Pharmacologic labour analgesia and its relationship to postpartum psychiatric disorders: a scoping review.

PURPOSE: This scoping review aimed to summarize the current literature on postpartum psychiatric disorders (e.g., postpartum depression, postpartum anxiety, postpartum post-traumatic stress disorder) and the possible relationship of these disorders to the use of pharmacologic labour analgesia (e.g., epidural analgesia, nitrous oxide, parenteral opioids) to identify knowledge gaps that may aid in the planning of future research. SOURCES: PubMed, PsycINFO, CINAHL, and EMBASE were searched from inception to November 9, 2018 for studies that included both labour analgesia and the postpartum psychiatric disorders specified above. PRINCIPAL FINDINGS: Two reviewers assessed the studies and extracted the data. Of the 990 identified citations, 17 studies were included for analysis. Existing studies have small sample sizes and are observational cohorts in design. Patient psychiatric risk factors, method of delivery, and type of labour analgesia received were inconsistent among studies. Most studies relied on screening tests for diagnosing postpartum psychiatric illness and did not assess the impact of labour analgesia on postpartum psychiatric illness as the primary study objective. CONCLUSIONS: Future studies should correlate screen-positive findings with clinical diagnosis; consider adjusting the timing of screening to include the antepartum period, early postpartum, and late postpartum periods; and consider the degree of labour pain relief and the specific pharmacologic labour analgesia used when evaluating postpartum psychiatric disorders.

RéSUMé: OBJECTIF: Cette étude exploratoire avait pour objectif de résumer la littérature actuelle portant sur les troubles psychiatriques postpartum (par ex., dépression postpartum, anxiété postpartum, état de stress post-traumatique postpartum) et la relation possible de ces troubles avec l'utilisation d'une analgésie pharmacologique pour le travail obstétrical (par ex., analgésie péridurale, protoxyde d'azote, opioïdes parentéraux) afin d'identifier les lacunes dans nos connaissances qui pourraient aiguiller la planification de futures recherches. SOURCES: Des recherches ont été effectuées dans les bases de données PubMed, PsycINFO, CINAHL et EMBASE de leur création jusqu'au 9 novembre 2018 afin d'en extraire les études incluant des informations concernant l'analgésie du travail et les troubles psychiatriques postpartum spécifiés ci-dessus. CONSTATATIONS PRINCIPALES: Deux évaluateurs ont passé en revue les études et extrait les données. Parmi les 990 citations identifiées, 17 études ont été incluses pour analyse. Les études existantes ont de petites tailles d'échantillon et sont conçues comme des cohortes observationnelles. Les facteurs de risque psychiatrique des patientes, le mode d'accouchement et le type d'analgésie reçue pour le travail n'étaient pas uniformes d'une étude à l'autre. La plupart des études s'appuyaient sur des tests de dépistage pour poser un diagnostic de maladie psychiatrique postpartum et n'évaluaient pas l'impact de l'analgésie du travail sur la maladie psychiatrique postpartum comme critère d'évaluation principal. CONCLUSION: Les études futures devraient corréler les résultats positifs au dépistage à un diagnostic clinique; envisager d'ajuster le moment de dépistage afin d'inclure la période antepartum ainsi que les périodes du postpartum initial et tardif; et tenir compte du degré de soulagement de la douleur du travail ainsi que de l'analgésie pharmacologique spécifique utilisée pour le travail lors de l'évaluation des troubles psychiatriques postpartum.

Spuriously raised serum amylase in a five-year-old girl: a note of caution in paediatric blood sampling.

INTRODUCTION: Capillary (finger prick) blood sampling is commonplace in paediatric practice but this method is prone to produce spurious laboratory results. CASE PRESENTATION: A five-year-old girl presented with abdominal pain, epigastric tenderness, tachycardia and reduced oxygen saturation. A venous blood sample haemolysed, and serum amylase on a finger prick sample was reported as 2831 units/L. The working diagnosis was acute pancreatitis and respiratory tract infection. A repeat amylase 9 h later was within the normal range. The patient was known to bite her fingers and the possibility of salivary contamination was considered. Serum isoenzyme analysis confirmed presence of high salivary amylase levels with no pancreatic amylase detected. A viral respiratory tract infection and buried gastrostomy bumper were eventually thought to account for the patient's presentation. CONCLUSION: Increased awareness of the potential for salivary contamination of serum amylase in finger prick samples may prevent misdiagnoses of pancreatitis.

Minimally invasive surgery for superior mesenteric artery syndrome: a case report and literature review.

INTRODUCTION: Superior mesenteric artery syndrome is a rare condition characterised by nausea, vomiting, postprandial pain, anorexia and early satiety. Conservative management is tried initially, but if this fails, surgery is indicated. There are few reports in the literature concerning superior mesenteric artery syndrome in children, and fewer still managed surgically by minimally invasive means. CASE PRESENTATION: A 12-year-old girl presented with weight loss, early satiety and vomiting after corrective scoliosis surgery. After upper gastrointestinal endoscopy, contrast study and computed tomography imaging, a diagnosis of superior mesenteric artery syndrome was made. Conservative management by nasojejunal feeding failed; therefore, a laparoscopic duodeno-jejunostomy was undertaken. At follow-up, her symptoms had improved. CONCLUSION: This report describes the youngest child to undergo laparoscopic duodeno-jejunostomy for superior mesenteric artery syndrome. Laparoscopic duodeno-jejunostomy appears to be the most widely employed and reliable minimally invasive approach to superior mesenteric artery syndrome with a high success rate and acceptably low complication rate.

Intestinal atresia in association with gastroschisis: a 26-year review.

PURPOSE: We reviewed our experience with gastroschisis (GS) complicated by intestinal atresia over the last 26 years. Our aim was to determine the effect of different management strategies employed and the morbidity associated with this condition in our unit. METHODS: A retrospective casenote review was carried out. Data regarding the operative management of the GS and atresia was recorded. Primary outcome measures included time to commence and establish full enteral feeds, duration of parenteral nutrition, complications and outcome. RESULTS: Of 179 neonates with GS, 23 also had intestinal atresia. 13 underwent primary closure of the defect, 5 had patch closure and 5 had a silo placed. 4 atresias were 'missed' at first operation. The 19 recognised atresias were managed either by stoma formation, primary anastomosis or deferred management with subsequent primary anastomosis. There was wide variation in the outcomes of patients in each group. CONCLUSION: Differences in outcome between the management strategies are likely to reflect an inherent variability in patient condition, site of atresia, and bowel suitability for anastomosis at first surgery, rather than the mode of surgical management. Individual management plans should be tailored to the clinical condition of each patient.

A mesothelial-lined cyst: an unusual presentation.

A 12-year-old girl presented with a "threadlike fiber" in her underwear associated with lower abdominal pain. She denied insertion of any foreign body, and at examination under anesthetic, a threadlike substance was seen exiting her external cervical os. Her only medical history was of an open appendicectomy for perforated appendicitis. Subsequent pathologic examination showed a collapsed mesothelial cyst, and laparoscopy showed a cyst and inflammatory changes consistent with previous appendicectomy surrounding her right ovary. We review the possible causes for this most unusual presentation.

Laparoscopic surgery for varicoceles in children: an audit in a single centre.

BACKGROUND: Varicoceles are associated with a time dependent decline in testicular function. The pathophysiology and timing of this remains unclear. However surgery for adolescent varicoceles is a relatively common procedure. There are several treatment options for this condition and in 1999 laparoscopic management was commenced at our institute. We performed an audit to compare our results with those reported in the literature. METHODS: A retrospective case-note review of patients identified from our theater database was performed. We reviewed patient demographics, indications, technique used, grade of surgeon, and outcomes. A review of the literature was carried out to identify a gold standard to compare our results with. RESULTS: Between 1999-2007 we operated on 24 adolescent varicoceles, all left side. Median age was 13.5 years (range 8-16). Indications for surgery included high grade varicocele, discomfort and testicular atrophy. All patients underwent laparoscopic Palomo technique dividing all vessels and lymphatics. The grade of primary operator was consultant (54%) and trainee (46%). Complications included wound infection (4.1%), hydrocele (12.5%), and recurrence (8.3%). We found no consensus view regarding the management of varicoceles in adolescents within the literature; however, our outcomes compared favorably with other published results using the laparoscopic Palomo technique. CONCLUSIONS: Laparoscopic management of varicoceles is safe and effective at our institute. The indications and timing of surgery remain varied. The surgery is performed by both consultants and trainees.

Review of laparoscopic training in pediatric surgery in the United Kingdom.

AIM: To review the exposure pediatric surgery trainees have to laparoscopic surgery in the United Kingdom (UK). METHODS: A confidential postal questionnaire was sent to all trainees working at registrar level in centers responsible for pediatric surgical training in the UK. Questions assessed the number of consultants with an interest in laparoscopic surgery, types of cases performed laparoscopically, and trainees' role in laparoscopic appendicectomy (LA). RESULTS: Questionnaires were sent to 112 trainees with a 55% response rate (62 replies). At least one response was received from each unit. Based on responses, 49 to 67 consultants in 21 training centers have an interest in laparoscopic surgery (0%-100% of consultants per unit). LA was offered in 20 out of 21 training centers. There was no significant difference in the proportion of appendicectomies performed laparoscopically by junior (years 1-3) and senior (years 4-6) trainees. A significantly higher proportion of junior trainees had not performed any LAs (P = 0.02). Seventy-three percent of trainees were the principal operator. For trainees who were principal operators, the cameraperson was a consultant in 52% and a junior trainee in 17%. The time of day affected the likelihood of a procedure being carried out laparoscopically in 43 (81%) responses. CONCLUSIONS: The majority of trainees' exposure to laparoscopic surgery could be viewed as suboptimal; however, the exposure gained varies significantly between different units throughout the UK. In an age moving in favor of minimal access surgery, all units must be in a position to offer pediatric laparoscopic surgical training.

A roadmap for the establishment of pediatric laparoscopic fundoplication.

AIM: The way to introduce laparoscopic fundoplication (LF) to a pediatric surgical unit has not been well described. We have taken a measured approach to introducing LF and report our experience in this paper. METHODS: All patients undergoing LF from the first case in April 2003 to December 2007 were reviewed retrospectively. Cases were identified from theater and discharge databases, and data were captured by using a structured proforma. RESULTS: Eighty-five LFs were performed on 51 males and 34 females, with a median age of 46.5 months (range, 2-218). Fifty-one cases (60%) were neurologically impaired; a further 26 (31%) had significant comorbidity. Seventy-eight (92%) cases were performed by, or under the supervision of, the two senior authors. The first 10 cases were performed under the mentorship of a visiting surgeon from an established pediatric laparoscopic center. Thereafter, LF was conducted as a two- then a one-consultant operation and was finally performed primarily by trainees under consultant supervision. The total number of LFs increased from 4 in 2003 to 29 in 2007. Nine major complications occurred in 8 patients (5 gastric perforations, 1 colonic gastrostomy tube insertion, 1 nasogastric tube sutured into a wrap, 1 midgut, and 1 gastric volvulus). Seven cases required a conversion to an open fundoplication. There was no 30-day mortality. Six patients have died since surgery; in none of the patients was the LF implicated. CONCLUSION: We recommend a measured approach to the introduction of LF with the transition from mentorship to local consultant practice and, finally, to a trainee procedure under consultant supervision. This approach yielded satisfactory results while minimising the disruption to trainee experience.