The ins and outs of pyloromyotomy: what we have learned in 35 years.

PURPOSE/BACKGROUND: The aim of the study is to evaluate a large series of infantile hypertrophic pyloric stenosis (IHPS) patients treated by one pediatric surgeon focusing on their diagnostic difficulties and complications. METHODS: From July 1969 to December 2003 (inclusive), the charts of 791 infants with IHPS were retrospectively reviewed. RESULTS: There were 647 (82%) males and 144 (18%) females; mean age was 38 days, median 51 (range 7 days-10 months). When ultrasonography (US) was routinely used (1990), the age at diagnosis decreased to <40 days. The mean weight before and after routine US was 3.2 kg, median 3 (range 1.5-6). Twenty-five (3.1%) were premature at diagnosis, mean age 49 days, median 56, (range 1-3 months) and mean weight 2.5 kg, median 2.3 (range 1.5-3.2). Eighty-one (10%) had a positive family history. Forty-four (5%) were non-Caucasians. Seventy-five (9 %) had other medical conditions, anomalies and/or associated findings. Sixty (7%) patients had abnormal preoperative electrolytes. Ten (1.2%) pylorics occurred after newborn operations. Of the entire total (791) who were treated, there were 13 (1.7%) not operated on. All operations were done open initially through one of two right upper quadrant incisions, and then through an upper midline incision under general endotracheal anesthesia; 14 (1.7 %) had concomitant procedures. Prophylactic antibiotics (from 1982) decreased the wound infection rate to 3.9%. There were a total of 87 (10%) complications which included 9 (1.1%) intraoperative, (including mistaken diagnoses) 78 (9%) postoperative: 59 (2%) early (<1 month) and 19 (2.4%) late (>1 month). The 13 (1.6%) postoperative transfers (12 from non-pediatric surgeons) had 16 (18%) complications (including 1 death); five (33%) requiring reoperation (4 incomplete, 1 perforation). There were two deaths. CONCLUSIONS: IHPS should be considered in any vomiting infant. US allows earlier diagnosis. Serious complications are uncommon and avoidable, but recognizable and easily corrected. Higher surgeon volume of pyloromyotomies (>14 per year) is associated with fewer complications.

Testicular atrophy after attempted pediatric orchidopexy for true undescended testis.

BACKGROUND/PURPOSE: A normal testis in the scrotum is the most important outcome of the attempted pediatric orchidopexy for a true undescended testis. The reports of post-orchidopexy testicular atrophy in the literature have ranged from non-existent to unclear. Our purpose in this study was to estimate the incidence of and associated risk factors for post-orchidopexy testicular atrophy. METHODS: We performed a retrospective review of data from children who had an attempted orchidopexy for a true undescended testis from 1969 to 2003 inclusive. REB approval 1000011987. RESULTS: There were 1400 attempted orchidopexies involving common (low) type (n=1135), ectopic type (n=174), and high type testes (n=91). There were a total of 111/1400 (8%) atrophic testes, mostly right-sided. 66/111 (59%) were MADE atrophic, and 45 (41%) were FOUND atrophic. Of the 1135 common type, 56 (5%) were MADE atrophic. In the ectopic and high types, the incidence of post-operative testicular atrophy was 1% and 9%, respectively. The most significant risk factors associated with testes MADE atrophic were high testicle, vas problems, and pre-operative torsion. CONCLUSIONS: In this series, the incidence of post-operative testicular atrophy that was MADE was 5% in the common (low) type and 9% in the high type. These numbers and the above risk factors should be quoted to the caregiver during pre-operative informed consent.

Open appendectomy for pediatric ruptured appendicitis: a historical clinical review of the prophylaxis of wound infection and postoperative intra-abdominal abscess.

BACKGROUND: We conducted a 3-decade clinical review of prophylaxis for wound infection and postoperative intra-abdominal abscess after open appendectomy for pediatric ruptured appendicitis. METHODS: We reviewed the charts of patients with ruptured appendicitis who underwent open appendectomy performed by the same pediatric surgeon at the Hospital for Sick Children, Toronto, Canada, between 1969 and 2003, inclusive. We evaluated 3 types of prophylaxis: subcutaneous (SC) antibiotic powder, peritoneal wound drain and intravenous (IV) antibiotics. We divided the sample into 4 treatment groups: peritoneal wound drain alone (group 1); peritoneal wound drain, SC antibiotic powder and IV antibiotics (group 2); SC antibiotic powder and IV antibiotics (group 3); and IV antibiotics alone (group 4). We used the χ(2) test with Bonferroni correction for multiple comparisons. RESULTS: There were 496 patients: 348 (70%) boys and 148 (30%) girls, with a mean age of 7 (range newborn to 17) years. There were 90 (18%) wound infections. Compared with the current standard of practice, IV antibiotics alone (group 4), peritoneal wound drain (group 1) was associated with the lowest number of wound infections (7 [7%], p = 0.023). There were 43 (9%) postoperative intra-abdominal abscesses. Compared with IV antibiotics alone, SC antibiotic powder with IV antibiotics (group 3) was associated with the lowest number of postoperative intra-abdominal abscesses (14 [6%], p = 0.06). CONCLUSION: Over a 35-year period of open appendectomy for pediatric ruptured appendicitis, wound infection was least frequent in patients who received prophylactic peritoneal wound drain, and postoperative intra-abdominal abscess was least frequent in those who received prophylactic SC antibiotic powder and IV antibiotics.

CONTEXTE: Nous avons procédé à une revue clinique sur 3 décennies de la prophylaxie des infections de plaies et des abcès intra-abdominaux consécutifs à l'appendicectomie ouverte pour rupture de l'appendice en pédiatrie. MÉTHODES: Nous avons passé en revue les dossiers de patients admis pour rupture de l'appendice qui ont subi une appendicectomie ouverte exécutée par le même pédochirurgien à l'Hôpital pour enfants malades (SickKids) de Toronto, au Canada, de 1969 à 2003 inclusivement. Nous avons évalué 3 types de prophylaxie : poudre antibiotique sous-cutanée (s.-c.), drain péritonéal de la plaie et antibiothérapie intraveineuse (i.v.). Nous avons divisé l'échantillon en 4 groupes selon les traitements administrés : drain péritonéal seul (groupe 1); drain péritonéal, poudre antibiotique s.-c. et antibiothérapie i.v. (groupe 2); poudre antibiotique s.-c. et antibiothérapie i.v. (groupe 3); antibiothérapie i.v. seule (groupe 4). Nous avons utilisé un test de χ2 avec correction de Bonferroni pour comparaisons multiples. RÉSULTANTS: L'échantillon regroupait 496 patients : 348 garçons (70 %) et 148 filles (30 %) âgés en moyenne de 7 ans (de nourrisson à 17 ans). On a dénombré 90 cas (18 %) d'infection de plaie. Comparativement à la norme actuelle de pratique, soit l'antibiothérapie i.v. seule (groupe 4), le drain péritonéal (groupe 1) a été associé au nombre le plus faible d'infections de plaies (7 [7 %], p = 0,023). On a dénombré 43 cas (9 %) d'abcès intra-abdominaux postopératoires. Comparativement à l'antibiothérapie i.v. seule, la poudre antibiotique s.-c. avec antibiothérapie i.v. (groupe 3) a été associée au plus faible nombre d'abcès intra-abdominaux postopératoires (14 [6 %], p = 0,06). CONCLUSIONS: Dans les appendicectomies ouvertes pour rupture de l'appendice pratiquées chez des enfants sur une période de 35 ans, l'infection de plaie a été la moins fréquente chez les patients traités par drain péritonéal prophylactique et l'abcès intraabdominal postopératoire a été le moins fréquent chez ceux qui avaient reçu de la poudre antibiotique s.-c. et une antibiothérapie i.v. prophylactiques.

Predictors of metachronous inguinal hernias in children.

PURPOSE: Surgical management of the contralateral groin in unilateral inguinal hernia remains controversial. Our aim was to determine predictors of metachronous inguinal hernias in children using multivariable analysis. METHODS: A retrospective cohort study of 6,302 patients presenting with inguinal hernia to a single surgeon's practice over 35 years was undertaken. Patients with bilateral hernias (n=698), contra-lateral groin exploration (n=235) or missing data (n=274) were excluded. Multiple forward logistic regression was used to predict metachronous hernia (MH). Entry into the model was with a P-value of 0.05 and exit was at 0.10. To account for the non-linear relationship of age at time of initial hernia, age was dichotomized into four quartiles. RESULTS: A total of 5,095 patients were eligible for inclusion [median age 2 years (range 1 month-18 years); males 84.4%; indirect type 99%]. In total, 267 (5.2%) patients developed a MH at a median time of 1 year. Predictors of developing a MH were the following: presentation with a left-sided hernia (OR=2.2, CI=1.7-2.8; P<0.0005) was associated with increased odds of MH, while age at initial presentation<6 months was associated with a reduced risk of MH (OR=0.39, CI=0.25-0.59; P<0.0005). Other co-variates [any age>6 months (P=0.35), gender (P=0.20) and history of incarceration (P=0.67), prematurity (P=0.94), twins (P=0.13), or ventriculo-peritoneal shunt (P=0.68)] were not associated with MH development. The rate of incarceration in patients who developed a MH was 2/267 (0.7%). CONCLUSION: As the overall rate of metachronous inguinal hernias in children is low (5.2%) and the risk of incarceration is 0.7%, we do not advocate routine contralateral exploration. A primary left-sided hernia is associated with twofold increased odds of developing a contra-lateral hernia, within a median time of 1 year; therefore, this higher risk subpopulation should receive closer follow-up over this time period.

Six thousand three hundred sixty-one pediatric inguinal hernias: a 35-year review.

PURPOSE: This study, by its mere size and uniformity (1 pediatric surgeon), aims to corroborate or refute the teachings and myths of the pediatric inguinal hernia. METHODS: From July 1969 to January 2004, 6361 infants and children with inguinal hernias were seen, operated on, and followed by the senior author. A retrospective survey of their charts was carried out to evaluate the demographics and clinical aspects of these patients. The hospital's research ethics board approved of this study. RESULTS: The ages ranged from premature to 18 years (mean age, 3.3 years) with a male-to female ratio of 5:1. There were 59% right, 29% left, and 12% bilateral hernias (almost all indirect). Hydroceles were found in 19%. Incarceration occurred in 12%. A modified Ferguson repair was used. An opposite-side hernia developed in 5%, 95% within the first 5 years, and was not sex or age specific. There were 1.2% recurrences, 96% within 5 years. Thirteen percent had ventriculo-peritoneal shunts, 1.2% wound infections, and 0.3% testicular atrophy. There were no postoperative deaths. One percent had a documented hernia disappearance. CONCLUSIONS: Three of our results have not corresponded with previous teachings and myths: (1) a hernia of a premature baby should be fixed sooner than later; (2) routine contralateral groin exploration is not indicated in any situation; and (3) teenage recurrence rate is 4 times greater than the overall series.