Chest drains after open paediatric lung resections: not always required.

INTRODUCTION: Chest drains are often a great source of pain and anxiety in paediatric patients. While there is growing evidence to support the selective omission of chest drains after thorascopic lung resection in children, the safety of this practice following open lung resection has yet to be evaluated. Chest drains are not routinely placed at our institution. We therefore aimed to describe our experience of selective chest drain placement in children undergoing open lung resection, and report the safety and complication profile of this practice. METHODS: Retrospective review of all open lung resections performed at Wellington Regional Hospital, in children < 16 years of age, from June 2009 to June 2022. Clinical, radiological and operative outcomes were identified and analyzed. The cohort was divided into two groups - those that had a chest drain placed intraoperatively, and those that did not. RESULTS: 35 children underwent open lung resection over the study period. The mean operative age was 8.0 ± 5.4 months, with the most common resection being a lobectomy (80%). Eight children (23%) did not have a chest drain placed, whereas the remaining 29 children (77%) had at least one drain placed intraoperatively, with a median drainage time of 3.0 days. Length of stay was significantly shorter in children who did not have a chest drain placed intraoperatively, compared to those that did (2.5 vs. 5.0 days, p = 0.019). There were no significant differences observed in complication or reintervention rates between the two groups. Similarly, there were no significant differences in the incidence of a residual pneumothorax or effusion on the pre-discharge CXR between the groups. CONCLUSIONS: Chest drains may not always be required following open paediatric lung resection. The selective omission of a chest drain following open lung resection, does not appear to result in a significantly higher rate of complications or reintervention, and is associated with significantly shorter hospital length of stay.

Stress Ulcer Prophylaxis in Cardiac Surgery: A Retrospective Cohort Study to Analyze the Effects of SUP Cessation.

INTRODUCTION: Upper gastrointestinal bleeding (UGIB) is an important complication among critically ill adults, especially those having cardiac surgery as management is complicated by the requirement for antiplatelet/anticoagulant therapy. As a result, stress ulcer prophylaxis (SUP) has become routine practice in many centers, utilizing either proton pump inhibitors (PPIs) or histamine-2 receptor blockers (H2RBs). Recent evidence from the PEPTIC trial indicated an increase in mortality risk among cardiac surgery patients receiving PPIs compared to H2RBs. Considering these findings, alongside practical difficulties surrounding the transition to H2RBs as a prophylactic agent in New Zealand, Wellington Hospital intensive care unit elected to discontinue routine PPI use for SUP in cardiac surgery patients. A retrospective study was conducted to assess patient outcomes following the discontinuation of routine SUP. METHOD: A retrospective cohort study was conducted of all adult patients who underwent cardiac surgery at Wellington Hospital between February/2018 and January/2022, and divided patients into cohorts before and after the discontinuation of routine use of SUP on the 31st of January 2020. The primary outcomes were the rate of UGIB, oesophagogastroduodenoscopy (OGD) and 180-day postoperative mortality. Secondary outcomes included rates of postoperative Clostridium difficile enteritis, pneumonia, deep sternal wound infection, and length of stay of the index admission. RESULTS: The rate of UGIB statistically significantly increased since the cessation of routine SUP in January 2020 (2.4% vs 5.4%, P-value = .004). This finding was mirrored with the increased rates of OGD (1.9% vs 4.0%, P-value = .005). There were no significant changes in 180-day mortality, hospital length of stay, or any of the postoperative infective complications analyzed, pneumonia, deep sternal wound infection, or C difficile enteritis. CONCLUSION: This study suggests an association between routine use of SUP and reduced rates of clinically significant UGIB and OGD requirements in cardiac surgery patients without increasing risk of infective complications or postoperative mortality.

Epigastric Hernias in Children: A Personal Series and Systematic Review of the Literature.

Epigastric hernias are relatively uncommon in children, and there is a paucity of literature on their incidence, presenting features, natural history, and surgical outcomes. A systematic review was conducted according to PRISMA guidelines. Articles describing the incidence, outcome, and interventions for pediatric epigastric hernias, both open and laparoscopic, were analyzed. Eight relevant articles published between 1975 and 2019 were included in the analysis. Of 81 children, 58% were females, 35% were symptomatic and 8% were multiple. All hernias contained preperitoneal fat only and were repaired using standard open surgery or laparoscopic techniques. No recurrences were recorded. In a personal series of 37 hernias in 36 children of median age 4 years, there were no recurrences; however, this series included two children with a recurrent or persistent epigastric hernia after surgery by others. Epigastric hernias in children are relatively uncommon. They typically contain only preperitoneal fat but more than a third are symptomatic. Standard open repair can be undertaken with minimal morbidity. Laparoscopic repair takes longer and provides a marginal cosmetic benefit.

Esophageal length in children: Reference data and a novel predictive equation.

Minimal information exists on the length of the child's esophagus, namely the distance from the cricopharyngeus to the esophagogastric junction (EGJ). We aimed to investigate the relationship between esophageal length (EL) and the age, height, and weight of the child. Children undergoing upper gastrointestinal endoscopy between February 2019 and May 2021 at our institution were prospectively audited. Children with anatomical esophageal disorders were excluded. Endoscopic distances from the incisors to the cricopharyngeus and EGJ were obtained, and novel predictive equations derived to predict EL. Intra-observer agreement for endoscopic measurements showed an intra-class correlation coefficient of 0.99. A total of 290 children aged 0.4-17.3 years were included in the analysis; they were divided into a model development cohort (n = 261) and a model validation cohort (n = 29). Measured EL correlated best with height (r = 0.92) as compared to age (r = 0.90) or weight (r = 0.83). The optimal equation for predicting EL was 0.156 × height (cm) - 1.336 (adjusted R2  = 0.841); this had a success rate of 76% in the validation cohort. The optimal equation for predicting distance from incisors to EGJ was 0.199 × height (cm) + 6.470 (adjusted R2  = 0.889); this had a success rate of 69% in the validation cohort. This is the first study to report a predictive equation for estimating esophageal length in children. Accurate prediction of esophageal length may assist with clinical esophageal procedures in children such as nasogastric and pH probe placement.

Scoliosis after thoracotomy repair of esophageal atresia: a systematic review.

Standard surgical repair of esophageal atresia/tracheoesophageal fistula (EA/TEF) is via a right posterolateral thoracotomy. A recognized complication is the later development of scoliosis. The prevalence and pathogenesis of secondary scoliosis are poorly understood. We, therefore, conducted a systematic review on this topic. All English language articles reporting incidence, outcomes and/or interventions for scoliosis in children after EA repair via thoracotomy were identified. Fourteen relevant articles published between 1969 and 2019 reporting 1338 children were included in the analysis. The aggregate prevalence of scoliosis among 937 children without congenital vertebral anomalies was 13%, but this figure varied widely between studies. Severity of scoliosis was documented in 181 children; eight children had a Cobb angle > 40° and 10 had undergone spinal surgery. The spinal curvature in affected individuals was dominantly or exclusively convex to the left. In conclusion, the reported prevalence of scoliosis varies widely but on average affects about one in eight children after open repair of EA/TEF. Most cases are mild and do not require intervention. It is currently uncertain whether secondary scoliosis is preventable by using meticulous thoracotomy techniques or thoracoscopic repair.Level of evidence IV.

Neoadjuvant therapy in rectal cancer: how are we choosing?

BACKGROUND: Neoadjuvant therapy has revolutionized the management of rectal cancer; however, there is a need to examine the factors driving neoadjuvant treatment allocation. This study aimed to describe patterns of treatment allocation for patients with rectal cancer at our institution and identify predictors for receiving neoadjuvant therapy, and for choice of short- or long-course therapy. METHODS: A retrospective review of a prospectively maintained database of 122 patients undergoing surgical resection for rectal cancer with curative intent, between 1 November 2012 and 31 October 2017. Univariate and multivariate analyses were performed to identify factors that determined which patients received neoadjuvant therapy, and whether it was short or long course. RESULTS: Eighty-six patients (70%) received neoadjuvant therapy. Independent predictors for receiving neoadjuvant therapy were T3-4 tumours (P < 0.001), node-positive disease (P = 0.005) and mid (P = 0.045) or low rectal cancers (P < 0.001). Of those receiving neoadjuvant therapy, 38 (44%) received short course and 48 (56%) received long course. Node-positive disease was the only predictor for receiving long rather than short-course neoadjuvant therapy (P = 0.002). Overall, these factors predicted 76% of neoadjuvant treatment allocation. Our predictor model identified important areas of variance in our decision-making. CONCLUSION: Utilizing the identified factors, it appears that consistent decisions regarding neoadjuvant therapy are being made the majority of the time. These decisions are largely driven by T and N stage as well as tumour height. Mesorectal fascia involvement, pre-treatment carcinoembryonic antigen, age and comorbidity also influenced decision-making to a lesser and more variable extent.

Highly deficient alcohol health warning labels in a high-income country with a voluntary system.

INTRODUCTION AND AIMS: To examine the prevalence and design elements of the voluntary health warning labels and related industry initiatives on a purposive sample of alcoholic beverage containers sold in New Zealand (NZ), a country with no mandatory health warning labels. DESIGN AND METHODS: We selected a purposive (e.g. low-cost) sample of 59 local and imported beers, wines and ready-to-drink alcoholic beverage containers available in NZ in 2016-2017. We documented the occurrence, content, size, appearance and position of messages concerning drinking during pregnancy, drink-driving, other health effects and industry-led initiatives that could relate to warnings; and collected data about alcohol content, standard drinks, ingredients and energy information. RESULTS: A majority (80%) of the alcoholic beverage containers had a pregnancy-related warning, 73% had industry-led initiatives (e.g. advising 'responsible' consumption) and 19% had drink-driving/heavy machinery warnings. Warning labels were small, with the average area of pregnancy-related and drink-driving/heavy machinery pictograms being 45 and 36 mm2 , respectively (i.e. pea-size). The average heights of pregnancy-related and drink-driving text were 1.6 and 2.2 mm, respectively. Pregnancy-related pictograms occupied between an average of 0.13% (wine) and 0.21% (ready-to-drink) of the available surface area of the alcoholic beverage container (i.e. less than 1/400th of the available space). Drink-driving pictograms occupied an average of 0.12% (imported beer), and 0.13% (NZ beer) of the available surface area. DISCUSSION AND CONCLUSIONS: Voluntary recommendations in NZ appear to have been inadequate for producing health warnings on alcoholic beverage containers that are consistent with evidence-informed recommendations for effective labels. This finding suggests that mandatory standardised labelling outlining alcohol-related risks may be required to ensure adequate consumer information.