates (MUC 88.5% vs non-MUC 89.1%, p=0.84) or postoperative complications (9.8% vs 9.2%, p=0.78). There were no deaths. Conclusions: Patients living farther from a hospital were offered fewer follow-up appointments, but attended an equivalent rate of follow-ups when offered one. Telemedicine and remote follow-up are underused approaches that can permit follow-up appointments while reducing associated travel time and expenses.

Asthma Medication Use in Congenital Diaphragmatic Hernia Survivors: A Retrospective Population Level Data Analysis.

INTRODUCTION: The purpose of this study was to determine if congenital diaphragmatic hernia (CDH) survivors had worse long-term respiratory outcomes compared with age-matched controls, as measured by inhaled bronchodilator use, inhaled steroid use, and asthma-related physician visits. MATERIALS AND METHODS: We performed a retrospective case-control study of infants with isolated CDH from 1991 to 2013. The primary outcome measures were inhaled bronchodilator prescriptions, inhaled steroid prescriptions, and asthma-related physician visits between 0 and 5 years of age and between 5 and 10 years of age. Subgroup analysis compared the same outcomes for CDH patients grouped by: birth weight, gestational age, side of defect, defect size, liver herniation, hernia sac, and pulmonary hypertension. RESULTS: Fifty-six patients with CDH and 753 age-matched controls met the inclusion criteria for the 0 to 5 years of age analysis. Between 0 and 5 years of age, more CDH survivors were prescribed an inhaled bronchodilator (odds ratio [OR] = 2.47[1.38-4.48], p = 0.001) and inhaled steroid (OR = 2.03[1.07-3.74], p = 0.03), and had an asthma-related physician visit (OR = 1.92[1.00-3.56], p = 0.04). Thirty-eight cases and 491 controls met the inclusion criteria for the 5 to 10 years of age analysis. Between 5 and 10 years of age, CDH survivors were not more likely to be prescribed inhaled bronchodilators, inhaled steroids, or have an asthma-related physician visit. Among the CDH patients, we did not find a clinical characteristic associated with increased inhaled bronchodilator or steroid prescriptions at any age. CONCLUSION: A history of CDH is associated with higher rates of inhaled bronchodilator prescriptions, inhaled steroid prescriptions, and asthma-related physician visits from 0 to 5 years of age compared with age-matched controls. However, this difference resolves by 5 to 10 years of age.

Intrapleural Dornase and Tissue Plasminogen Activator in pediatric empyema (DTPA): a study protocol for a randomized controlled trial.

BACKGROUND: A randomized controlled trial of adults with empyema recently demonstrated decreased length of stay in hospital in patients treated with intrapleurally administered dornase alfa and fibrinolytics compared to fibrinolytics alone. Whether this treatment strategy is safe and effective in children remains unknown. METHODS/DESIGN: This study protocol is for a superiority, placebo-controlled, parallel-design, multicenter randomized controlled trial. The participants are previously well children admitted to a children's hospital with a diagnosis of empyema requiring chest tube insertion and fibrinolytics administered intrapleurally. Children will be randomized after the treating physician has decided that pleural drainage is required but prior to chest tube insertion. After chest tube insertion, participants in the treatment group will receive intrapleurally administered tissue plasminogen activator (tPA) 4 mg followed by dornase alfa 5 mg. Participants in the placebo group will receive tPA 4 mg followed by normal saline. Study treatments will be administered once daily for 3 days. All participants, parents or caregivers, clinicians, and research personnel will remain blinded. The primary outcome is length of stay from chest tube insertion to discharge from hospital. Secondary outcomes include time to meeting discharge criteria, chest tube duration, fever duration, need for additional procedures, adverse events, hospital readmission, cost of hospitalization, and mortality. DISCUSSION: This multicenter randomized controlled trial will assess the safety, effectiveness, and cost-effectiveness of combined treatment with dornase alfa and fibrinolytics compared to fibrinolytics alone for the treatment of empyema in children. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01717742 . Registered on 8 October 2012.

The surgical management of malrotation: A Canadian Association of Pediatric Surgeons survey.

PURPOSE: Some surgeries are now performed almost exclusively via a laparoscopic approach to enhance recovery and reduce postoperative complications. This survey explored institutional and individual physician practice patterns of the surgical management of malrotation. METHODS: All 2015 Canadian Association of Pediatric Surgeons annual meeting attendees were invited to complete an anonymous prepiloted survey. Descriptive statistics were calculated. RESULTS: The response rate was 35% (150 distributed, 52 returned). Most institutions (39.5%) saw on average 5-10 cases of malrotation per year. Most respondents (54.2%) indicated that the laparoscopic (LL) and open Ladd's (OL) procedures were equal surgical approaches for stable patients. Respondents were nearly equally divided (47.9% yes; 44.7% no) with respect to whether an LL procedure led to a higher risk of postoperative volvulus. Of those who answered yes, most indicated that an increased risk of postoperative volvulus was because of an inadequate widening of mesentery (45.8%), reduced "beneficial" postoperative adhesions (29.2%), or both (16.7%). 100% of respondents who perform an OL as their standard procedure indicated that there was a higher risk of postoperative volvulus with LL procedure. Only 1/8 who performed a LL as a standard approach routinely performed an appendectomy. CONCLUSION: There remain polarized views on the best surgical approach to malrotation yet a persistent belief in the reduction in postoperative adhesions in leading to a postoperative volvulus with LL procedures. Collaboration to permit long-term follow-up of a large cohort may help develop guidelines for the operative management of malrotation. LEVEL OF EVIDENCE: Level V.

Glycerin enemas and suppositories in premature infants: a meta-analysis.

BACKGROUND AND OBJECTIVE: Premature infants are often given glycerin enemas or suppositories to facilitate meconium evacuation and transition to enteral feeding. The purpose of this study was to assess the available evidence for this treatment strategy. METHODS: We conducted a systematic search of Medline, Embase, Central, and trial registries for randomized controlled trials of premature infants treated with glycerin enemas or suppositories. Data were extracted in duplicate and meta-analyzed using a random effects model. RESULTS: We identified 185 premature infants treated prophylactically with glycerin enemas in one trial (n = 81) and suppositories in two other trials (n = 104). All infants were less than 32 weeks gestation and had no congenital malformations. Treatment was associated with earlier initiation of stooling in one trial (2 vs 4 days, P = .02) and a trend towards earlier meconium evacuation in another (6.5 vs 9 days, P = .11). Meta-analysis demonstrated no effect on transition to enteral feeding (0.7 days faster, P = .43) or mortality (P = 0.50). There were no reports of rectal bleeding or perforation but there was a trend towards increased risk of necrotizing enterocolitis with glycerin enemas or suppositories (risk ratio = 2.72, P = .13). These three trials are underpowered and affected by one or more major methodological issues. As a result, the quality of evidence is low to very low. Three other trials are underway. CONCLUSIONS: The evidence for the use glycerin enemas or suppositories in premature infants in inconclusive. Meta-analyzed data suggest that treatment may be associated with increased risk of necrotizing enterocolitis. Careful monitoring of ongoing trials is required.

Quality of reporting of the literature on gastrointestinal reflux after repair of esophageal atresia-tracheoesophageal fistula.

OBJECTIVES: There is variation in the management of postoperative gastroesophageal reflux (GER) in esophageal atresia-tracheoesophageal fistula (EA-TEF). Well-reported literature is important for clinical decision-making. We assessed the quality of reporting (QOR) of postoperative GER management in EA-TEF. METHODS: A comprehensive search of MEDLINE, EMBASE, CINHAL, CENTRAL databases and gray literature was conducted. Included articles reported a primary diagnosis of EA-TEF, a secondary diagnosis of postoperative GER, and primary treatment of GER with antireflux medications. The QOR was assessed using the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) checklist. RESULTS: Retrieval of 2910 articles resulted in 48 relevant articles (N=2592 patients) with an overall quality percentage score of 48%-95% (median=65%). The best reported items were "participants" and "outcome data" (93.8% each), "generalisability" (91.7%) and "background/rationale" (89.6%). Less than 20% of studies provided detailed "main results"; less than 5% of studies reported adequately on "bias" or "funding." Sample size calculation and study limitations were included in 17 (35.4%) and 16 (33.3%) studies respectively. Follow-up time was inconsistently reported. CONCLUSIONS: Although the overall QOR is moderate using STROBE, important areas are underreported. Inadequate methodological reporting may lead to inappropriate clinical decisions. Awareness of STROBE, emphasizing proper reporting is needed.

Compliance with published recommendations for postoperative antibiotic management of children with appendicitis: A chart audit.

BACKGROUND: Recommendations for postoperative antibiotics for appendicitis were published by the American Pediatric Surgical Association (APSA) in 2010. However, implementation of practice recommendations often takes years. We measured compliance of pediatric surgeons (who receive reminders every 6months from the Division Chief) with the APSA recommendations. METHODS: With Research Ethics Board approval, we completed a retrospective review of children who underwent appendectomy since 2010. Compliance with APSA recommendations was analyzed descriptively. Agreement between pediatric surgeons and pathologists was analyzed by kappa. RESULTS: We reviewed 242 charts. Patients were excluded for missing data (n=5) and diagnosis other than appendicitis (n=27), resulting in 210 patients with appendicitis (119 acute, 91 perforated). Agreement of perforation status between surgeons and pathologists was good (κ=0.75; 95% CI: 0.66-0.83). Many patients with nonperforated appendicitis received antibiotics in excess of the APSA recommendations (62/119 (52%)), as did those with uncomplicated perforated appendicitis (52/84 (62%)). CONCLUSIONS: Despite the availability of published recommendations, surgeons continue to prescribe postoperative antibiotics for appendicitis in excess of the recommendations. Overtreatment leads to potential medication errors and increased length-of-stay/medication costs. An intensive implementation program with ongoing education/monitoring may improve compliance with established recommendations to decrease the use of excess postoperative antibiotics and their associated costs/risks.

Fundoplication and gastrostomy versus percutaneous gastrojejunostomy for gastroesophageal reflux in children with neurologic impairment: A systematic review and meta-analysis.

BACKGROUND: Children with neurologic impairment often fail medical management of gastroesophageal reflux and proceed to fundoplication and gastrostomy (FG) or percutaneous gastrojejunostomy (GJ). Current guidelines do not recommend one treatment over the other, and there is ongoing uncertainty regarding clinical management. METHODS: We conducted a structured search of Medline, Embase, trial registries, and the gray literature. We included studies that compared outcomes for FG and GJ in children with neurologic impairment. RESULTS: We identified 556 children from three retrospective studies who underwent FG (n=431) or GJ (n=125). There were no differences in rates of pneumonia (17% vs 19%, p=0.74) or mortality (13% vs 14%, p=0.76). Few deaths were due to procedural complications (1%) or reflux (2%). There was a trend towards more major complications with FG (29%) compared to GJ (12%) (risk ratio=1.70, 0.85-3.41, p=0.14). Minor complications were more common with GJ (70%) than FG (45%), but this difference was also not statistically significant (risk ratio=0.38, 0.05-3.07, p=0.36). No studies reported quality of life using validated measures. CONCLUSIONS: The quality of the evidence for outcomes of FG versus GJ is very low. Large comparative studies are needed to determine which approach is associated with the best quality-of-life outcomes.

The quality of guidelines in pediatric surgery: can we all AGREE?

OBJECTIVE: Guidelines are meant to facilitate evidence-based clinical decision-making but vary in methodological rigor and quality of reporting. We assessed the quality of guidelines published in major pediatric surgery journals. METHODS: A MEDLINE search of 4 key pediatric surgery journals was performed. Included studies had guidelines, clinical practice guidelines, and consensus statements as a subject heading or keyword. Evaluations of guidelines were excluded. Eligible guidelines were assessed by three reviewers using the Appraisal of Guidelines for Research and Evaluation (AGREE II) Instrument. RESULTS: Our search identified ten guidelines for review. Agreement for study selection was excellent [K = 0.81 (95 % CI 0.63-0.99)]. The mean AGREE II score for individual guidelines was 18 % (SD 5.7 %). The best-scored quality domains were "scope and purpose" [mean score 49 % (SD 8.7 %)] and "clarity of presentation" [mean score 40 % (SD 18.7 %)]. The poorest score was for "editorial independence" [mean score 2 % (SD 3.7 %)]. CONCLUSIONS: The overall quality of guidelines in pediatric surgery, using AGREE II, is poor and may lead to inappropriate clinical decisions. Increased awareness of proper reporting and the methodological requirements for guideline development are needed to optimize the potential of guideline recommendations to improve practice. LEVEL OF EVIDENCE: n/a (Quality Appraisal).

Laparoscopic versus open repair of recto-bladderneck and recto-prostatic anorectal malformations: a systematic review and meta-analysis.

OBJECTIVE: The laparoscopically-assisted anorectal pull-through (LAARP) for recto-bladderneck and recto-prostatic anorectal malformations (RB/RP-ARMs) is believed to improve patient outcomes. We performed a systematic review of the effect of LAARP on postoperative mucosal prolapse and defecation dysfunction. METHODS: A comprehensive search of MEDLINE, EMBASE, CENTRAL, and grey literature was performed (2000-2014). Full-text screening, data abstraction and quality appraisal were conducted in duplicate. Included studies reported a primary diagnosis of RB/RP-ARM and compared LAARP versus open repair (OPEN). RESULTS: From 3681 retrieved articles, 7 studies enrolling 187 patients were analyzed. One was a randomized control trial, 6 were retrospective observational studies, and all were single-centre. The majority were of poor-moderate quality (MINORS scores: mean 16.42 (SD 2.225) out of 24). Mucosal prolapse was not significantly different after LAARP versus OPEN (p = 0.18). Defecation outcomes were inconsistently reported but were no different between LAARP and OPEN for either children >3 years old (p = 0.84), or all ages combined (p = 0.11). CONCLUSION: We found no significant difference in rates of mucosal prolapse or defecation scores for LAARP compared to OPEN for children with RB/RP-ARMs. However, studies are small and of poor-moderate quality and results are heterogeneous. Comprehensive, standardized, reliable reporting is necessary to guide practice and inform postoperative guidelines. LEVEL OF EVIDENCE: 1c.

The management of postoperative reflux in congenital esophageal atresia-tracheoesophageal fistula: a systematic review.

PURPOSE: Esophageal atresia (EA), with or without tracheoesophageal fistula (TEF), is associated with postoperative gastroesophageal reflux (GER). We performed a systematic review of the literature regarding routine anti-reflux medication post EA-TEF repair and its impact on postoperative GER and associated complications. METHODS: A comprehensive search was conducted using MEDLINE, EMBASE, CINHAL, CENTRAL (Cochrane library) electronic databases and gray literature. Full-text screening was performed in duplicate. Included articles reported a primary diagnosis of EA-TEF, a secondary diagnosis of postoperative GER, and primary treatment of GER with anti-reflux medications. RESULTS: Screening of 2,910 articles resulted in 25 articles (1,663 patients) for analysis. Most were single-center studies (92%) and retrospective (76%); there were no randomized control trials. Fifteen studies named the class of anti-reflux agent used, 3 the duration of therapy, and none either the dose prescribed or number of doses. Complications were inconsistently reported. Anti-reflux surgery was performed in 433/1,663 (26.0%) patients. Average follow-up was 53.2 months (14 studies). CONCLUSION: The quality of literature regarding anti-reflux medication for GER post EA-TEF repair is poor. There are no well-outlined algorithms for anti-reflux agents, doses, or duration of therapy. Standardized protocols and reliable reporting are necessary to develop guidelines to better manage postoperative GER in EA-TEF patients.

Post-operative management of esophageal atresia-tracheoesophageal fistula and gastroesophageal reflux: a Canadian Association of Pediatric Surgeons annual meeting survey.

BACKGROUND: Esophageal atresia (EA), with or without tracheoesophageal fistula (TEF), is commonly associated with gastroesophageal reflux (GER) after surgical repair. One risk factor for anastomotic stricture is post-operative GER. This survey assessed practice patterns among attendees at the Canadian Association of Pediatric Surgeons (CAPS) annual meeting with respect to management of GER post EA-TEF repair. METHODS: A pre-piloted survey was handed out and collected at the 2012 CAPS annual meeting. Data were entered and coded, and descriptive statistics were calculated. RESULTS: We distributed 70 surveys, and 57 (81.4%) surveys were returned. On average, the incidence of EA-TEF is 8-10 cases per institution, per year. Anti-reflux medication is started immediately post-operatively in 74% of patients at institution of feeds (11%), or if symptoms of reflux develop (14%). Proton pump inhibitors and H2-receptor antagonists are used in approximately equal proportion. Patients are typically kept on anti-reflux medication for 3-6 months (37%) or 6-12 months (35%). CONCLUSIONS: Most CAPS attendees treat postoperative GER prophylactically. However, there is no consistency in management strategy regarding which anti-reflux agent to use or for how long. A multi-centered study is required to establish a standardized protocol for the post-operative management of EA-TEF to prevent reflux and its effect on anastomotic strictures.

The role of tissue plasminogen activator in the management of complex intra-abdominal abscesses in children.

OBJECTIVE: The objective of this study is to assess the safety of fibrinolytic therapy using tissue plasminogen activator (tPA) in children with complex intra-abdominal abscesses. SUMMARY BACKGROUND DATA: Intra-abdominal abscesses are common in children. Antibiotics and percutaneous drainage are the mainstays of treatment, but drainage may be less effective when the fluid is thick or septated. Fibrinolytic therapy using tPA is effective in a rat model of intra-abdominal abscesses, has recently been reported for the treatment of intra-abdominal abscesses in adults, and is commonly used in the treatment of empyema in children. METHODS: This is a retrospective review of all patients over a 10-year period who had intra-abdominal collections managed with tPA abscess drainage. RESULTS: Sixty-four children had a total of 66 drains placed and 92 doses of tPA. Appendicitis was the cause of the abscesses in 52 of 64 children. Mean length of stay pre-tPA was 11.7 ± 7.63 days, mean time from drain insertion to tPA was 4.3 ± 3.78 days, and mean time from tPA to discharge was 8.6 ± 8.85 days. Thirty patients underwent an operation before tPA administration. No patients experienced bleeding complications, anastomotic or appendiceal stump leak, or wound dehiscence after the administration of tPA, and no patients had abnormalities in coagulation studies related to tPA administration. One child died of sepsis. CONCLUSIONS: Tissue plasminogen activator is safe for the management of thick or septated intra-abdominal abscesses in children. A prospective controlled study will be needed to evaluate the efficacy of this technique.