Inguinal Hernia in Premature Infants: To Operate Before or After Discharge from Hospital?

INTRODUCTION: This study aims to find out the optimal timing for herniotomy for premature infants with inguinal hernia (IH): early during hospitalisation or delayed after hospital discharge. METHOD: A retrospective cohort study was conducted on premature infants diagnosed with IH during their initial hospitalization between 2015 and 2020. Demographic data and clinical outcomes were compared between infants undergoing herniotomy before discharge ("early") and those who were discharged without herniotomy ("delayed"). Student's t-test or Mann-Whitney U test and Fisher's exact test were used for statistical analysis. RESULTS: Of 219 premature infants, 189 (86.3%) underwent early herniotomy, while 30 were discharged with unoperated IH. In the delayed group, 15 (50%) underwent planned delayed herniotomy, and the remaining 15 experienced spontaneous resolution (absence of inguinal bulge over at least 1-year follow-up). The gestational age and birth weight of both groups were similar. At surgery, the delayed group median (interquartile range) was significantly older (42.1[38-49] vs 37.7 [36-40] weeks, p < 0.001) and heavier (3.27 [2.21-4.60] vs 2.22 [2.00-2.70] kg, p < 0.001). Two infants (1%) in the early group presented with incarcerated IH requiring urgent operation. In the delayed group, no infant developed incarcerated IH while awaiting elective operation (time from diagnosis to operation 44 [21-85] days). There was no statistically significant difference in respiratory and surgical complications between the two groups, although the delayed group had lesser surgical complications (0% vs 9.5%). CONCLUSION: Deferring herniotomy after discharge for premature infants is safe with close monitoring and associated with a chance of spontaneous resolution. LEVEL OF EVIDENCE: Level III, treatment study.

Covid-19 Pandemic Strategy for Treatment of Acute Uncomplicated Appendicitis with Antibiotics- Risk Categorization and Shared Decision-Making.

BACKGROUND: During the Coronavirus disease 2019 (COVID-19) pandemic, a protocol was adopted by our department on antibiotics treatment for Acute Uncomplicated Appendicitis (AUA). Our study aimed to determine the feasibility and safety of non-operative treatment (NOT), compared to upfront laparoscopic appendectomy (LA), for AUA in children during the pandemic. METHOD: Our prospective comparative study was conducted from May 1, 2020 to January 31, 2021. Patient selection criteria included: age ≥5 years, abdominal pain duration ≤48 h, ultrasound (US)/Computered Tomography scan confirmation of AUA, US appendiceal diameter 6-11 mm with no features of perforation/abscess collection and no faecolith. For NOT patients, intravenous antibiotics were administered for 24-48 h followed by oral for 10-day course. Comparison was performed between patients whose parents preferred NOT to those who opted for up-front appendectomy. Primary outcomes were NOT success at index admission, early and late NOT failure rates till 27 months. Secondary outcomes were differences in complication rate, hospital length of stay (LOS) and cost between groups. RESULTS: 77 patients were recruited: 43 (55.8%) underwent NOT while 34 (44.2%) patients opted for LA. Success of NOT at index admission was 90.7% (39/43). Overall, NOT failure rate at 27 months' follow-up was 37.2% (16/43). Of the NOT failures, 1 appendix was normal on histology while only 1 was perforated. There were no significant differences in secondary outcomes between both groups except for LOS of late NOT failure. Cost for upfront LA was nearly thrice that of NOT. CONCLUSION: Our stringent COVID protocol together with shared decision-making with parents is a safe and feasible treatment option during a crisis situation. LEVEL OF EVIDENCE: Treatment study, Level II.

Delayed versus early repair of inguinal hernia in preterm infants: A systematic review and meta-analysis.

OBJECTIVES: To evaluate the clinical outcomes of herniotomy in preterm infants undergoing early versus delayed repair, the risk factors for complications, and to identify best timing of surgery. METHODS: Medline, Embase and Central databases were searched from inception until 25 Jan 2021 to identify publications comparing the timing of neonatal inguinal hernia repair between early intervention (before discharge from first hospitalization) and delayed (after first hospitalisation discharge) intervention. Inclusion criteria was preterm infants diagnosed with inguinal hernia during neonatal intensive care unit admission. Results were analyzed using fixed and random effects meta-analysis (RevManv5.4). RESULTS: Out of 721 articles found, six studies were included in the meta-analysis. Patients in the early group had lower odds of developing incarceration [odds ratio (OR) 0.43, 95% confidence interval (CI) 0.34-0.55, I2 = 0%, p < 0.001]; but higher risk of post-operative respiratory complications (OR 4.36, 95% CI 2.13-8.94, I2 = 40%, p < 0.001). No significant differences were reported in recurrence rate (OR 3.10, 95% CI 0.90-10.64, I2 = 0%, p = 0.07) and surgical complication rate (OR 0.94, 95% CI 0.18-4.83, I2 = 0%, p = 0.94) between early and delayed groups. CONCLUSION: While early inguinal hernia repair in preterm infants reduces the risk of incarceration, it increases the risk of post-operative respiratory complications compared to delayed repair. Surgeons should discuss the risks and benefits of delaying inguinal hernia repair with the caregivers to make an informed decision best suited to the patient physiology and circumstances. LEVEL OF EVIDENCE: Treatment study, level 3.

Revisiting testicular torsion scores in an Asian healthcare system.

INTRODUCTION: Testicular pain is a common presentation amongst young boys. It is important to distinguish between testicular torsion and other testicular pathology as testicular viability is dependent on timely diagnosis and surgical intervention. OBJECTIVES: The aim of this study was to evaluate the utility of the TWIST score in our population. Our second objective was to compare a new testicular torsion score (TT score) developed in a paediatric Asian population, with the TWIST score in risk stratification for testicular torsion. Duration of symptoms and delays after presentation were also correlated with testicular viability. METHODS: This is a prospective cohort study of children admitted with testicular pain from January 2016 to December 2018 at a tertiary care hospital in Singapore. Relevant findings such as age, nausea/vomiting, testicular swelling/firmness, absence of cremasteric reflex and abnormal lie were collected. Univariate and multivariate logistic regression was performed to identify significant predictive factors of testicular torsion to generate TT score. RESULTS: A total of 315 patients were involved in this study. Mean age of patients was 121.3 ± 44.2 months. There were 43 patients with testicular torsion. No patients with a TT score of ≤1 were found to have testicular torsion. In contrast, 10 patients with a TWIST score of ≤2 were found to have testicular torsion. Of the patients with testicular torsion, 16 had a TWIST score of ≥5 and 22 had a TT score of ≥6. In this study, the area under the curve was 0.87 for the TWIST score and 0.93 for the TT score. CONCLUSION: In conclusion, the TT score is a reliable score for excluding testicular torsion in an Asian patient population with a sensitivity and negative predictive value of 100% at a cut-off value of ≤1. Both TWIST and TT score performed equally well in early presenters (<6 h) Further prospective validation studies are needed to evaluate the utility of the TT score. Delay in presentation to hospital is the most important determinant of outcome.

A novel noninvasive appendicitis score with a urine biomarker.

PURPOSE: The aim of our study was to develop an appendicitis score incorporating a urine biomarker, Leucine rich alpha-2-glycoprotein (LRG), for evaluation of children with abdominal pain. METHODS: From January to August 2017 we prospectively enrolled children aged 4-16 years old admitted for suspected appendicitis. Urine samples for LRG analysis were obtained preoperatively and quantified by enzyme-linked immunosorbent assay (ELISA) after correction for patient hydration status. The diagnosis of appendicitis was based on operative findings and histology. Logistic regression was used to identify prospective predictors. RESULTS: A total of 148 patients were recruited, of which 42(28.4%) were confirmed appendicitis. Our Appendicitis Urinary Biomarker (AuB) model incorporated urine LRG with 3 clinical predictors: 'constant pain', 'right iliac fossa tenderness', 'pain on percussion'. Area under the ROC curve for AuB was 0.82 versus 0.78 for the Pediatric Appendicitis Score (PAS) on the same cohort of patients. A model-calculated risk score of <0.15 is interpreted as low risk of appendicitis. Sensitivity for the AuB at this cutoff was 97.6%, specificity 37.7%, negative predictive value 97.6%, positive predictive value 38.3%, and negative likelihood ratio 0.06. CONCLUSION: The noninvasive AuB score appears promising as a diagnostic tool for excluding appendicitis in children without the need for blood sampling. TYPE OF STUDY: Study of diagnostic test. LEVEL OF EVIDENCE: Level III.