Introduction of paediatric laparoscopic cholecystectomy in Scotland: a national review of incidence, outcomes and training implications.

BACKGROUND: We present a national data series to determine the incidence, outcomes and training opportunities for laparoscopic cholecystectomy among children <16yrs in Scotland as performed by paediatric surgeons. METHODS: A retrospective cohort study was performed reviewing laparoscopic cholecystectomy performed at the three children's hospitals in Scotland. Using the National Records Scotland Database mid-year population estimates; age and sex specific annual incidence rates of laparoscopic cholecystectomy were calculated between 1998-2015. Trends in the observed case mix were tested using univariate linear regression and students t-test. RESULTS: Between 1998-2015; 141 paediatric laparoscopic cholecystectomies were performed. The annual rate of cholecystectomy increased from 0.10/100,000 to 0.88/100,000 (p = 0.069). Sex specific incidences were identified; 0.00-0.90/100,000 (p = 0.098) in girls and 0.20-0.86/100,000 in boys (p = 0.28). Cholecystectomy was more frequent in girls (63%; p = 0.04). No major complications, defined as common bile duct injury or mortality were identified. Overall; 75% of cases were performed by consultants (n = 17 consultants, median = 5 cases, p < 0.05) and 25% by trainees. CONCLUSION: We have demonstrated that despite a low national case load (8 laparoscopic cholecystectomies per year) paediatric surgeons have been able to perform laparoscopic cholecystectomy safely without major morbidity.

Limits to sustained energy intake XXIV: impact of suckling behaviour on the body temperatures of lactating female mice.

The objective of this study was to investigate the potential causes of high body temperature (Tb) during lactation in mice as a putative limit on energy intake. In particular we explored whether or not offspring contributed to heat retention in mothers while suckling. Tb and physical activity were monitored in 26 female MF1 mice using intraperitoneally implanted transmitters. In addition, maternal behaviour was scored each minute for 8 h d(-1) throughout lactation. Mothers that raised larger litters tended to have higher Tb while nursing inside nests (P < 0.05), suggesting that nursing offspring may have influenced heat retention. However, Tb during nursing was not higher than that recorded during other behaviours. In addition, the highest Tb during the observation period was not measured during nursing behaviour. Finally, there was no indication that mothers discontinued suckling because of a progressive rise in their Tb while suckling. Tb throughout lactation was correlated with daily increases in energy intake. Chronic hyperthermia during lactation was not caused by increased heat retention due to surrounding offspring. Other factors, like metabolic heat produced as a by-product of milk production or energy intake may be more important factors. Heat dissipation limits are probably not a phenomenon restricted to lactation.

Paediatric femoral hernia--the diagnostic challenge.

INTRODUCTION: Femoral herniae are uncommon in childhood and pre-operative misdiagnosis is common. This can result in increased complications or inappropriate inguinal exploration. The aim of this retrospective study was to assess a tertiary centre's experience with paediatric femoral hernia over a 12 year period. METHODS: Children who underwent femoral hernia repair at a single centre were identified from a prospectively maintained database. Casenotes were reviewed for demographic data and details of presentation, operation and recurrence. RESULTS: Sixteen children with a median age of 7 (range 3-16) years were identified. One patient developed bilateral femoral herniae. All children were referred with a groin lump but in only one instance did the referring clinician establish the diagnosis of femoral hernia. Emergency repair was required in 2 patients (12%). Eleven femoral herniae were diagnosed following clinical assessment ultrasound. The remainder were identified intra-operatively following negative inguinal exploration. Intra-operatively the femoral canal was closed with sutures (n = 16) or mesh plug (n = 1). Only one patient had a laparoscopic repair. Two other patients underwent laparoscopy to confirm bowel viability (n = 1) and for inguinal canal assessment with subsequent open femoral hernia repair (n = 1). All patients were reviewed in surgical clinic and no morbidity or hernia recurrences were reported. CONCLUSION: Femoral herniae are a diagnostic challenge and a high index of clinical suspicion is necessary. Ultrasonography or laparoscopy may be appropriate in equivocal cases. The long-term results of paediatric femoral hernia surgery are excellent.

Regionally acquired intestinal failure data suggest an underestimate in national service requirements.

UNLABELLED: OBJECTIVES, SETTING AND PATIENTS: With complete case referral for prolonged parenteral nutrition (PN) beyond term equivalent, serving a stable population of 1.25 million people, we describe the long-term outcome and survival of patients referred to an intestinal failure (IF) nutrition support team over the first 8 years of existence at a regional paediatric centre, and extrapolate to potential numbers of national home parenteral nutrition (HPN) cases and intestinal transplantation data. DESIGN AND OUTCOME MEASURES: Retrospective analysis detailing patient demographics, interventions, use of HPN, occurrence of intestinal failure-associated liver disease (IFALD), and outcomes of enteral adaptation, survival, and referral for and receipt of organ transplantation. RESULTS: 23 patients were referred over 8 years, 20 being PN dependent within the neonatal period. Diagnoses included short bowel syndrome (SBS) (18), neuromuscular abnormalities (4) and congenital enterocyte disorder (1). 12 696 days of PN were delivered with 314 confirmed episodes of sepsis at a median of 12 episodes per patient. 144 central venous catheters (CVCs) were required at a median of four per patient. IFALD occurred in 17 (73%) patients, with 10 (44%) referred for transplant assessment. Thirteen (56%) children received HPN. Overall mortality was 44%. A significant predictor for survival in the SBS group was residual bowel >40 cm (82% vs 28%, p = 0.049). CONCLUSIONS: Survival for IF at 56% was lower than reported from non-UK supra-regional centres, and nationally collected data, possibly reflecting pre-selected referral populations. Data from regional centres with complete ascertainment may be important both when counselling parents and when planning regional and national HPN and IF specialist services.

Analyses of livestock production, waste storage, and pathogen levels and prevalences in farm manures.

Survey results describing the levels and prevalences of zoonotic agents in 1,549 livestock waste samples were analyzed for significance with livestock husbandry and farm waste management practices. Statistical analyses of survey data showed that livestock groups containing calves of <3 months of age, piglets, or lambs had higher prevalences and levels of Campylobacter spp. and Escherichia coli O157 in their wastes. Younger calves that were still receiving milk, however, had significantly lower levels and prevalence of E. coli O157. Furthermore, when wastes contained any form of bedding, they had lowered prevalences and levels of both pathogenic Listeria spp. and Campylobacter spp. Livestock wastes generated by stock consuming a diet composed principally of grass were less likely to harbor E. coli O157 or Salmonella spp. Stocking density did not appear to influence either the levels or prevalences of bacterial pathogens. Significant seasonal differences in prevalences were detected in cattle wastes; Listeria spp. were more likely to be isolated in March to June, and E. coli O157 was more likely to be found in May and June. Factors such as livestock diet and age also had significant influence on the levels and prevalences of some zoonotic agents in livestock wastes. A number of the correlations identified could be used as the basis of a best-practice disposal document for farmers, thereby lowering the microbiological risks associated with applying manures of contaminated livestock to land.

Early appendicitis--a safe diagnosis?

INTRODUCTION: Serosal inflammation of the appendix in association with a significant peritoneal exudate can be mistaken for early acute appendicitis. We highlight the importance of looking for other sources of intra-abdominal sepsis in this clinical setting. CLINICAL PICTURE: We present 3 cases of so-called "mild" appendicitis with serosal inflammation that was ultimately shown to be caused by Meckel's diverticulitis. TREATMENT: All 3 patients initially underwent an appendicectomy. In 2 of these cases, a further laparotomy and excision of a Meckel's diverticulum was carried out. All 3 made an uneventful recovery. CONCLUSION: Meckel's diverticulitis can mimic acute appendicitis in clinical history, physical findings and operative findings. It is important to always consider this as a possible cause for an acute abdomen.

A critical role for the parabrachial nucleus in generating central nervous system responses elicited by a systemic immune challenge.

Using Fos immunolabelling as a marker of neuronal activation, we investigated the role of the parabrachial nucleus in generating central neuronal responses to the systemic administration of the proinflammatory cytokine interleukin-1beta (1 microg/kg, i.a.). Relative to intact animals, parabrachial nucleus lesions significantly reduced the number of Fos-positive cells observed in the central amygdala (CeA), the bed nucleus of the stria terminalis (BNST), and the ventrolateral medulla (VLM) after systemic interleukin-1beta. In a subsequent experiment in which animals received parabrachial-directed deposits of a retrograde tracer, it was found that many neurons located in the nucleus tractus solitarius (NTS) and the VLM neurons were both retrogradely labelled and Fos-positive after interleukin-1beta administration. These results suggest that the parabrachial nucleus plays a critical role in interleukin-1beta-induced Fos expression in CeA, BNST and VLM neurons and that neurons of the NTS and VLM may serve to trigger or at least influence changes in parabrachial nucleus activity that follows systemic interleukin-1beta administration.

Laparoscopic Nissen fundoplication in children: 2-5-year follow-up.

PURPOSE: This study aims to document the current status of a cohort of children who underwent laparoscopic fundoplication at a single centre between 1996 and 1998. METHODS: Parents were contacted and a questionnaire regarding preoperative and current symptoms completed. Case notes were reviewed for results of postoperative investigations. RESULTS: Forty-five laparoscopic Nissen fundoplications were performed. The median age was 5 years. Twenty-eight children were neurologically impaired. Five died of underlying medical problems during follow-up. Two were lost to follow-up, leaving 38 parents interviewed. Median follow-up was 36 months. Twenty-five children were asymptomatic, and 13 reported upper gastrointestinal symptoms. In ten, symptoms were less severe than preoperatively. Nine of the 13 children were taking acid suppressing drugs. No children reported problems with dysphagia. Twelve of the 13 symptomatic children had investigations for recurrent reflux. In no case was there evidence of reflux or wrap disruption. One of the children who died had been demonstrated to have recurrent reflux on barium swallow. CONCLUSIONS: Sixty-six percent of patients reported complete relief, and a further 26% reported considerable improvement of their symptoms. There was a high degree of parental satisfaction with the outcome of the operation. The results suggest that laparoscopic fundoplication is a durable procedure with documented recurrent reflux in only 2% of children at a median follow-up of 3 years.

Troubles with the foreskin: one hundred consecutive referrals to paediatric surgeons.

To assess the reasons for and outcomes of referrals concerning the foreskin, 100 consecutive patients seen in paediatric clinics were followed to discharge. 18 referrals were for circumcision on religious grounds. Of the other 82, the main reason for referral was non-retractability or phimosis. At clinic, 24 (29%) of these were deemed normal for age, 31 (38%) were treated with topical steroid (successfully in 25), 9 (11%) were listed for preputioplasty, 7 (9%) were listed for adhesiolysis, 7 (9%) were listed for circumcision, and 4 were listed for other forms of surgery. 6 patients were identified as having balanitis xerotica obliterans (BXO), a condition that had not been suggested on referral. With the advent of new treatments for foreskin disorders, circumcision is decreasingly necessary. Knowledge of the natural history of the foreskin, and the use of topical steroids, could shift the management of paediatric foreskin problems from the hospital outpatient department to primary care. BXO is not sufficiently recognized as a form of phimosis that requires operation.

The role of laparoscopy in the management of lower gastro-intestinal bleeding.

This report describes three cases of significant lower gastro-intestinal haemorrhage caused by a bleeding Meckel's diverticulum. In the first two cases a pre-operative technetium-pertechnetate or Meckel's scan was negative or inconclusive, and in the third case no Meckel's scan was carried out. The diagnosis was established at laparoscopy in all three cases and in each case the diverticulum was excised extracorporeally.

Congenital colonic atresia: should primary anastomosis always be the goal?

We report 4 cases of the rare condition, congenital colonic atresia, presenting over 9 years. Two patients had dilated loops of bowel noted on routine ante-natal ultrasound. Three had primary anastomosis for lesions in transverse or distal descending colon and one had a staged procedure with colostomy formation. All had type III atresia. One patient had an early leak following primary colo-colic anastomosis for atresia extending from the hepatic flexure to the sigmoid colon. If it is desired to preserve the proximal colon in a right sided lesion with significant loss of colonic length then primary anastomosis may not be safe and we would advocate a staged procedure. Otherwise we would support current moves towards primary anastomosis in this condition. We also urge early investigation in all patients who exhibit intestinal dilatation on antenatal ultrasound.

Factors influencing the shedding of verocytotoxin-producing Escherichia coli O157 by beef suckler cows.

A study was designed to investigate management factors that might influence the shedding of verocytotoxin-producing Escherichia coli (VTEC) O157 by beef cows in Scotland, where there is a particularly high rate of human infection. Thirty-two herds were visited at least monthly over approximately 1 year for collection of fresh faecal pat samples and information on management factors. The faecal pat samples were tested for VTEC O157 by established culture and immunomagnetic separation methods. Questionnaires were completed at the monthly visits to record management factors. Data were analysed using both univariate and multi-factor (GLMM) analysis. Changes in the number of cows in a group, dogs, wild geese, housing, and the feeding of draff (distillers' grains) were statistically significant as risk factors. The event of calving appeared to reduce the likelihood of shedding. Any effects of weaning or turnout were not statistically significant. It appears that the rate of shedding of VTEC O157 is influenced by several factors but possibly the most important of these are the circumstances of animals being housed, or, when outside, the presence of wild geese.

Urinary ascites in infancy: varied etiologies.

Three cases of urinary ascites are presented, each with a different underlying aetiology. The age and modes of presentation also varied and management strategies were accordingly tailored to each patient's clinical requirements. All 3 patients survived and subsequently were discharged with good renal function. Although a rare condition, infants with urinary ascites can present as clinical emergencies in need of prompt resuscitation with subsequent drainage of the urine and decompression of the urinary tract. The ultimate management regime will vary and depend upon site of urinary extravasation and underlying aetiology.

The addition of antiemetics to the morphine solution in patient controlled analgesia syringes used by children after an appendicectomy does not reduce the incidence of postoperative nausea and vomiting.

BACKGROUND: We studied the effect of intraoperative ondansetron 0.1 mg x kg(-1) or droperidol 0.01 mg.kg-1, followed by the same dose of the antiemetic agent added to the morphine solution during patient controlled analgesia (PCA) on the incidence of nausea and vomiting in children following an appendicectomy. METHODS: Sixty children, aged 5-13 years, were recruited and randomly allocated to receive no prophylactic antiemetic, the control group (group C), ondansetron (group O) or droperidol (group D). The PCA pump was programmed to deliver a bolus dose of 20 microg x kg(-1) of morphine.with a 5-min lockout period and a background infusion of 4 microg x kg(-1) x h(-1). RESULTS: Postoperatively, the three groups were compared for nausea, vomiting and sedation scores for 24 h. The incidence of postoperative nausea and vomiting was 33% for group C, 44% for group O and 41% for group D. There was no increase in sedation scores in the droperidol group. CONCLUSIONS: We were unable to show any significant benefit from the prophylactic administration of ondansetron or droperidol to children using morphine PCA devices following appendicectomy in the doses we employed.

Contralateral groin exploration is not justified in infants with a unilateral inguinal hernia.

BACKGROUND: In children undergoing a unilateral inguinal herniotomy, the contralateral groin is often explored on the basis of a high incidence of patency of the processus vaginalis. The patency rate is highest in infants but there are no data on the subsequent risk of contralateral hernia development purely in this population. This was a study of the incidence of contralateral inguinal hernia following unilateral inguinal herniotomy in infancy (aged less than 1 year). METHODS: All infants who underwent a unilateral inguinal herniotomy between January 1986 and December 1991 were studied retrospectively. RESULTS: One hundred and eighty-one infants (165 boys and 16 girls) were studied. Median gestational age was 37 (range 25-42) weeks and median age at operation was 87 (range 1-365) days. The herniotomy was right sided in 82.9 per cent of infants. Follow-up ranged from 5 to 10 years. A contralateral hernia/hydrocele developed in 14 infants (7.7 per cent). None of the hernias was incarcerated. Median time from operation to occurrence of the contralateral hernia was 18 (2-67) months. Gestational age, sex and the side of the hernia did not influence the incidence of contralateral hernia development. CONCLUSION: The low incidence of contralateral hernia development in infants undergoing a unilateral inguinal herniotomy does not justify routine contralateral groin exploration.

An audit of post-pyloromyotomy feeding regimens.

A retrospective audit was carried out to assess patient outcome in relation to the timing of feeding after pyloromyotomy for hypertrophic pyloric stenosis. Fifty-two patients received the first feed within 8 hours of surgery and 49 patients were fed between 13 and 20 hours post-operatively. Seventy-seven per cent of patients in the early group vomited compared to 53% in the late group. Sixty-one per cent of patients in the early group produced large vomits compared to 29% in the late feeding group. However, time to establish feeding and post-operative stay were comparable in both groups. We recommend feeding to be delayed for 12 hours after pyloromyotomy unless the patient is distressed because of hunger in which case the parents are warned of the increased risk of vomiting.