Pneumatosis intestinalis in a cohort of children with neurological impairment: A patient group with a management dilemma.

AIM: Pneumatosis intestinalis (PI) is uncommon in school-age children. We studied a cohort of neurologically impaired school-age children with PI to formulate an optimum management plan. METHODS: We retrospectively studied all school-age children who were referred to paediatric surgeons with radiological evidence of PI identified between 2011 and 2015. We analysed data on patient demographics, medications, feeding, associated comorbidities, presentation, investigations and treatments. RESULTS: Five patients (3F:2M) with a median age of 7 years (range 5-9) were referred for surgical opinion with the evidence of pneumatosis on their abdominal X-rays. Four of them had associated pneumoperitoneum. All children had neurological impairment significant enough to make them unable to communicate clearly. Four patients were gastrostomy fed, one was jejunally fed. Four children had recurrent episodes of pneumatosis. Four patients had surgery at the initial presentation where colonic pneumatosis was detected; however, there was no evidence of bowel ischaemia or perforation despite of the presence of pneumoperitoneum. Recurrent episodes were successfully managed conservatively even in the presence of pneumoperitoneum. CONCLUSION: In neurologically impaired school-age children, the presence of pneumatosis and pneumoperitoneum does not mandate bowel ischaemia or perforation and therefore could be successfully managed conservatively without the need for surgery.

Lung biopsy in children: when is it useful?

AIM: To provide a further insight into the usefulness of lung biopsy in children. METHODS: Lung biopsies in children from January 2007 to December 2017 were reviewed (n=39). The histology results were categorised as: definitive diagnosis, normal lung parenchyma, inconclusive. RESULTS: Lung biopsy provided a definitive diagnosis in 25 (64%) cases. A suspected diagnosis was confirmed in 16 (41%) and a new diagnosis was found in 9 (23%) children. Histology was inconclusive in 11 (28%) cases and normal in 3 (8%). Fifteen (38%) children had treatment altered due to the biopsy result. CONCLUSION: Lung biopsy mostly confirmed the suspected diagnosis and was associated with a low procedure related morbidity (n=1) and mortality (n=0). Importantly, the biopsy result identified a pathology which altered treatment in over one third of patients. However, in a number of cases the histology was inconclusive, therefore careful patient selection is recommended to maximise diagnostic yield.

A comparative study examining open inguinal herniotomy with and without hernioscopy to laparoscopic inguinal hernia repair in a pediatric population.

AIMS: Open herniotomy with or without hernioscopy has been performed in our unit for a decade. Since 2005 the laparoscopic repair was also introduced. The aims of this study were: (1) to compare detection rates for direct visualization of the contralateral deep inguinal ring via the known sac using a 70 degrees scope and via umbilical 30 degrees laparoscopy and (2) to compare operative timings, metachronous and recurrence rates for the three different management pathways for inguinal hernia. METHODS: A retrospective case note review was carried out over a 29 month period since the introduction of the laparoscopic hernia repair. All patients with inguinal hernia were identified from the work load of six surgeons encompassing the three methods of hernia management. Case notes were retrieved and the data analyzed using SPSS v.17. RESULTS: A total of 308 patients had 326 hernias performed. Follow-up ranged from 3 months to 1 year (median 8 months). The male-female ratio was 4:1. Of the patients, 12% were neonates; 299 children presented with unilateral hernia. Of those, 164 (55%) children had open herniotomy without contralateral inspection, and 5 (3%) had metachronous hernia; 77 (26%) children had an open herniotomy with 70 degrees hernioscopy; 2 (3%) children, who were considered to have closed contralateral deep inguinal ring during hernioscopy, had metachronous hernia, and 58 (19%) children had a laparoscopic hernia repair and none of them had metachronous hernia. Detection of contralateral patent deep inguinal ring for 70 degrees hernioscopy and 30 degrees laparoscopy was 10 (13%) and 16 (28%), respectively (P = 0.0465). Operative timing was significantly longer for laparoscopic repair (P < or = 0.0001). During the study period there were 11 recurrences; 9 (5%) in the open only group and 2 (3%) in the laparoscopic group. CONCLUSIONS: The results of the laparoscopic inguinal hernia repair are important for discussion as operative methods differ from that of herniotomy. The detection rate of contralateral patent deep inguinal ring appears to be higher for direct visualization via umbilical 30 degrees laparoscopy versus 70 degrees scope via the hernia sac. Whilst laparoscopy offers potential advantage of improved visualization, longer term prospective data collection is needed to compare these methods of operative hernia management.

Varicocele surgery: 10 years of experience in two pediatric surgical centers.

AIM: The study was designed to compare recurrence rates and complications after laparoscopic versus open varicocele surgery in children. SUBJECTS AND METHODS: A retrospective case-note review of all varicocele surgery over a 10-year period (April 1999-March 2009) in two pediatric surgical centers was performed. Multivariate analysis using logistic regression was performed using SPSS Statistics version 18 (SPSS Inc., Chicago, IL). RESULTS: Thirty-seven patients had varicocele surgery during the study period. The median age at surgery was 14 years (range, 11-16 years). Most children had left-sided Grade 2 varicocele. Twenty-five (68%) primary procedures were laparoscopic (17 artery-sparing), and 12 (32%) procedures were open (9 artery-sparing). Six (16%) children had recurrence, and 6 (16%) had postoperative hydrocele. Recurrence rates after laparoscopic (16%) and open (17%) surgery were similar. Increasing age significantly decreased recurrence (odds ratio, 0.373; 95% confidence interval 0.161-0.862; P = .021). Although laparoscopy was associated with higher rates of postoperative hydrocele (odds ratio, 2.817; 95% confidence interval, 0.035-3.595; P = .380) and artery-sparing ligation was associated with higher rates of recurrence (odds ratio, 2.667; 95% confidence interval, 0.022-4.235; P = .787), these associations were not statistically significant. CONCLUSIONS: The best results of varicocele surgery in terms of recurrence and postoperative hydrocele were achieved by open mass ligation; however, larger prospective studies are warranted.