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.

Incidence of necrotising enterocolitis before and after introducing routine prophylactic Lactobacillus and Bifidobacterium probiotics.

OBJECTIVE: To compare rates of necrotising enterocolitis (NEC), late-onset sepsis, and mortality in 5-year epochs before and after implementation of routine daily multistrain probiotics administration in high-risk neonates. DESIGN: Single-centre retrospective observational study over the 10-year period from 1 January 2008 to 31 December 2017. SETTING: Level 3 neonatal intensive care unit (NICU) of the Norfolk and Norwich University Hospital, UK. PATIENTS: Preterm neonates at high risk of NEC: admitted to NICU within 3 days of birth at <32 weeks' gestation or at 32-36 weeks' gestation and of birth weight <1500 g. INTERVENTION: Prior to 1 January 2013 probiotics were not used. Thereafter, dual-species Lactobacillus acidophilus and Bifidobacterium bifidum combination probiotics were routinely administered daily to high-risk neonates; from April 2016 triple-species probiotics (L. acidophilus, B. bifidum, and B. longum subspecies infantis) were used. MAIN OUTCOME MEASURES: Incidence of NEC (modified Bell's stage 2a or greater), late-onset sepsis, and mortality. RESULTS: Rates of NEC fell from 7.5% (35/469 neonates) in the pre-implementation epoch to 3.1% (16/513 neonates) in the routine probiotics epoch (adjusted sub-hazard ratio=0.44, 95% CI 0.23 to 0.85, p=0.014). The more than halving of NEC rates after probiotics introduction was independent of any measured covariates, including breast milk feeding rates. Cases of late-onset sepsis fell from 106/469 (22.6%) to 59/513 (11.5%) (p<0.0001), and there was no episode of sepsis due to Lactobacillus or Bifidobacterium. All-cause mortality also fell in the routine probiotics epoch, from 67/469 (14.3%) to 47/513 (9.2%), although this was not statistically significant after multivariable adjustment (adjusted sub-hazard ratio=0.74, 95% CI 0.49 to 1.12, p=0.155). CONCLUSIONS: Administration of multispecies Lactobacillus and Bifidobacterium probiotics has been associated with a significantly decreased risk of NEC and late-onset sepsis in our neonatal unit, and no safety issues. Our data are consistent with routine use of Lactobacillus and Bifidobacterium combination probiotics having a beneficial effect on NEC prevention in very preterm neonates.

Educational survey of regional general practitioner's management of paediatric patients with undescended testis.

INTRODUCTION: Recent recommendations have lowered the ideal age of surgery for undescended testis (UDT) to 3-6 months of age. However, many publications demonstrate that age at surgery is still above the recommended age of 1 year as originally suggested in 1996. AIM: Through a web-based educational survey, we aimed to combine questions regarding General Practioner's (GPs) management of these patients with educational slides with advice to update them with current recommendations. METHODS: The regional GPs were invited by email and letter to undertake the web-based questionnaire devised using SurveyMonkey(®). Educational slides were shown after each questionnaire slide. Feedback was immediate and a one-page summary was emailed to the GP on completion. A pre- and post-educational intervention audit was undertaken to ascertain the change in age of referral for patients <5 years of age. RESULTS: 144 (36%) of 401 GPs undertook this survey. 84% were happy assessing infants (<1year) with UDT. 16% were unhappy discussing management with parents for palpable UDT. 52% were happy discussing malignant risk with parents. 80% thought that ultrasonography was routinely used. Optimal referral time was thought to be 6-12 months (42%) and time of surgery was 1-2 years (50%). 72% would refer a patient with palpable UDT after 6 months of age. Only 41% were happy to assess testicular size at puberty. 98% found this format of an educational survey was helpful. The average age of referral for patients <5 years improved significantly after educational intervention from 2.8 years in 2010 to 1.25 years in 2013 (p < 0.01). DISCUSSION: With an interactive survey, we were able assess and also educate the regional GPs with regard to management of paediatric patients with UDT. There is a varied range of knowledge and practice demonstrated which we hoped to standardise and thereby increase efficiency and decrease the age of referral. A large majority would refer patients with UDT after 6 months of age that would make the target of surgery <6 months unachievable unless they are aware of current recommendations. This study is limited by a 36% response rate but that is comparable to other surveys. Also, referrals come from other sources that were not included. The causal effect of the educational survey is hypothesised. CONCLUSION: This educational survey has confirmed the varied management by GPs. The referral age was demonstrated to be reduced after this intervention and this process was widely accepted by GPs that undertook the educational survey.

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.

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.

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.

The role of laparoscopy in the management of adnexal lesions in children.

AIM: Laparoscopy has replaced laparotomy in a variety of surgical abdominal conditions. In pediatric patients the vast majority of adnexal lesions are benign. The aim of this study was to assess the safety and feasibility of laparoscopy in adnexal pathology in children. MATERIALS AND METHODS: The case notes of girls with confirmed adnexal disorders treated in a single center between 1998 and 2008 were reviewed retrospectively. Demographic data, clinical and imaging features, surgical findings and procedures, pathologic features, complications, and outcomes were recorded. RESULTS: Over a 10-year-period 21 patients underwent laparoscopic surgery. Median age at operation was 14 years (range: 2 d to 16 y). Laparoscopy was diagnostic in 1 patient whereas it was therapeutic in 14; 2 patients underwent a laparoscopy-assisted minilaparotomy. The procedure was converted to open in 4 patients due to technical difficulties. The most commonly performed procedures laparoscopically were cyst aspiration (n=6), cystectomy (n=4), unilateral oophorectomy (n=2), and cyst aspiration with deroofing (n=2). No operative or postoperative complications occurred. The overall mean postoperative length of stay was 2.3 days (range: 1 to 6 d); it was 1.8 days (range: 1 to 3 d) for patients who had laparoscopic procedures. Pathology revealed benign lesions in all cases. CONCLUSIONS: In children with benign adnexal pathology, minimally invasive surgery is a feasible and safe approach. Additional benefits of shorter hospital stay, superior cosmetic result, and lesser risk of infertility, make laparoscopy a method of choice for managing pediatric patients.

Pediatric advanced appendicitis: open versus laparoscopic approach.

PURPOSE: Optimal surgical approach for advanced pediatric appendicectomy remains controversial. We compare the open versus the laparoscopic approach. METHODS: Retrospective case notes review of children operated on for advanced appendicitis between January 2005 and July 2006 was undertaken for length of hospital stay, operating time, wound complications, need for further surgery, and hospital readmission. RESULTS: Forty children were included, 17 were treated with open approach and 23 with laparoscopic approach. There was no conversion from laparoscopic to open approach. Overall complication rate, length of hospital stay, and need for further surgery were similar in both groups. The mean operative time was longer in the laparoscopic group. Wound complications occurred more in the open group. Readmission for gastrointestinal obstruction was noted in the laparoscopic group. CONCLUSIONS: Laparoscopic approach is safe for advanced appendicitis in children. The outcomes are comparable in both study groups.

Single scrotal incision orchiopexy for palpable undescended testis.

OBJECTIVE: To prospectively evaluate the Bianchi single scrotal incision technique for orchiopexy in boys with palpable undescended testis. METHODS: A total of 35 orchiopexies were performed in 28 patients. The patent processus vaginalis was dissected and cut high without ligation, while in Bianchi's original procedure, the patent processus vaginalis is dissected up to the external inguinal canal, ligated high and divided. Testicular size and position were assessed at 2 and 6 weeks and 6 months. RESULTS: The single incision technique was successful in all cases. All testes were satisfactorily positioned in the scrotum. All testes showed good anatomical and cosmetic results at 6-month follow-up. CONCLUSION: Single scrotal incision orchiopexy without ligation of the patent processus vaginalis has proved to be simple, safe and effective in selected cases compared with the standard two-incision approach in the treatment of palpable undescended testis.