Repair of oesophageal atresia by consultants and supervised trainees results in similar outcomes.

INTRODUCTION: Consultants and trainees require exposure to complex cases for maintaining and gaining operative experience. Oesophageal atresia (OA) repair is a neonatal surgical procedure with indicative numbers for completion of training. A conflict of interest may exist between adequate training, maintaining consultant experience and achieving good outcomes. We aimed to review outcomes of procedures performed primarily by trainees and those performed by consultants. METHODS: We carried out a retrospective case note review of all consecutive infants who underwent surgical repair of OA with distal tracheooesophageal fistula (TOF) between January 1994 and December 2014 at our institution. Only cases that underwent primary oesophageal anastomosis were included. Surgical outcomes were compared between cases that had a trainee and those that had a consultant listed as the primary operator. RESULTS: One hundred and twenty-two cases were included. A total of 52 procedures were performed by trainees, and 68 by consultants. Two cases were undeterminable and excluded. Infant demographics, clinical characteristics and duration of follow-up were similar between groups. All infants survived to discharge. Procedures performed by trainees and those performed by consultants as primary operators had a similar incidence of postoperative pneumothorax (trainees 4, consultants 3; p=0.46), anastomotic leak (trainees 5, consultants 3; p=0.29) and recurrent TOF (trainees 0, consultants 2; p=0.5). Overall 52% of cases had an anastomotic dilatation during follow-up, with no difference between the trainee and consultant groups (50% vs 53%; p=0.85). CONCLUSIONS: Surgical outcomes for repair of OA/TOF are not adversely affected by trainee operating. Trainees with appropriate skills should perform supervised OA/TOF repair. These data are important for understanding the interrelationship between provision of training and surgical outcomes.

Testicular atrophy following paediatric primary orchidopexy: A prospective study.

BACKGROUND: With the Nordic consensus statement advocating orchidopexy at an earlier age, the present study sought to investigate the outcomes of primary paediatric orchidopexy at a tertiary UK centre. OBJECTIVE: To prospectively assess testicular atrophy following primary orchidopexy for undescended testes in a paediatric population. Secondary outcomes were complication rates and whether outcomes were dependent on grade of operating surgeon. STUDY DESIGN: Prospective data regarding age at operation, classification of the undescended testis, length of follow-up, and subjective comparison of intraoperative and postoperative testicular volumes compared with the contralateral testis were collected. Testicular atrophy was defined as >50% loss of testicular volume or a postoperative testicular volume <25% of the volume of the contralateral testis. Patients were excluded for incomplete data and follow-up <6 months. RESULTS: Data for 234 patients were analysed. Testicular atrophy occurred in 2.6% of cases. There was no reported testicular re-ascent. All secondary acquired cases underwent a previous ipsilateral hernia repair. There was no significant difference in outcomes comparing the grade of surgeon (consultant n = 8, trainee/staff-grade surgeon n = 7-8). There was a trend towards postoperative catch-up growth in approximately one fifth of cases. DISCUSSION: Previous studies have reported a testicular atrophy rate of 5%. The present study reported a similar rate of 2.6%. In agreement with a previous publication, it was also found that testicular atrophy was not dependent on the grade of operating surgeon. The mechanism for testicular catch-up growth is not well understood. Animal studies have supported the hypothesis that increased temperature has a detrimental effect on testicular volume. However, follow-up in the present cohort was short (median 6.9 months), making interpretation of this finding difficult. It is acknowledged that clinical palpation alone to determine testicular volume potentially introduces intra-observer and inter-observer error. However, prospective studies using ultrasound to determine testicular volumes following orchidopexy have reported catch-up growth. CONCLUSION: This study represented one of the larger collections of prospective assessments of outcomes following primary orchidopexy. It was acknowledged that subjectively assessing testicular volume is not ideal; however, the data correlated with similar studies.

Scope and feasibility of operating on the neonatal intensive care unit: 312 cases in 10 years.

PURPOSE: To report the scope, feasibility and learning experience of operating on neonates on the neonatal intensive care unit (NICU). METHODS: (1) Review of all NICU operations performed by general neonatal surgeons over 10 years; (2) 6-month prospective comparison of procedures performed in NICU or operating room; (3) structured interviews with five surgeons with 1-13 years experience of operating on NICU. RESULTS: 312 operations were performed in 249 infants. Median birth weight was 1,494 g (range 415-4,365), gestational age 29 weeks (22-42), and age at operation 25 days (0-163). Nearly half (147) were laparotomy for acute abdominal pathology in preterm, very low birth-weight infants There were no surgical adverse events related to location of surgery. Surgeon satisfaction with operating on NICU for this population was high (5/5). Several factors contribute to making this process a success. CONCLUSIONS: This is the largest reported series of general neonatal surgical procedures performed on NICU. Operating on NICU is feasible and safe, and a full range of neonatal operations can be performed. It removes risks associated with neonatal transfer and is likely to reduce physiological instability. We recommend this approach for all ventilated neonates and urge neonatal surgeons to operate at the cotside of unstable infants.

Trans-anastomotic tubes reduce the need for central venous access and parenteral nutrition in infants with congenital duodenal obstruction.

PURPOSE: To determine the effect of trans-anastomotic tube (TAT) feeding on outcome following repair of congenital duodenal obstruction (CDO). METHODS: Retrospective comparative study of all infants with CDO over 10 years. Data are median (range). Mann-Whitney U test and Fisher's exact test were used. RESULTS: Of 55 infants with CDO (48 atresia, 7 stenosis), 17 were managed with a TAT, 38 without. Enteral feeds were commenced earlier in infants with a TAT compared to those without (TAT 2 days post-repair [1-4] vs. no-TAT 3 days post-repair [1-7]; p = 0.006). Infants with a TAT achieved full enteral feeds significantly sooner than those without (TAT 6 days post-repair [2-12] vs. no-TAT 9 days post-repair [3-36]; p = 0.005). Significantly fewer infants in the TAT group required central venous catheter (CVC) placement and parenteral nutrition (PN) than in the no-TAT group (TAT 2/17 vs. no-TAT 28/38, p < 0.0001). There were six CVC-related complications (5 infections, 1 PN extravasation) and four TATs became displaced and were removed before achieving full enteral feeds. One infant with a TAT with trisomy 21 and undiagnosed Hirschsprung disease developed an anastomotic leak and jejunal perforation requiring re-operation. CONCLUSIONS: A TAT significantly shortens time to full enteral feeds in infants with CDO significantly reducing the need for central venous access and PN.

"Stretching the limits of laparoscopic surgery": two-stage laparoscopic liver resection.

INTRODUCTION: The safety and feasibility of laparoscopic liver resections have recently been confirmed. This has encouraged laparoscopic surgeons to widen the indications and push the boundaries in laparoscopic liver resections. However, a complete laparoscopic two-stage liver resection has not been reported previously. AIM: The aim of this work was to assess the feasibility and safety of the two-stage laparoscopic liver resection for metastatic disease. METHODS: The two-stage laparoscopic liver resection was safely performed in a 58-year-old man with colorectal liver metastasis (one in segment 2/3 and one in the right lobe). A left lateral sectionectomy was first performed, followed by right portal vein embolization 1 week later, and a nonanatomic resection of the right liver was performed after 6 weeks. CONCLUSIONS: Laparoscopic liver surgery is gaining popularity and major procedures can now be performed in centers with wide experience. The laparoscopic approach should always be considered for left lateral sectionectomy, and in selected cases, a complete laparoscopic two-stage resection can safely be performed.

Patterns of management of intussusception outside tertiary centres.

BACKGROUND/PURPOSE: Intussusception is a common problem in young children and should have an excellent outcome in expert hands. Many children are treated in district general hospitals (DGH), which do not have specialist paediatric surgeons. The aim of this study was to clarify current patterns of management for such patients. METHODS: The authors conducted a postal survey of DGH consultant paediatricians, radiologists, and general surgeons in a populous region of England. RESULTS: One hundred forty-one (44%) consultants who responded comprised similar proportions of consultants from each specialty. Most respondents (79%) thought that in their location paediatricians should take responsibility for resuscitation of children with suspected intussusception. Two-thirds indicated that abdominal ultrasound scan, either alone or in combination with another modality, was their investigation of choice for confirming the diagnosis. Preferences for contrast medium for radiologic reduction varied; paediatricians favoured air (46%) or saline (28%), surgeons preferred water-soluble contrast (58%), and radiologists preferred to use barium (49%). Fifty-three percent of consultants indicated they would transfer a child with confirmed intussusception to a tertiary centre before attempting reduction, 42% would attempt reduction locally, and 5% would operate locally without attempting radiologic reduction. After failed reduction, a further 23% of consultants would consider transfer, but the remainder would operate locally. Only 13% of paediatricians thought that their surgeons had appropriate facilities and support to operate on intussusception, but 36% of surgeons claimed to be doing so. Most consultants (84%) admitted seeing fewer than 5 cases per year; 98% of surgeons were in this group. Only 16% of consultants (mostly paediatricians) were aware of any written clinical policy for managing paediatric intussusception in their hospital. CONCLUSION: This study shows that the management of paediatric intussusception outside tertiary centres is not uniform or standardised, and that improvements are necessary. J Pediatr Surg 36:312-315.

Oral contrast with computed tomography in the evaluation of blunt abdominal trauma in children.

BACKGROUND: The use of oral contrast in evaluating children by computed tomography (CT) following blunt trauma is controversial. The aim of this study was to evaluate retrospectively the use of oral contrast with abdominal CT in children with suspected abdominal injury. METHODS: The medical records of 101 children who underwent CT for abdominal trauma between 1993 and 1997 were reviewed for data pertaining to the mechanism of injury, clinical findings and management. Scans were reviewed by a paediatric radiologist and criteria of intestinal injury on CT described by Cox and Kuhn were used: (1) extraluminal air or contrast material, (2) focal area of thickening of bowel wall and mesentery, and (3) free intraperitoneal fluid in the absence of solid organ injury. RESULTS: CT was performed within a median time of 2.4 (range 1-48) h after the injury. On 37 (62 per cent) of 60 scans in children who had oral contrast, the duodenum was not opacified after a mean delay of 30 min. Intestinal injury was suspected on CT in four children. In two children with CT evidence of intestinal injury (with/without oral contrast) rupture of the duodenojejunal flexure (n = 1) or ileal perforation (n = 1) was found at laparotomy. Two children had a false-positive scan, leading to negative laparotomy; one scan with oral contrast incorrectly suggested a duodenal leak and in another child CT without oral contrast showed thickening of bowel wall with free intraperitoneal fluid but no specific intestinal injury was identified at laparotomy. One patient had two negative CT scans (with and without oral contrast) and underwent laparotomy for clinical suspicion of bowel injury; rupture of the splenic flexure of the colon was found at laparotomy. CONCLUSION: CT is not reliable for diagnosing intestinal injuries and this is not improved by use of oral contrast. Omission of oral contrast was not associated with delay in the diagnosis of intestinal injury. Since intestinal injuries are uncommon in children, a prospective multicentre study would determine more precisely the role of the routine use of oral contrast.

Management of the impalpable testis: the role of laparoscopy.

PURPOSE: To evaluate the use of laparoscopy in the management of the impalpable testis. DESIGN: A retrospective analysis of the clinical findings, interventions, and outcome in 87 consecutive boys undergoing laparoscopy for 97 impalpable testes. RESULTS: Fifty seven testes were either absent (n = 35) or present as a small remnant (n = 22), which was removed at contemporaneous groin exploration. There were 27 intra-abdominal testes, including four hypoplastic testes, which were removed laparoscopically. The 13 remaining viable testes were located in the groin. Conventional orchidopexy followed laparoscopy for 21 testes, and was successful in 17 cases. Two stage laparoscopically assisted Fowler Stevens orchidopexies were performed for 13 intra-abdominal testes, with eight satisfactory results. Ultrasound evaluation significantly reduced the number of conventional orchidopexies following laparoscopy. IMPLICATIONS: Laparoscopy is a rational and safe approach for precise localisation of the impalpable testis. Laparoscopically assisted two stage orchidopexy is a successful treatment procedure for intra-abdominal testes.