Femoral hernias: A paediatric surgical enigma.

PURPOSE: In the paediatric population, femoral hernia (FH) represents an uncommon and often misdiagnosed pathology. This study aimed to review our experience with the management of FH in children. METHODS: Medical records were retrospectively reviewed for all patients presenting to the paediatric surgical service in Ireland over a 15-year period (2004-2019), who were operated on for FH. Collected data included demographics, preoperative diagnosis, operative details, complications and follow-up. RESULTS: During the study period, n = 26 patients (n = 18 males) underwent FH repair, with a median age at surgery 6.9 years (range 3-16 years). During the same period n = 5693 patients underwent inguinal herniotomy, resulting in a FH to inguinal hernia (IH) ratio of 1:219 and a FH incidence of 0.45% of all groin hernias. The right side was affected in n = 18 (69.2%) cases and all cases were unilateral. A correct preoperative diagnosis was established in n = 16 (61.5%) cases, n = 8 (30.8%) cases were misdiagnosed as IH and the diagnosis was equivocal in 2 cases (7.7%). All operations were performed on an elective basis. In 3 patients from the misdiagnosed group, FH was found at first operation following negative groin exploration for IH. The remaining 5 patients underwent previous groin exploration for suspected IH and represented with clinical picture of groin hernia recurrence. All patients with a correct preoperative diagnosis underwent a FH repair via an inguinal or infra-inguinal approach. The content of the hernia sac was preperitoneal fat in n = 18 cases, lymph nodes in n = 2 cases, omentum in n = 1 and an empty sac in n = 1. There were no postoperative complications or recurrences. Median follow-up time was 6 weeks (range 0-2.5 years). CONCLUSION: In the paediatric population, FH is a rare pathology and can be a challenging diagnosis. FH is commonly misdiagnosed as IH and may require more than one operation to correctly identify and treat. A high index of suspicion of FH should be maintained in patients who have a negative groin exploration for IH in the setting of a clear pre-operative diagnosis of a groin hernia. FH should also be considered in the differential diagnosis when an IH appears to recur.

Adolescent de novo hydroceles - should they be dealt with by inguinal or scrotal approach?

AIM: The objective of this study was to investigate the optimal approach for the treatment of hydroceles in adolescents. MATERIALS AND METHODS: A retrospective chart review of all adolescents (10-16 years old) diagnosed with a de-novo hydrocele in 2 tertiary care institutions over a 10 year period (2007-2016) was performed comparing the inguinal and trans-scrotal (Jaboulay) approaches. RESULTS: Fifty-three boys with a mean age of 13.4 years (range 10-16 years) were diagnosed with hydrocele. The inguinal approach was used in 31 (59%) patients for treatment of their hydrocele. In 19 (61%) of these cases a patent processus vaginalis (PPV) ligation was performed. In the other 12 (39%) patients the PPV was closed or not found and a further repair of the hydrocele through the same inguinal incision was performed. A transcrotal Jaboulay procedure was performed in 22 (41%) of the patients. There was no difference in the complications rate between inguinal and trans-scrotal approaches (p = 0.71). Age of presentation less than 12 years was associated with the presence of a PPV (p < 0.05). CONCLUSIONS: A trans-scrotal approach should be considered as first-line in adolescents when the history is not suggestive of a communicating hydrocele. Children less than 12 years of age are more likely to have a PPV and an inguinal approach may be more appropriate. TYPE OF STUDY: Retrospective comparative study LEVEL OF EVIDENCE: Level II.

Open tunneled central line insertion in children - External or internal jugular vein?

BACKGROUND/PURPOSE: Tunneled central venous catheters (TCVCs) are commonly used to manage pediatric patients with chronic disease. The aim of this study is to compare the outcomes of external jugular vein (EJV) and internal jugular vein (IJV) tunneled catheters inserted using the open technique. METHODS: This is a single institution retrospective analysis of patients requiring an IJV or EJV TCVC in the period between 2009 and 2014. Data collected included the following: patient demographics, site/side of insertion, catheter size, number of lumens, duration of catheter in situ, and complications. RESULTS: A total of 942 TCVCs (690 IJV; 252 EJV) were inserted in 761 patients. No statistical difference was seen between the two groups for procedure indications, age, gender, duration of line in situ, side of insertion, catheter size, number of lumens, and rate of premature catheter removals owing to complications. Rates of infection, blockage, and breakage were similar, but dislodgement was higher in the IJV group. EJV access was successful in 91% of attempts. CONCLUSIONS: Open EJV TCVC insertion is a safe, quick, and feasible alternative to IJV insertion. EJV access offers comparable outcomes, reduced surgical morbidity, and improved hemostasis especially in children with coagulopathy and/or reduced platelet counts. TYPE OF STUDY: Retrospective comparative study. LEVEL OF EVIDENCE: Level 3.

Incidence and outcome of retained Port-A-Cath fragments during removal.

PURPOSE: Port-A-Cath devices are frequently used for long-term venous access. We postulate that long-term use predisposes them to getting stuck and retained in a central vein at the time of removal. We aim to report the incidence and outcome of this complication. METHODS: Between January 2006 and July 2016, a retrospective review of all Port-A-Cath removals that were performed at our centre was conducted. At the time of removal, catheters that could not be removed from the vein were considered retained. RESULTS: During the study period, 107 children had 174 episodes of silicone Sitimplant (Vygon, Ecouen, France) Port-A-Cath insertions. These children required 135 removal episodes and there were 3 (2.2%) instances whereby the catheter fragment was retained. These episodes of retained catheters only occurred in children with factor VIII deficiency (4.1% incidence in this cohort). For each episode of catheter insertion and removal, the catheters had been left in situ for a mean duration of 43 months in children with factor deficiency and no retained fragments, and the mean duration was 91 months in children with factor deficiency and retained catheter fragments (p = 0.0011). CONCLUSIONS: Port-A-Caths that are retained after attempted removal is a complication encountered predominantly in catheters that have been in use for a prolonged duration. Furthermore, factor replacement therapy in haemophiliacs may be a risk factor for this complication.

Abdominal radiography is not necessary in children with intussusception.

BACKGROUND: Children with intussusception require rapid and accurate diagnosis to enable timely intervention for satisfactory outcome. Ultrasonography is the recommended standard diagnostic modality; however, abdominal radiography (AR) is still used as an initial investigation. The aim of this study was to investigate the benefit of AR in intussusception by determining diagnostic accuracy and analysing correlation of AR findings with outcome. METHODS: Index cases of intussusception presenting over 15 years (1998-2013) were analysed. Those who had AR performed were allocated into groups with positive or normal findings. Outcome of pneumatic reduction of intussusception (PRI) between these groups was compared. RESULTS: Six hundred and forty-four cases of intussusception treated with PRI were identified, 412 (64 %) had AR performed and 232 (36 %) did not. 303 (74 %) radiographs had positive findings and 109 (26 %) were normal. The success rate of PRI did not differ between AR positive (82 %) and AR normal (84 %). Occult pneumoperitoneum was not detected in any patient by AR in our cohort. CONCLUSION: AR is not recommended for the diagnosis of intussusception in children, for the prediction of the outcome of PRI or for the detection of occult pneumoperitoneum. AR should always be performed when clinical peritonism is present but is not otherwise necessary in children with suspected or confirmed intussusception.

The top 100 cited articles in urology: An update.

BACKGROUND: In this paper, we identify and analyze the top 100 cited articles in urology since 1965 and assess changes in the top 100 since 2007. METHODS: We selected highest impact journals in both urological and general medicine journals from the 2011 edition of Journal Citation Reports: Science edition. We identified and analyzed the 100 most cited articles using the Science Citation Index Expanded (1965-present). RESULTS: The top 100 articles were cited a mean of 892 times (range: 529-2088) and published between 1966 and 2009, with 21 published since 2000. In 2012, 19 new articles appeared in the updated top 100 cited articles. Also, 16 journals were represented, led by the New England Journal of Medicine (n=36), the Journal of Urology (n=16) and the Lancet (n=12). In total, 81 articles were published from North America (USA=77, Canada=4). From the United States, the following institutes were among the top 5 represented: Johns Hopkins University (n=12), Harvard University, Memorial Sloan Kettering Cancer Centre, National Institute of Health and Washington University (all 5). Only one institute outside the United States published more than one article in the top 100 (Institut Gustave Roussy, France). Nine urologists were first authors of 2 or more articles. Oncology (n=54) and transplantation (n=22) were the most common subspecialties represented. CONCLUSION: It is important to acknowledge the top cited articles as they mark key topics and advances in urology. There has been a 19% change in the top 100 cited articles in the past 5 years. Oncology and transplantation remain the most highly cited topics.

Scrotal exploration for acute scrotal pain: a 10-year experience in two tertiary referral paediatric units.

OBJECTIVE: Acute scrotal pain is a common presentation to the paediatric emergency department. Testicular torsion is one of the most common causes of acute scrotal pain. Testicular torsion is a surgical emergency requiring immediate surgical exploration to prevent permanent testicular damage or loss. The aim of this study was to determine the surgical outcome of all scrotal explorations and to assess the use of colour Doppler ultrasound (CDUS) in the assessment of acute scrotal pain in two tertiary referral paediatric units. MATERIAL AND METHODS: A retrospective review of a prospectively maintained database was carried out for all scrotal explorations between 1999 and 2010. RESULTS: In total, 155 scrotal explorations were carried out for acute scrotal pain. The mean age was 9.1 years (range 0-15 years). The pathology in 46.5% (n = 72) was testicular torsion, 30.3% (n = 47) were torsion of a testicular appendage, 16.1% (n = 25) were epididymitis, 3.3% (n = 5) had no obvious pathology identified and other pathology accounted for 4%. There was a significant difference in age of presentation between those with testicular torsion and those with torsion of a testicular appendage (9 vs 10 years, p = 0.0074). CDUS was performed by a trained radiologist on 40 patients. Overall sensitivity, specificity, positive predictive value and negative predictive value for CDUS predicting testicular torsion were 96.9%, 88.9%, 96.9% and 89%, respectively. Overall, 36 patients (23%) with acute scrotal pain (50% of patients in the group with confirmed testicular torsion at exploration) required orchidectomy. CONCLUSION: This study supports the practice of immediate surgical exploration with a clinical suspicion of testicular torsion in a paediatric population.

Hydrocele on the web: an evaluation of Internet-based information.

OBJECTIVE: To evaluate the quality of health-based information available to patients and their parents on the Internet regarding hydrocele, a common paediatric condition, an Internet search was performed and a questionnaire distributed. MATERIAL AND METHODS: The top 100 websites from the five most accessed search engines were reviewed by entering the term "Hydrocele" into each search engine. Website authorship was determined by close examination of each website. Websites were assessed for accuracy and validity according to the Health On the Net Foundation Code (HONcode), DISCERN score and JAMA benchmark criteria, recognized scoring systems. A voluntary written questionnaire was distributed to parents of patients on two consecutive days outside a paediatric clinic. RESULTS: After duplicate and inaccessible sites had been excluded, 37 unique websites were identified: 11 were academic, eight were produced by physicians not affiliated with an academic institution, three were commercial, four were attached to discussion groups or social media sites, four were media related and seven were unspecified. There was a significant difference between the academic and the physician-related sites compared with the other categories, with academic and physician sites scoring highest on the recognized scoring systems (p = 0.0001). It was found that 56.7% of patients accessed the Internet regarding their condition and 33% believed this information to be accurate. CONCLUSION: The quality of health-related information overall is of a poor quality. Academic and physician-provided websites were shown to contain better quality information. Clinicians have a potential role not only to direct patients to appropriate sites, but also to help to develop content on the Internet.

Proximal large bowel volvulus in children: 6 new cases and review of the literature.

BACKGROUND: Proximal large bowel volvulus is considered as an extremely rare surgical emergency in children. Approximately 40 cases have been reported, and because of its rarity, the diagnosis is often missed or delayed. The purpose of this study was to review the presentation, treatment, and clinical outcome of proximal large bowel volvulus. METHODS: A systematic review and analysis of the data relating to 6 patients from the author's practice and cases published in the English literature from 1965 to 2010 was performed. Detailed information regarding demographics, clinical presentation and methods of diagnosis, surgical procedure, complications, and outcome were recorded. RESULTS: Thirty-six cases of proximal large bowel volvulus were retrieved from the English literature, and 6 cases, from the author's practice. The male-female ratio was 1:1, with a median age of 10 years. There were 29 (69%) cases with neurodevelopmental delay. Clinical presentation included 29 (69%) cases with constipation, 41 (98%) with colicky abdominal pain, 42 (100%) with abdominal distension, and 35 (83%) with vomiting. Plain radiography was specific in 64% (27/42) of cases, barium enema in 100% (15/15), and computed tomography in 100% (2/2). All patients underwent surgery, with resection and primary anastomosis in 24 (57%) cases, stoma formation in 11 (26%), and detorsion of volvulus without resection in 7 (17%) cases. Six patients (14%) died postoperatively. CONCLUSION: A child with neurodevelopmental delay and a history of constipation presenting with an acute onset of colicky abdominal pain and progressive abdominal distension with vomiting should be suspected of having a cecal and proximal large bowel volvulus.

Urinary incontinence in children: botulinum toxin is a safe and effective treatment option.

PURPOSE: This study's aim was to assess the use of intravesical injection of botulinum neurotoxin type A (BoNT-A) as a treatment of overactive bladder (OAB) in children. METHODS: A 6-year retrospective study of children who received BoNT-A for OAB was performed. Treatment outcome was classified as complete success (CS), partial success (PS) or treatment failure (TF). RESULTS: Of the 57 patients who received BoNT-A treatment for OAB, 35 were males. CS occurred in 74.2% of males and 54.5% of females. PS was achieved in 20% of males and 18.2% of females. TF occurred in 2.9% of males and 22.7% of females. Anticholinergics had previously been used and had been effective in 58.6% and 83.3% of males and females. Significant side effects to medications were experienced in 12 (41.4%) males and 4 (22.2%) females. Of these, BoNT-A achieved CS in seven (53.3%) males and two (50%) females and PS in three (25%) males and one (25%) female. BoNT-A was successful in seven (58.3%) males and two (66.7%) females where anticholinergics were ineffective. CONCLUSIONS: BoNT-A has a role in a carefully selected subgroup of children with overactive bladder symptoms including those with medication side effects and treatment compliance issues. It may have a role in patients who do not respond to conventional therapy.

Does the length of the history influence the outcome of pneumatic reduction of intussusception in children?

PURPOSE: Intussusception is the most common cause of acute abdomen in infants and preschool children. Nonoperative reduction using air enema is an established treatment in children with intussusception. The aim of this study was to determine whether length of the history influences the outcome of pneumatic reduction of intussusception in children? METHODS: The medical records of 256 consecutive children with intussusception between July 1998 and June 2010, who underwent air enema reduction regardless of the length of the history were reviewed. In all 256 patients, intussusception was confirmed by ultrasound before proceeding to air enema. RESULTS: The length of history ranged from 2 to 240 h with median time of 18.5 h. The median age in 256 patients was 7 months (range 1 day to 12 years). The presenting clinical features included irritability/abdominal pain (77%), vomiting (80%), bleeding per rectum (36%) and palpable abdominal mass (50%). Air enema reduction was successful in 234 (91.5%) of the 256 patients. In 22 (8.5%) patients, air enema failed to reduce the intussusception and 3 (1.1%) of these patients had colonic perforation during the procedure. All 22 patients required surgery. The duration of symptoms did not influence the outcome of pneumatic reduction. 37 (14%) patients developed recurrence after successful pneumatic reduction of intussusception, with 58% presenting within 48 h of the initial procedure. CONCLUSION: Our data suggest that pneumatic reduction should be first-line treatment in all children with intussusception regardless of the length of the history.

Omphalocele minor associated with complete absence of the large bowel.

Colonic atresia, unlike small intestine atresia, is a rare congenital malformation. Congenital absence of the entire colon is exceptionally rare. Moreover, an association of omphalocele and complete absence of the colon has not yet been reported in the literature. We present an infant born with such combination of congenital anomalies.

Symptomatic Meckel's diverticulum in children: a 16-year review.

Meckel's diverticulum (MD) has varied presentations and often becomes a diagnostic challenge. The purpose of this study was to review the various presentations of symptomatic MD and to assess the sensitivity of the Meckel's scan as a diagnostic tool in patients with bleeding MD. The hospital records of 71 consecutive patients with a diagnosis of MD from 1990 to 2005 were retrospectively reviewed. The data was assessed for age at presentation, sex, clinical features, investigations performed, surgical intervention and histopathological findings. There were 71 patients with a diagnosis of MD (age 2 days-14 years). In eight patients, MD was an incidental finding at laparotomy. The remaining 63 patients were symptomatic and presented with various clinical features. Ten patients (15.8%) had clinical features of peritonitis; of these, six had perforated MD and four had Meckel's diverticulitis at laparotomy. Nine patients (14.2%) were diagnosed as intestinal obstruction, and at laparotomy, a Meckel's band was found to be the cause of the obstruction. Nine patients (14.2%) had a patent vitello-intestinal duct and presented with umbilical discharge. Thirty-five patients (55.5%) presented with episodes of bleeding per rectum or malaena. Ultrasound scans revealed intussusception in six patients requiring open reduction. Of the remaining 29 patients with bleeding per rectum, 27 underwent a Meckel's Tc99 scan that showed a positive tracer in 18 patients (66.6%) and negative in 9 (33.3%). All patients with a symptomatic MD underwent resection of the diverticulum. Histology revealed ectopic gastric mucosa in 43 patients (68.3%). MD has various presentations and can be easily misdiagnosed. It is necessary to maintain a high index of suspicion in the paediatric age group. The Meckel's scan has a poor positive predictive value and cannot be relied upon for a diagnosis in cases of bleeding MD if Tc99 scan is negative.

Oesophageal replacement in children with indolent stricture of the oesophagus.

OBJECTIVE: To evaluate the indications for and results of oesophageal replacement for acquired oesophageal stricture in children. METHODS: This was a descriptive interventional study. Between 1987 and 2003, patients who had peptic or corrosive stricture were included in the study. Age and gender were analysed and any history of ingestion of caustic agents or untreated reflux was noted. Types of symptoms such as progressive dysphagia to solids and liquids and extent of respiratory infections were evaluated. Nutritional deprivation was also measured. Success or failure of dilatation at the time of endoscopy was taken into account. The criterion for oesophageal replacement was recurrence of stricture within 3 weeks of the previous dilatation. Patients were prepared with general supportive care. Feeding gastrostomy was performed in 12 patients who were severely malnourished. No patients underwent oesophagectomy of the strictured oesophagus. Short- and long-term complications were recorded. RESULTS: Of the 54 patients, 34 were male and 20 were female. Colonic conduit and reverse gastric tube were used in 27 patients each. Three patients had leak and were treated conservatively. Six patients developed anastomotic stricture but benefited remarkably from periodic dilatation and, in the long-term, remained symptom-free. Results were generally very gratifying. CONCLUSION: Most patients who require oesophageal conduit do well and catch up with their growth and development.

Palliative surgery for advance osteosarcoma of shoulder region.

We are presenting here eight cases of advanced osteosarcoma of shoulder region involving scapula and upper humerus in children upto the age of thirteen years. All patients had complete loss of movement. Five patients underwent fore quarter amputation. Extensive amputation although a major mutilating procedure, provides patients a dramatic relief for the period that he survives.