Are we informing our patients correctly? Evaluation of perioperative counselling for paediatric intestinal stoma formation: a national study.

PURPOSE: Adequate preoperative information is known to improve patient outcomes. We aimed to evaluate perioperative education for paediatric patients and families undergoing intestinal stoma formation. METHODS: UK paediatric surgery centres were invited to recruit patients aged 6-16 years with a stoma in situ or reversed within the last 2 years. Patient and parent questionnaires were posted for potential participants. RESULTS: Eighty-three patient/parent dyads returned questionnaires. Median age was 11.5 years (range 4.1-17.8), with 48% (n = 40) formed electively. Parents rated how well-informed they felt perioperatively out of 10 (0 poorly, 10 highly informed). Parents were better informed about surgical issues and stoma care than psychological and social impacts (7.45 vs 6.11; p < 0.0001). 54% reported surgical complications but significantly fewer patients listed these amongst the worst things about having a stoma (24.4%) when compared with psychosocial issues: distress from bag leaks (90.8%; p < 0.0001), self-consciousness (54.1%; p = 0.0001), and restricted activity (40.2%; p = 0.03). CONCLUSION: Parents felt well-informed for medical and practical aspects but less well-informed of psychological and lifestyle impacts of having a stoma. Surgical complications were less important to patients than the impact on daily life. Increased psychosocial information would enable families to be better prepared for life with a stoma.

Neonatal skin care: Developments in care to maintain neonatal barrier function and prevention of diaper dermatitis.

BACKGROUND: Understanding the importance of the barrier function of the skin of preterm and term neonates is crucial in effective neonatal skin and diaper care. This literature search aimed to review the development of different practices in neonatal care to maintain skin barrier function, in turn preventing diaper dermatitis. METHODS: We performed two quantitative literature searches of English language studies: an initial literature search of studies published in the last 5 years was conducted using Cinahl, Medline, Embase, British Nursing Index, and DelphiS, followed by a second search of publications from 1990 to 2017 using the National Institute of Clinical Excellence Health Databases Advanced Search using key words, synonyms, and Boolean phrasing. Titles and abstracts were reviewed for relevance. RESULTS: One hundred ten studies were analyzed for the purpose of this review; however, data are of variable quality. Guidance can be drawn from the existing literature relating to best practice options for diaper area cleansing methods, diaper type selection, and use of barrier creams. More research is required into the benefit or otherwise of diaper-free time. CONCLUSIONS: Super-absorbent diapers reduce moisture at skin level and reduce diaper dermatitis. Barrier creams carry benefit both in prevention and cure but do not provide a substitute for frequent diaper changes. The literature does not demonstrate superiority of one cleansing method over another, but neither the use of wipes nor water increases diaper dermatitis prevalence. Further studies are required to explore the potential benefit of diaper-free time, taking due consideration of the practicalities, particularly for vulnerable neonates within the Intensive Care setting.

Congenital Vascular Malformations of the Liver: An Association With Trisomy 21.

A link between congenital vascular malformation (CVM) of the liver and trisomy 21 has been suggested. We reviewed all children with trisomy 21 referred for investigation to a specialist pediatric hepatobiliary unit (1985-2015). Forty-five children with trisomy 21 were identified; 7 (15%) had a defined CVMs (4 girls). All such infants were also diagnosed with a range of cardiac defects. CVMs were divided according to the nature of the vascular connection. Group (i) (n = 3): Abnormal venovenous anomaly. This included portocaval shunt and patent ductus venosus (n = 2). Group (ii) (n = 4): Involvement of all 3 vascular systems. Two infants had arterioportal hypertension caused by hepatic arteries feeding into a left portal vein aneurysm within the umbilical fissure. Two infants had more complex hepatic artery to hepatic vein shunts developing early cardiorespiratory failure with progressive jaundice. Our series shows a clear association between cardiac anomalies and CVM in children with trisomy 21.

A comparative study of survival after minimally invasive and open oesophagectomy.

BACKGROUND: Oesophageal cancer is increasing in incidence worldwide. Minimally invasive techniques have been used to perform oesophagectomy, but concerns regarding these techniques remain. Since its description by Cuschieri in 1992, the use of minimally invasive oesophagectomy (MIO) has increased, but still only used in a minority of resections in the UK in 2009. In particular, there has been reluctance to use minimally invasive (thoracoscopic and laparoscopic) techniques in more advanced cancers for fears regarding the adequacy of the oncological resection. In order to identify any factors that could affect survival, we undertook a retrospective analysis on all patients who underwent surgery in our department over an 8-year period. METHODS: A retrospective data analysis was undertaken on all patients who underwent oesophagectomy in a tertiary upper gastrointestinal surgery unit, from 2005 to 2012 inclusive. Data were collected from the departmental database and case note review, with follow-up and survival data to time of data collection. The survival data were analysed using univariate and multivariate Cox proportional hazard regression models to determine which variables affected survival. Variables examined included age, tumour position, tumour stage (T0, 1, 2 vs T3, 4), nodal stage (N0 vs N1), tumour histology, completeness of resection (R0 vs R1), use of neoadjuvant chemotherapy and operative technique (thoracoscopic/laparoscopic (MIO) vs laparoscopic abdomen/open chest (Lap assisted) vs Open. RESULTS: 334 patients underwent oesophagectomy between 2005 and 2012. Male to female ratio was 3.75:1, with a mean age of 64 years (range 36-87). There were 83 open oesophagectomies, 187 laparoscopically assisted oesophagectomies and 64 minimally invasive oesophagectomies. Following univariate regression analysis the following factors were found to be correlated to survival: use of neoadjuvant chemotherapy (Hazard Ratio 2.889, 95 % CI 1.737-4.806), T stage 3 or 4 (3.749, 2.475-5.72), Node positive (5.225, 3.561-7.665), R1 resection (2.182, 1.425-3.341), type of operation (MIO compared to open oesophagectomy) (0.293, 0.158-0.541). There was no significant relationship between age, tumour position or tumour histology and length of survival. When these factors were entered into a multivariate model, the independently significant factors correlated to survival were found to be T stage 3 or 4 (HR 1.969, 1.248-3.105), Node positive (3.833, 2.548-5.766) and type of operation (MIO compared to open) (0.5186, 0.277-0.972). CONCLUSION: Multiple small studies have found reduced pulmonary complication rates and duration of hospital stay when using a minimally invasive approach compared to open. Concerns in the literature over long-term outcomes, however, have led to limited utilisation of this method, especially in advanced disease. The data from this large study show significantly better survival following operations performed using minimally invasive techniques compared to open, however, we have not adjusted for some known or unknown confounding factors. International and national RCTs, however, will provide more information in due course.

Association between timing of re-introduction of enteral feeding and short-term outcomes following laparotomy for necrotising enterocolitis.

PURPOSE: To investigate the relationship between timing of re-introduction of feeds following surgery for Necrotising Enterocolitis (NEC) and important early outcomes. METHODS: Secondary analysis of prospectively collected data from paediatric surgical units in UK/Ireland of infants who underwent laparotomy for NEC between 01/03/2013 and 28/02/2014. Multivariable logistic regression analysis was used to compare the relationship of early (≤ 7 days) and later (8-27 days) re-introduction of feeding after surgery on death or need for PN at 28 days, correcting for known cofounders. RESULTS: 41/143 infants (29%) received early and 102/143 infants (71%) had delayed reintroduction of feeding. Infants in the early feeding group had a higher gestational age at birth, higher proportion of growth restriction, lower inotrope requirement, and weremore likely to have undergone primary anastomosis. Following adjustment there was no statistically significant difference detected in the rate of death or need for PN at 28 days, adjusted OR 0.4 (95% CI 0.2-1.1), noting the limited statistical power of this comparison. CONCLUSIONS: There is no evidence from this study to support a minimum period of 7 days nil by mouth post laparotomy for infants with NEC. Early feed reintroduction following laparotomy for NEC is safe in appropriate cases. LEVEL OF EVIDENCE: Level II - Treatment Study Group; Prospective comparative study.

Health-related quality of life and functional outcome measures for pediatric multiple injury: A systematic review and narrative synthesis.

BACKGROUND: Pediatric multiple injury is a major cause of mortality and morbidity worldwide, with varied long-term sequelae. To improve care, a better understanding of the outcome tools used following multiple injury is needed. OBJECTIVES: This study aimed to (1) identify the outcome tools used to assess functional and health-related quality of life outcomes in pediatric multiple injury and to (2) describe the tool domains and validity. METHODS: Eligible studies were those that included pediatric participants aged 0 to 17 years who experienced multiple injury or severe trauma based on Injury Severity Score/Abbreviated Injury Scale score and a functional outcome tool was used to assess outcomes (e.g., physical, psychological, quality of life). Excluded study designs were editorials, narrative, and systematic reviews. RESULTS: Twenty-two papers were included encompassing 16,905 participants and 34 different outcome tools. Ten tools were validated in children of which 4 were multiple injury specific; 18 were validated in adults of which 8 were trauma specific, and 6 were previously unvalidated. The tools were a mixture of patient reported (7 of 10 validated in children and 13 of 18 validated in adults) and clinician reported (3 of 10 validated in children and 2 of 13 validated in adults). Pediatric tool domains assessed were function, mobility, activities of daily living, pain, school, cognition, emotional domains, mental health, behavior, and high-risk behaviors. Using adult-validated tools to assess children may not capture the children's true function and health-related quality of life. CONCLUSION: There was a lack of consistency in the outcome tools used following multiple injury in children. Adult-validated measures may not accurately capture pediatric outcomes after multiple injury. To fully understand the impact of pediatric multiple injury and make comparisons between studies, development of a core outcome set is required. LEVEL OF EVIDENCE: Quantitative observational studies, level III.

Bullying and undermining behaviours in surgery: A qualitative study of surgical trainee experiences in the United Kingdom (UK) & Republic of Ireland (ROI).

BACKGROUND: Bullying and undermining (B/U) behaviours are documented in the international surgical workplace. This study is the largest assessment of prevalence of B/U behaviours within UK & ROI surgical training to date. MATERIALS AND METHODS: UK & ROI surgical trainees were electronically surveyed in July 2017. The survey was open for one month and sent to all registered trainees at Core and Specialty level by the Joint Committee on Surgical Training (JCST) along with email and social media dissemination by the Association of Surgeons in Training (ASiT) and the British Orthopaedic Trainees Association (BOTA). A consensus session on the topic was conducted at the ASiT Conference in Edinburgh in March 2018. Standards for reporting of Qualitative Research were followed. RESULTS: 1412 responses were received (26.6% response rate). All training regions, grades and specialties were represented. 60% of trainees (n = 837) reported witnessing or experiencing B/U behaviours in the surgical workplace. The most common reports related to sexism; 42% (n = 568) reported witnessing or experiencing sexist language/attitudes in the workplace. This was reported more by female respondents (66% compared to 27% male). 21% (n = 291) and 13% (n = 180) reported witnessing or personally experiencing racist and homophobic language or attitudes respectively. Consultants were identified as the most frequent perpetrators. The surgical wards or theatres were the most frequently reported areas that trainees either witnessed or experienced B/U behaviours. Of those trainees who had reported a personal experience of B/U behaviours (n = 344), 20% described their experiences of reporting as negative or very negative. 48.1% of respondents felt that surgery as a whole had a moderate, high or very high degree of a concern about B/U behaviours. CONCLUSION: B/U behaviours are prevalent in the surgical domain. Urgent action is required to eradicate this unacceptable behaviour. A cross-specialty, intercollegiate response is required to tackle this issue and improve the working culture in surgery for all.

Degloving injury to groin, scrotum and penis due to low-velocity handlebar injury.

Bicycles are a common cause of blunt abdominal trauma causing 5%-14% of injuries. However, impalement or shear injuries from low-velocity mechanism of injury are rare. We report a case of a 14-year-old boy presenting with an extensive left groin injury sustained while cycling one-handed along the pavement at walking pace. The laceration ran for 12-14 cm from the left groin across the pubis to the right and 10 cm inferiorly into the perineum. This inverted the left scrotum and partially degloved the penis. The corpus cavernosa and tunica vaginalis were exposed up to the level of the superficial inguinal ring. Literature on handlebar-impalement injuries is sparse and the majority of penile degloving injuries described in the literature result from alternative mechanisms. This unusual case demonstrates the potential forces involved, and potential damage resulting from handlebar injuries even at low velocity.

3D printing to simulate laparoscopic choledochal surgery.

AIMS OF THE STUDY: Laparoscopic simulation has transformed skills acquisition for many procedures. However, realistic nonbiological simulators for complex reconstructive surgery are rare. Life-like tactile feedback is particularly difficult to reproduce. Technological innovations may contribute novel solutions to these shortages. We describe a hybrid model, harnessing 3D technology to simulate laparoscopic choledochal surgery for the first time. METHODS: Digital hepatic anatomy images and standard laparoscopic trainer dimensions were employed to create an entry level laparoscopic choledochal surgery model. The information was fed into a 3D systems project 660pro with visijet pxl core powder to create a free standing liver mold. This included a cuboid portal in which to slot disposable hybrid components representing hepatic and pancreatic ducts and choledochal cyst. The mold was used to create soft silicone replicas with T28 resin and T5 fast catalyst. The model was assessed at a national pediatric surgery training day. RESULTS: The 10 delegates that trialed the simulation felt that the tactile likeness was good (5.6/10±1.71, 10=like the real thing), was not too complex (6.2/10±1.35; where 1=too simple, 10=too complicated), and generally very useful (7.36/10±1.57, 10=invaluable). 100% stated that they felt they could reproduce this in their own centers, and 100% would recommend this simulation to colleagues. CONCLUSION: Though this first phase choledochal cyst excision simulation requires further development, 3D printing provides a useful means of creating specific and detailed simulations for rare and complex operations with huge potential for development.

Acute visceral obstruction.

Gastric volvulus is a rare cause for acute visceral obstruction, with a high mortality rate that rises with delay in definitive treatment. A 33-year-old woman with a rare chromosomal mutation (46,XX,del(6)(q25.1q25.3)) presented with evidence of acute visceral obstruction. Diagnostic difficulties delayed treatment and she clinically deteriorated. Urgent CT imaging revealed acute mesentero-axial gastric volvulus. At laparotomy, global failure of colonic and splenic fixation was found. The viscera were de-rotated, the stomach salvaged and gastropexy and colopexy were performed. This is the first report of gastric volvulus secondary to congenital absence of colonic and splenic ligamentous attachments occurring in a patient over 30 years of age. This case is interesting not only due to unique pathology, but also highlights that general surgeons must be aware of the possibility of unusual causes for intestinal obstruction in patients with recognised genetic abnormalities, even in adult cases, to avoid harmful diagnostic delay.