Long-Term Impact of a Low-Cost Paediatric Intussusception Air Enema Reduction Simulation-Based Education Programme in a Low-Middle Income Country.

INTRODUCTION: Intussusception is one of the commonest causes of bowel obstruction in infants. Most infants in Low- and Middle-Income Countries (LMICs) undergo an invasive operative intervention. Supported by simulation-based education (SBE), the Air Enema (AE) non-operative technique was introduced in 2016 in Myanmar. This study assesses the long-term outcomes. METHODS: Mixed methods study design over 4 years including clinical outcomes and surgeon's attitudes towards the AE technique and SBE. Prospectively collected clinical outcomes and semi-structured interview with reflexive thematic analysis (RTA). Primary outcome measure was a long-term shift to non-operative intervention. SECONDARY OUTCOMES: Length of Stay (LoS), recurrence rates, intestinal resection rates, compared to the operative group. The data was analysed according to intention to treat. Quantitative data analysis with Mann-Whitney U test, Fisher's exact test, Student's T-Test or Wilcoxon Signed-Rank Test utilised. A p-value of <.05 was considered significant. RESULTS: A total of 311 infants with intussusception were included. A sustained shift to AE was revealed with high success rates (86.1-91.2%). AE had a reduced LoS (4 vs. 7 days p ≤ 0.0001), Duration of Symptoms (DoS) was lower with AE (1.9/7 vs. 2.5/7, p = 0.002). Low recurrence rates (0-5.8%) and intestinal resection rates stabilised at 30.5-31.8% vs.15.3% pre-intervention. Four RTA themes were identified: Expanding conceptions of healthcare professional education and training; realising far reaching advantages; promoting critical analysis and reflective practice of clinicians; and adapting clinical practice to local context. RTA revealed an overall positive paradigm shift in attitudes and application of SBE. CONCLUSIONS: A sustained change in clinical outcomes and appreciation of the value of SBE was demonstrated following the intervention.

Parental Views on the Non-Operative Management of Simple Appendicitis in Children: Results of a Cross-Sectional Survey.

BACKGROUND: To determine parental attitudes for the non-operative management of simple appendicitis and determine willingness to participate in research evaluating different management options. METHOD: Voluntary cross-sectional survey of parents/guardians presenting to paediatric outpatient department. Likert scale of 0-10 (strongly disagree-strongly agree) was utilised, analysis by individual question responses. Results are presented as medians [IQR], paired t test, the Mann-Whitney U test and Kruskal-Wallis test analysis as appropriate. A p value of < 0.05 is considered significant. RESULTS: Of 311 respondents, 81% (252/311) completed all the questions. The majority (73%, 220/303) believed that appendicitis needed an urgent operation, and 88% (264/299) believed that perforated appendicitis was a life-threatening condition. Fifty-two per cent (131/252) preferred operative management, and 48% (121/252) preferred antibiotic treatment. The most important factors influencing treatment choice were removal of pain (84%, 246/293), removal of infection (83%, 244/293) and minimising complications (54%, 162/293). Concerns regarding antibiotic treatment included the potential for recurrence (75%, 204/271), the risk of progression (63%, 170/271) and the potential of future surgery (53%, 145/271). The perceived beneficial factors of antibiotic treatment included avoiding surgery, 64% (173/269) and surgical complications 68% (184/269). When asked to consider whether they would participate in clinical research evaluating the two treatment options, parents were equally in favour (39%), against (26%) or unsure (35%). CONCLUSION: Our study demonstrates equipoise in the parental acceptance of antibiotics as a treatment simple appendicitis in children, or participation in research evaluating this topic. However, the important factors that may influence this decision have been identified to guide future conversations.

Current assessment of parental and health professional perception of the colour of neonatal vomiting: Results of a scoping survey.

PURPOSE: To determine current perceptions of doctors, nurses and parents for the colour of a neonatal vomit which should prompt an urgent surgical review. METHODS: A voluntary scoping survey of parents/guardians of patients and non-surgical healthcare professionals was conducted with respondents asked to choose from 8 different selections in a colour swatch from pale yellow to dark green. A control group consisted of 13 paediatric surgeons. Data were analysed using the paired t test, Fishers exact test. A p value of < 0.05 was considered to be significant. RESULTS: 365 participants responded: 36% (131/365) parents, 18% (64/365) nurses and 46% (166/365) doctors. 4/365 (1%) did not state their role. 343 participants completed all questions and responses were analysed using total responses for each question. 82% (121/148) of doctors and 78% (50/64) of nurses had more than 3 years of post-graduate experience. Overall, 63% (227/361) of participants (100% paediatric surgeons, 78% other doctors, 75% nurses/midwives & 30% parents) considered dark and light green vomits to be a sign of intestinal obstruction. 67% (242/361) of participants (100% paediatric surgeons, 72% other doctors, 56% nurses/midwives and 62% parents) believed dark and light green vomiting needed an urgent surgical referral. There were significant differences between the control group and other groups in terms of whether the neonate could wait until the next day for a review; nursing staff (p = 0.0002), postnatal/midwifery (p = < 0.0001), emergency medicine (p = 0.04), general practice (p = 0.002), neonatal (p = 0.0001) and paediatricians (p = 0.005). Only the neonatologists (p = 0.04), nursing staff (p = 0.001) and postnatal/midwifery (p = 0.004) believed that the neonate could have safe observation. CONCLUSION: Although the perception that green vomiting is potentially serious is acknowledged by the majority of healthcare professionals surveyed, there is still a requirement for more targeted educational practices in nursing, midwifery and medical staff.

The application of simulation-based medical education in low- and middle-income countries; the Myanmar experience.

Simulation-based medical education (SBME) has become a routine part of practice in many disciplines including paediatric surgery. There is an evolving evidence base of its benefits both for surgical education, training and also patient education in high-income countries (HICs) but not in the low- and middle-income country (LMIC) setting. The advantages are hypothesised to be the same in both of these settings, although our experience is that they may be increased. In this article we describe the various modalities of SBME that maybe utilised in a LMIC in South East Asia. The various tips for the establishment of a successful simulation-based paediatric surgical programme and the potential pitfall that should be avoided are discussed.

Evidence-based treatment of multicystic dysplastic kidney: a systematic review.

OBJECTIVES: There is a lack of a standardised protocol for the investigation and non-operative management of paediatric multicystic dysplastic kidney (MCDK). Institutional protocols for non-operative management remain essentially ad hoc. The primary outcome of this systematic review is to establish the incidence of hypertension associated with an MCDK. The secondary outcome is to determine the malignancy risk associated with an MCDK. The tertiary outcome is to assess the rate of MCDK involution. Subsequent to these, an evidence-based algorithm for follow-up is described. METHODOLOGY: A systematic review of all relevant studies published between 1968 and April 2017 was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies were identified by specific inclusion and exclusion criteria, all of which included data relevant to the primary, secondary and tertiary outcomes. Hypertension was defined as systolic blood pressure greater than the 95th centile for gender, age and height centile. Subset analysis was performed for hypertension associated with an MCDK. RESULTS: The primary outcome measure revealed a 3.2% (27/838) risk of developing hypertension associated with an MCDK. The secondary outcome measure noted a 0.07% malignancy risk (2/2820). The tertiary outcome measure established that 53.3% (1502/2820) had evidence of involution of the dysplastic kidney. A total of 44 cohort studies (2820 patients) were analysed. CONCLUSION: Given the low risk of hypertension and malignancy, which is similar to the general population, the current conservative non-operative pathway is an appropriate management strategy. An algorithm to help support clinicians with ongoing management is proposed.

Simulation in paediatric urology and surgery, part 2: An overview of simulation modalities and their applications.

Surgical training has changed radically in the last few decades. The traditional Halstedian model of time-bound apprenticeship has been replaced with competency-based training. In our previous article, we presented an overview of learning theory relevant to clinical teaching; a summary for the busy paediatric surgeon and urologist. We introduced the concepts underpinning current changes in surgical education and training. In this next article, we give an overview of the various modalities of surgical simulation, the educational principles that underlie them, and potential applications in clinical practice. These modalities include; open surgical models and trainers, laparoscopic bench trainers, virtual reality trainers, simulated patients and role-play, hybrid simulation, scenario-based simulation, distributed simulation, virtual reality, and online simulation. Specific examples of technology that may be used for these modalities are included but this is not a comprehensive review of all available products.

Is routine excision of testicular remnants in testicular regression syndrome indicated?

BACKGROUND: Undescended testicles are a common finding in full-term male infants. In the majority of these infants, the testicle spontaneously descends in the first year of life. However, in others, it remains impalpable in an abnormal position or there may only be a small abnormal testicular remnant present. For these infants there is still controversy surrounding inguinal exploration and/or excision of these testicular remnants at the time of operative intervention. The controversy centres on their potential future malignant potential. AIM: The aim of the study was to ascertain the incidence of the presence of either germ cells (GCs) or seminiferous tubules (SNTS) in the excised testicular remnants. This was performed at a paediatric surgical tertiary centre and contributes to the evidence base for this condition. METHOD: A retrospective data analysis occurring over a 15-year period of all excised testicular remnants. The testicular remnants were analysed for age, laterality, histological analysis and clinical diagnosis. Subset analysis included subdivision into both intra-abdominal or inguinal positions, and age ranges. Statistical analysis was using Fisher's exact test and a P-value of <0.05 was considered to be significant. RESULTS: A total of 140 paediatric male patients were identified as having had a testicular remnant excised during the study period. Their demographics and also the main results are summarised in the overall summary Table. The mean age at intervention was 3.5 years (range: 3 months to 17 years). A total of 132/140 of the boys underwent excision of an inguinal testicular regression syndrome (TRS) remnant and 8/140 an intra-abdominal remnant. Comparison of these two groups revealed no significant difference for the presence of GCs (12 (9%) vs 2 (25%), P = 0.18). However, intra-abdominal TRS remnants were much more likely to contain SNTs (27 (21%) vs 7 (88%), P = 0.0002). There was no decreased incidence of either GCs or SNTs with increased patient age. DISCUSSION: The main reason for the debate over the management of boys with TRS is the variable incidence of viable germ cells reported in different studies: it has been reported between 0 and 16%. The incidence of GCs (10%) and also SNT (24%) in the present series therefore contributes to this evidence base and is in the middle of this range. It is still unclear as to whether these remnants have a future malignancy risk, as there is only one case of intratubular germ cell neoplasia (ITGCN) in a testicular remnant reported in the literature and this was not immunohistochemically supported. The presence of ITGCN, although considered as a precursor to the development of a testicular germ cell tumour in adult patients, has also not been established in paediatric patients. The natural history of the GCs in TRS specimens is also unknown. In the present series, however, there was no decreased incidence demonstrated with increased patient age, although older patient numbers limited this subset analysis. Despite this controversy, as these patients were already under general anaesthetic, an inguinal exploration and excision of any TRS remnant that was present did not significantly increase the operative procedure or time, and removed any potential malignancy risk. CONCLUSION: This evidence supports the exploration and excision of inguinal testicular remnants, as one in ten boys have GCs present and one in four have SNTs, which may have a potential future malignant transformation risk.

The full spectrum of handlebar injuries in children: a decade of experience.

BACKGROUND: Traumatic paediatric handlebar injury (HBI) is known to occur with different vehicles, affect different body regions, and have substantial associated morbidity. However, previous handlebar injury research has focused on the specific combination of abdominal injury and bicycle riding. Our aim was to fully describe the epidemiology and resultant spectrum of injuries caused by a HBI. METHODS: Retrospective data analysis of all paediatric patients (<18 years) in a prospectively identified trauma registry over a 10-year period. Primary outcome was the HBI, its location and management. The effects of patient age, vehicle type, the impact region, and Injury Severity Score (ISS) were also evaluated. HBI patients were compared against a cohort injured while riding similar vehicles, but not having sustained a HBI. RESULTS: 1990 patients were admitted with a handlebar-equipped vehicle trauma; 236 (11.9%) having sustained a HBI. HBI patients were twice as likely to be aged between 6 and 14 years old compared with non-HBI patients (OR 2.2; 95% CI 1.5-3.2). 88.6% of the HBI patients sustained an isolated injury, and 45.3% had non-abdominal handlebar impact. There were no significant differences in median ISS (p=0.4) or need for operative intervention (OR 1.1; 95% CI 0.9-1.5) between HBI and non-HBI patients. HBI patients had a significantly longer LOS (1.8 days vs. 1.2 days; p=0.001), and more frequently required a major operation (OR 3.4; 95% CI 2.2-5.4). The majority of splenic, renal and hepatic injuries were managed conservatively. CONCLUSIONS: Although the majority of paediatric HBI is associated with both intra-abdominal injury and bicycle riding, it produces a spectrum of potentially serious injuries and patients are more likely to undergo major surgery. Therefore these patients should always be treated with a high degree of suspicion.

Technical aspects of the thoracoscopic repair of a late presenting congenital H-type fistula.

Congenital H-type fistulae are a rare abnormality. They commonly present with only minor respiratory complications and can, therefore, be difficult to identify. Conventionally, correction is via a ligation performed via either a cervical or thoracotomy incision, dependant on the fistula site. Thoracoscopic repair is emerging as a tenable alternative to traditional approaches and offers some advantages. This paper details the technical aspects of the thoracoscopic ligation of an H-type fistula.

Surgical skills training in the laparoscopic era: the use of a helping hand.

The aim of this study was to evaluate whether a training programme involving an assessment exercise performed on a laparoscopic trainer model leads to an improvement in the acquisition of laparoscopic skills in surgical trainees. Subjects were recruited from a cross-section of surgical trainees at the Great Ormond Street Hospital, Department of Surgery and the Institute of Child Health. All subjects completed both a baseline laparoscopic surgical skills questionnaire and three exercises on a new laparoscopic trainer model. Thirteen subjects completed both the baseline questionnaire and all three assessment exercises. These subjects exhibited a wide range of previous experience in laparoscopic surgery. Sixty-nine percent of subjects showed a significant improvement in the assessment exercise score with training (ANOVA; P = 0.01). Sixty-two percent of subjects showed a greater improvement between exercises 2 and 3 than between exercises 1 and 2. The difference in score between exercises 1 and 2 was not statistically significant (P = 0.597), whereas the difference in score between both exercises 2 and 3 and exercises 1 and 3 was statistically significant (P = 0.018 and P = 0.005, respectively). The double glove training model is thus a simple, inexpensive, and easily reproducible tool that elicits a significant improvement in laparoscopic surgical skills in surgical trainees with a broad range of previous laparoscopic experience. It can therefore be used as part of a training programme to facilitate the acquisition of laparoscopic skills in a paediatric surgery setting.

Pilot study of new training model for laparoscopic surgery.

The aim of this study was to evaluate whether an assessment exercise performed on a laparoscopic trainer model reliably reflects previous laparoscopic experience and can therefore be used to accurately assess laparoscopic skills in surgical trainees. Subjects were recruited from a cross-section of surgical trainees and students at the Great Ormond Street Hospital for Children and the Institute of Child Health. Subjects were required to complete a baseline laparoscopic surgical skills questionnaire and an exercise on a new laparoscopic trainer model. Nine subjects completed both the baseline questionnaire and the exercise. These subjects exhibited a wide range of previous experience in laparoscopic surgery. Subjects with higher self-assessment scores had the lowest exercise scores (i.e. better scores; P=0.003). Furthermore, the exercise score was strongly negatively correlated with the baseline number of training modalities received (P=0.007) and the laparoscopic experience score (P=0.027). The assessment exercise on a novel laparoscopic trainer was capable of differentiating between subjects with little laparoscopic experience and those with more extensive previous laparoscopic training. The correlation between the exercise score and measured baseline variables suggests that the scoring system used in this model is sensitive and specific to measuring skills relevant to laparoscopic surgery.