Pre-operative mechanical bowel preparation and prophylactic oral antibiotics for pediatric patients undergoing elective colorectal surgery: a protocol for a randomized controlled feasibility trial.

BACKGROUND: Infections after elective colorectal surgery remain a significant burden for patients and the healthcare system. Adult studies suggest that the combination of oral antibiotics and mechanical bowel preparation is effective at reducing infections after colorectal surgery. In children, there is limited evidence for either of these practices and the utility of combining oral antibiotics with mechanical bowel preparation remains uncertain. METHODS: This study aims to determine the feasibility of conducting a randomized controlled trial assessing the efficacy of oral antibiotics, with or without mechanical bowel preparation, in reducing the rates of post-operative infection in pediatric colorectal surgery. Participants aged 3 months to 18 years undergoing elective colorectal surgery will be randomized pre-operatively to one of three trial arms: (1) oral antibiotics; (2) oral antibiotics and mechanical bowel preparation; or (3) standard care. Twelve patients will be included in each trial arm. Feasibility outcomes of interest include the rate of participant recruitment, post-randomization exclusions, protocol deviations, adverse events, and missed follow-up appointments. Secondary outcomes include the rate of post-operative surgical site infections, length of hospital stay, time to full enteral feeds, reoperation, readmission, and complications. DISCUSSION: If the results of this trial prove feasible, a multi-center trial will be completed with sufficient power to evaluate the optimal pre-operative bowel preperation for pediatric patients undergoing elective colorectal surgery. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03593252.

Management of Pediatric Patients With Spontaneous Pneumomediastinum: A Retrospective Chart Review.

PURPOSE: Given the paucity of data on pediatric spontaneous pneumomediastinum (SPM), management is largely informed by extrapolation from adult studies or personal clinical experience, resulting in significant heterogeneity. The purpose of this study was to describe how pediatric patients with SPM are clinically managed at our institution and propose a treatment algorithm. METHODS: Retrospective chart review of pediatric patients with SPM from April 2002 to December 2021 at a single Canadian tertiary care center. Data on medical history, presentation characteristics, clinical management, and complications were gathered. Descriptive and inferential statistics were used to analyze data. RESULTS: We identified 63 patients for inclusion, median age was 15 years. Twenty-nine patients were transferred from another facility. Most common presenting symptoms were chest pain (72.3%), shortness of breath (44.6%), and subcutaneous emphysema (21.5%). Initial workup included chest x-ray (93.6%), CT scan (20.6%), and upper GI series (7.9%). There was no difference in the number of initial tests between admitted and discharged patients (p = 0.10). Of admitted patients (n = 35), 31.4% had primary SPM (no underlying comorbidity/inciting event) and 68.8% were secondary SPM (underlying comorbidity/inciting event). No patients with primary SPM developed complications or recurrences. In contrast, 16.7% of those with secondary SPM developed complications and 54.2% had at least one additional intervention after admission. DISCUSSION: There is significant variability in diagnostic investigation and treatment of pediatric SPM at our center. Amongst primary SPM, additional tests did not change complication rate or recurrence, including those transferred from another facility. An expeditious treatment algorithm is warranted. TYPE OF STUDY: Retrospective Cohort Study. LEVEL OF EVIDENCE: III.

Observation, Aspiration, or Tube Thoracostomy for Primary Spontaneous Pneumothorax: A Systematic Review, Meta-Analysis, and Cost-Utility Analysis.

BACKGROUND: Primary spontaneous pneumothorax (PSP) has several commonly used management strategies: observation, aspiration, and chest tube placement. Economic modelling of pooled data comparing techniques has not been performed. RESEARCH QUESTION: Based on studies from the past 20 years, which approach to management of PSP delivers the highest utility? STUDY DESIGN AND METHODS: A systematic review of PSP management strategies (observation, aspiration, or chest tube placement) included in the Medline and EMBASE databases from January 1, 2000, through April 10, 2020, was conducted. Text screening, bias assessment, and data extraction were performed by two authors (G. E. and C. A. P.). Inclusion and exclusion criteria were defined a priori. The primary outcome was PSP resolution after the initial intervention. Secondary outcomes were PSP recurrence, length of stay, rate of surgical management, and complications. The meta-analysis compared treatment arms; dichotomous outcomes were reported as relative risk (RRs) and continuous outcomes were reported as mean differences. A cost-utility analysis within the Canadian health care system context with deterministic and probabilistic sensitivity analyses was performed. RESULTS: Five thousand one hundred seventy-nine articles were identified; after screening, 22 articles were included. Most trials showed a high risk of bias, but randomized trials showed a lower risk. Compared with chest tube placement, observation (mean difference, 5.17; 95% CI, 3.75-6.59; P < .01; I2 = 62%) and aspiration (mean difference, 2.72; 95% CI, 2.39-3.04; P < .01; I2 = 0%) showed a shorter length of stay. Compared with observation, chest tube placement (RR, 0.81; 95% CI, 0.71-0.91; P < .01; I2 = 62%) and aspiration (RR, 0.73; 95% CI, 0.61-0.88; P < .01; I2 = 67%) showed higher resolution without additional intervention. Two-year recurrence rates did not differ between management strategies. Observation showed the best utility (0.82) and lowest cost; observation was the optimal strategy in 98.2% of Monte Carlo simulations. INTERPRETATION: Observation is the dominant choice compared with aspiration and chest tube placement for PSP. It should be considered as the first-line therapy in appropriately selected patients.

Treatment and Outcomes of Congenital Ovarian Cysts A Study by the Canadian Consortium for Research in Pediatric Surgery (CanCORPS).

OBJECTIVE: We conducted a multicenter study to assess treatments and outcomes in a national cohort of infants with congenital ovarian cysts. SUMMARY BACKGROUND DATA: Wide variability exists in the treatment of congenital ovarian cysts. The effects of various treatment strategies on outcomes, specifically ovarian preservation, are not known. METHODS: Female infants diagnosed with congenital intra-abdominal cysts between 2013 and 2017 at 10 Canadian pediatric surgical centers were retrospectively evaluated. Sonographic characteristics, median time to cyst resolution, incidence of ovarian preservation, and predictors of surgery were evaluated. Subgroup analyses were performed in patients with complex cysts and cysts ≥40 mm in diameter. RESULTS: The study population included 189 neonates. Median gestational age at diagnosis and median maximal prenatal cyst diameter were 33 weeks and 40 mm, respectively. Cysts resolved spontaneously in 117 patients (62%), 14 (7%) prenatally, and the remainder at a median age of 124 days. Intervention occurred in 61 patients (32%), including prenatal aspiration (2, 3%), ovary sparing resection (14, 23%), or oophorectomy (45, 74%). Surgery occurred at a median age of 7.4weeks. Independent predictors of surgery included postnatal cyst diameter ≥40 mm [odds ratio (OR) 6.19, 95% confidence interval (CI) 1.66-35.9] and sonographic complex cyst character (OR 63.6, 95% CI 10.9-1232). There was no significant difference in the odds of ovarian preservation (OR 3.06, 95% CI 0.86 -13.2) between patients who underwent early surgery (n = 22) and those initially observed for at least 3 months (n = 131). CONCLUSIONS: Most congenital ovarian cysts are asymptomatic and spontaneously resolve. Early surgical intervention does not increase ovarian preservation.

Differentiating congenital ovarian cysts from other abdominal cystic lesions in female infants: A study by the Canadian Consortium for Research in Pediatric Surgery (CanCORPS).

PURPOSE: The origin of congenital abdominal cysts in the female fetus often dictates management. While most arise from the ovary and are often managed non-operatively, some are non-ovarian and are frequently removed. We analyzed a national sample of female infants with congenital abdominal cysts to elucidate prenatal and postnatal factors associated with the diagnosis of a non-ovarian cyst. METHODS: A retrospective cohort study of female infants who were prenatally diagnosed with abdominal cysts between 2013 and 2017 at 10 Canadian pediatric surgical centres was performed. Clinical characteristics, pre- and postnatal sonographic findings, and cyst trajectories were compared between patients with proven ovarian etiology and those with cysts arising from other organs. RESULTS: Of 185 infants with prenatally diagnosed abdominal cysts, 22 (12%) were non-ovarian, five of which had clear non-ovarian organ of origin on prenatal ultrasound. Comparison of the other 17 cysts with 163 congenital ovarian cysts showed the following factors to be associated with a non-ovarian origin: earlier gestational age at diagnosis (23.5 vs 33.5 weeks, p <0.001), smaller diameter on first prenatal ultrasound (15.8 vs. 39.7 mm, p <0.001), change in sonographic character from simple to complex (87% vs 22%, p <0.001), and postnatal sonographic characteristics of complex cyst (87% vs. 48%, p = 0.004). CONCLUSION: Clear organ of origin, diagnosis earlier in gestation, smaller initial prenatal cyst diameter, and sonographic cyst character change differentiate congenital non-ovarian cysts from their ovarian counterparts. These characteristics may be used to guide diagnosis and management.

Desmoplastic Small Round Cell Tumor With Ascending Intraspinal Metastasis at Recurrence: Case Report and Review of the Literature.

BACKGROUND: Desmoplastic small round cell tumor (DSRCT) is a rare and aggressive malignancy commonly involving the abdomen and/or pelvic peritoneum. Despite aggressive therapy, the prognosis remains poor. Central nervous system relapse is rare in abdominal/pelvic primary DSRCT. OBSERVATION: We report a case of a 10-year-old female with a large pelvic DSRCT and involvement of the rectosigmoid colon and liver. Following treatment with chemotherapy, and cytoreductive surgery with hyperthermic intraperitoneal chemotherapy an initial response was noted. With progressive lower limb weakness, recurrence with perineural invasion in the lumbosacral nerve root involving the conus was noted 2.5 years from diagnosis. Cerebrospinal fluid showed tumor cells with a molecular confirmation. CONCLUSIONS: Perineural invasion and ascending paralysis secondary to primary abdominal DSRCT has not been previously reported to our knowledge. We recommend a high index of suspicion for early and accurate diagnosis of this rare presentation.

Generalised urticaria following ingestion of a nickel-plated coin in a 4-year-old girl.

We report the case of a 4-year-old girl who presented to the emergency department after ingestion of a nickel-plated coin. Abdominal radiographs confirmed the presence of a coin in her stomach but she was otherwise asymptomatic. She was discharged with assurances that the foreign body would pass spontaneously. The patient developed significant generalised urticaria the next day, which became progressively more severe. Her symptoms prompted endoscopic removal of the nickel-plated coin and a postoperative course of corticosteroids and antihistamine therapy. This is the first reported case of generalised urticaria secondary to ingestion of a coin with nickel plating only (2% nickel content overall). A review of similar cases is provided.

The fragility of statistically significant findings from randomized controlled trials in pediatric appendicitis: A systematic review.

PURPOSE: Randomized controlled trials (RCT) in pediatric appendicitis remain limited, and the robustness of available evidence is unknown. The aim of this study was to determine the fragility of results in pediatric appendicitis RCTs. METHODS: A systematic search of Embase and MEDLINE was performed. Eligible studies were two-armed RCTs that included at least one statistically significant dichotomous outcome, had parallel-group allocation, and assessed pediatric patients (0-17) with a primary diagnosis of appendicitis. The Fragility Index (FI) for one statistically significant outcome per trial was calculated using a Fisher's exact test, with statistical significance set at p < 0.05. RESULTS: Six studies were identified for inclusion. Studies included a median of 103 patients (interquartile range [IQR] 86-127), with a median of 18 (IQR 4.5-41.25) events for analyzed outcomes. The primary outcome variable was included in analysis for 4(67%) studies. The median FI across studies was 3 (IQR 0.75-4.25), with results ranging from 0 to 5. Results indicate that overall, converting 3 patients from non-events to events in a single trial arm would change the significant dichotomous outcome to nonsignificant. CONCLUSION: The fragility of results in RCTs in pediatric appendicitis should be considered before clinical practice is changed. Investigators should consider reporting the FI alongside study results, as p-values alone may be misleading. TYPE OF STUDY: Randomized Controlled Trial. LEVEL OF EVIDENCE: Level I.

Management of the normal-appearing appendix during laparoscopy for clinically suspected acute appendicitis in the pediatric population.

PURPOSE: The widespread use of laparoscopy has brought forth the question of how to manage a macroscopically normal-appearing appendix in cases of clinically suspected appendicitis. This study aimed to determine the current practices of pediatric general surgeons in Canada regarding this matter. METHODS: An online survey was created following the American Pediatric Surgical Association (APSA) guidelines and distributed via email to the Canadian Association of Pediatric Surgeons (CAPS) staff surgeons. The questions assessed clinician characteristics, standard practice, and rationale. Results were analyzed using descriptive statistics. RESULTS: A total of 54/72 (75%) CAPS members practicing in Canada completed the survey. All (100%) agreed they would remove a normal-appearing appendix during laparoscopy for suspected acute appendicitis. The most common reasons were: possibility of microscopic appendicitis (39/54, 72.2%), avoiding future diagnostic confusion (28/54, 51.9%), and patient preference/consent discussion (21/54, 38.9%). Most (53/54, 98.1%) had performed a negative appendectomy and 49/54 (90.7%) agreed there were no sufficient guidelines. CONCLUSIONS: The majority of pediatric surgeons agree sufficient guidelines do not exist to support decision making when a normal-appearing appendix is found during laparoscopy for suspected acute appendicitis. This survey shows that removal of the appendix in this case would be supported by the majority of Canadian pediatric surgeons. TYPE OF STUDY: Survey LEVEL OF EVIDENCE: VII (Expert Opinion).

Neutropenia at the time of subcutaneous port insertion may not be a risk factor for early infectious complications in pediatric oncology patients.

BACKGROUND: The risk of infection associated with subcutaneous port (SQP) placement in patients with neutropenia remains unclear. We reviewed the rate of early infectious complications (<30 days) following SQP placement in pediatric oncology patients with or without neutropenia [absolute neutrophil count (ANC) <500/mm3]. METHODS: Baseline characteristics and infectious complications were compared between groups using univariate and multivariate analyses. RESULTS: A total of 614 SQP were placed in 542 patients. Compared to nonneutropenic patients, those with neutropenia were more likely to have leukemia (n = 74, 94% vs n = 268, 50%), preoperative fever (n = 17, 22% vs n = 25, 5%), recent documented infection (n = 15, 19% vs n = 47, 9%), and were younger (81 vs 109 months) (p values <0.01). After adjusting for fever and underlying-disease, there was a nonsignificant association between neutropenia and early postoperative infection (OR 2.42, 95% CI 0.82-7.18, p = 0.11). Only preoperative fever was a predictor of infection (OR 6.09, 95% CI 2.08-17.81, p = 0.001). CONCLUSION: SQP placement appears safe in most neutropenic patients. TYPE OF STUDY: Retrospective comparative study. LEVEL OF EVIDENCE: Level III.

Modified Uniportal Video-Assisted Thoracic Surgery Versus Three-Port Approach for Lung Nodule Biopsy in Pediatric Cancer Patients.

BACKGROUND: Uniportal video-assisted thoracic surgery (VATS) is gaining popularity among thoracic surgeons, but the limited space in the thorax of children makes uniportal VATS difficult to perform. The purpose of this study was to evaluate procedural and outcome differences between a modified uniportal VATS (MU-VATS) and three-port VATS (TP-VATS) for peripheral lung nodule biopsy in pediatric cancer patients. MATERIALS AND METHODS: This is an Institutional Review Board-approved retrospective analysis of all consecutive MU-VATS and TP-VATS peripheral lung nodule biopsies performed at a single institution between June 2014 and December 2016. Patients with diffuse lung disease who underwent a lung biopsy were excluded. RESULTS: Over a 30-month period, 22 patients with a median age of 12 years (range, 7-21) underwent MU-VATS or TP-VATS for excisional biopsy of a peripheral lung nodule. MU-VATS lung biopsy was attempted in 11 patients and TP-VATS lung biopsy in the remaining 11. Both groups were comparable with regard to demographics, primary diagnosis, purpose of biopsy, and lung nodule location. MU-VATS demonstrated no difference when compared with TP-VATS lung biopsy in operative time (54 versus 62 min, P = .899), estimated blood loss (14 versus 15 mL, P = .587), pain score (2.8 versus 2.9, P = .717), and discharge day (1.3 versus 1.2 days, P = .572). No difference existed between groups with regard to conversion, need for intraoperative blood transfusion, and duration of chest tube. Complications including pneumothorax (n = 2) and subcutaneous emphysema (n = 1) were only seen in the TP-VATS group. CONCLUSIONS: MU-VATS can be safely utilized for biopsy of peripheral lung nodules in pediatric cancer patients without increasing procedural duration, hospitalization, pain scores, or need for intraoperative blood transfusion. Further studies need to evaluate the theoretical cosmetic advantage from a single surgical scar.

Replacing gastrostomy tubes with collapsible bumpers in pediatric patients: Is it safe to "cut" the tube and allow the bumper to pass enterally?

PURPOSE: The "cut and push" technique for removal of percutaneous endoscopic gastrostomy (PEG) tubes with collapsible bumpers offers an alternative to the standard traction method of removal. This study compared the outcomes of these techniques. METHODS: We completed a research ethics board-approved retrospective cohort study, identifying all patients less than 18years of age who underwent PEG tube removal at a children's hospital between December 2013 and December 2016. Outcomes included need for sedation and complications. RESULTS: We identified 127 children who had PEG tubes removed. Significantly fewer children required sedation with the cut and push group (1.1% vs. 60.6%, p≤0.001). Ten complications occurred, including 9 in the cut and push group (9.6% vs. 3%, p=0.23). Mean age at time of complication was significantly younger in the cut and push group (2.2 vs. 6.3years p=0.004). CONCLUSION: This is the largest reported series comparing the cut and push vs. traction removal methods. The cut and push technique significantly reduced the need for procedural sedation but was associated with increased risk of complications. While these data suggest that the technique is safe in older children, caution should be taken in younger children who appear to be more likely to vomit the residual bumper. LEVELS OF EVIDENCE: Level III-Treatment study, Retrospective comparative study.

Use of ultrasound in diagnosing postoperative small-bowel intussusception in pediatric surgical oncology patients: a single-center retrospective review.

BACKGROUND: Postoperative intussusception can be a complication of abdominal surgery and often poses a diagnostic dilemma. OBJECTIVE: The purpose of this study was to evaluate the utility of ultrasonography in the diagnosis of intussusception in children who had recently undergone resection of a primary solid tumor. MATERIALS AND METHODS: We performed a retrospective review of all pediatric surgical oncology patients undergoing laparotomy for excision of an abdominal tumor at our institution from 1995 to 2015. We reviewed those with documented postoperative intussusception. In addition we searched the radiology database for all ultrasound examinations requested to rule out postoperative intussusception during our study interval. We analyzed demographics, primary diagnosis, surgical procedure, presentation, diagnostic investigations and definitive treatment. RESULTS: At our institution 852 laparotomies for abdominal tumor resection were performed during the study period, resulting in 10 postoperative intussusceptions (1.2% of cases), of which half were following neuroblastoma resection and the other half following nephrectomy for Wilms tumor. Postoperative intussusception was suspected if the patient had increasing nasogastric output, abdominal distension or feeding intolerance. Ultrasound was used to diagnose intussusception in 9/10 cases, on postoperative day 6 (standard deviation [SD] 5.6 days) on average, with a sensitivity of 89% (8/9; one false negative; 95% confidence interval [CI] 0.52, 1.00) and a specificity of 100% (no false positives; 95% CI 0.96, 1.00). CONCLUSION: Ultrasound was highly accurate in diagnosing postoperative intussusception in children who underwent resection of retroperitoneal tumors.

Operative and Immediate Postoperative Differences Between Traditional Multiport and Reduced Port Laparoscopic Total Splenectomy in Pediatric Patients.

BACKGROUND: Laparoscopy offers many benefits to splenectomy, such as reduced incisional pain and shortened hospital duration. The purpose of this study is to evaluate procedural and outcome differences between multiport (MP) and reduced port (RP) splenectomy when utilized to treat children. PATIENTS AND METHODS: An institutional review board approved retrospective analysis of all consecutive laparoscopic total splenectomies performed at a single institution between January 2010 and October 2015 was conducted. We evaluated demographics, surgical technique, instance of conversion, operative duration, estimated blood loss, need for intraoperative blood transfusion, postoperative length of stay, time to full feeds, complications, and follow-up duration. RESULTS: Over a 5-year period, 66 patients less than 20 years of age underwent laparoscopic total splenectomy. RP splenectomy was attempted in 14 patients. The remaining 52 were MP operations. Populations were comparable with regard to demographics. Preoperative splenic volumes (mL) were greater in the RP population (median [IQR]: 1377 [747-1508] versus 452 [242-710], P = .039). RP splenectomy demonstrated no difference compared to MP splenectomy in operative time (153 versus 138 minutes, P = .360), estimated blood loss (120 versus 154 mL, P = .634), or percent of cases requiring intraoperative blood transfusion (14 versus 23, P = .716). By the first postoperative day, 57% of RP and 17% of MP patients could be discharged (P = .005). Thirty-day readmission rates were similar, at 7% for RP and 8% for MP operations. Fever was the indication for all readmissions. Mean duration of follow-up is 28 months for MP and 13 months for RP cases. CONCLUSION: A reduced number of ports can be safely utilized for total splenectomy in pediatric patients without increasing procedural duration or need for intraoperative blood transfusion. In addition, rate of discharge on the first postoperative day was significantly higher in the RP splenectomy group.

Hair epilation versus surgical excision as primary management of pilonidal disease in the pediatric population.

Pilonidal disease is a chronic, acquired inflammatory process of the skin due to entrapped hair at the natal cleft. Reported recurrence rates are as high as 30%, and recurrence has been attributed to persistent hair near the surgical site. Although conservative measures, such as meticulous hair control and improved perineal hygiene, have been shown to be effective, these techniques typically require much effort on behalf of the patient. Laser hair epilation (LE) might solve this issue of poor patient compliance while helping patients to avoid surgical excision. In this article, we discuss recurrence rates of pilonidal disease in children treated with LE versus surgical excision in relation to findings from our institution between 2005 and 2013 as well as patient satisfaction with the treatment method.

The significance of pseudoaneurysms in the nonoperative management of pediatric blunt splenic trauma.

PURPOSE: Nonoperative management is the standard of care for hemodynamically stable pediatric and adult blunt splenic injuries. In adults, most centers follow a well-defined protocol involving repeated imaging at 24 to 48 hours, with embolization of splenic pseudoaneurysms (SAPs). In children, the significance of radiologically detected SAP has yet to be clarified. METHODS: A systematic review of the medical literature was conducted to analyze the outcomes of documented posttraumatic SAP in the pediatric population. RESULTS: Sixteen articles, including 1 prospective study, 4 retrospective reviews, and 11 case reports were reviewed. Forty-five SAPs were reported. Ninety-six percent of children were reported as stable. Yet, 82% underwent splenectomy, splenorrhaphy, or embolization. The fear of delayed complications owing to SAP was often cited as the reason for intervention in otherwise stable children. Only one child with a documented pseudoaneurysm experienced a delayed splenic rupture while under observation. No deaths were reported. CONCLUSIONS: There is no evidence to support or dispute the routine use of follow-up imaging and embolization of posttraumatic SAP in the pediatric population. At present, the decision to treat SAP in stable children is at the discretion of the treating physician. A prospective study is needed to clarify this issue.