Antenatal diagnosis of surgically correctable anomalies: effects of repeated consultations on parental anxiety.

OBJECTIVE: To assess whether or not a correlation exists between antenatal consultations and parental anxiety. STUDY DESIGN: In total, 31 couples undergoing prenatal consultation after a diagnosis of a surgically correctable anomaly were asked to fill in a questionnaire (Spielberger State-Trait Anxiety Inventory) measuring anxiety levels (AL) both after the first consultation and at birth. Prenatal counselling was done by a perinatal team including paediatric surgeon, obstetrician, and psychologist. RESULTS: Malformations were: eight diaphragmatic hernias, 10 intestinal atresias, four abdominal masses, nine abdominal wall defects. Each fetus was subsequently followed up at regular intervals from diagnosis to birth. AL at birth were then compared with the number of antenatal consultations. A negative correlation (r=-0.688, p<0.001) was found between the number of consultations and the level of anxiety at birth. Patients having at least two consultations had significantly lower anxiety levels at birth. CONCLUSION: Irrespective of the type of malformation, there is evidence that having more than one antenatal consultation may significantly reduce AL at birth. Therefore, early antenatal diagnosis should be encouraged in order to increase as much as possible chances of repeated consultations for the prospective parents.

Esophagogastric dissociation versus fundoplication: Which is best for severely neurologically impaired children?

PURPOSE: Neurologically impaired children (NIC) often have swallowing difficulties, severe gastroesophageal reflux, recurrent respiratory infections, and malnutrition. Bianchi proposed esophagogastric dissociation (EGD) as an alternative to fundoplication and gastrostomy. The authors compared these 2 approaches. METHODS: Twenty-nine consecutive symptomatic NIC refractory to medical therapy were enrolled in a prospective study and divided into 2 groups: A (n = 12), NIC who underwent fundoplication and gastrostomy; B (n = 14), NIC who underwent EGD. Three were excluded because of previous fundoplication. Anthropometric (percentage of the 50th percentile/age of healthy children) and biochemical parameters, respiratory infections per year, hospitalization (days per year), feeding time (minutes), and "quality of life" (parental psychological questionnaire, range 0 to 60), were analyzed (t test and Mann-Whitney test) preoperatively and 1 year postoperatively. Complications were recorded. RESULTS: Compared with group A, group B presented a statistically significant increase of all anthropometric and nearly all biochemical parameters with a statistical difference in terms of respiratory infections, hospital stay, feeding time, and psychological questionnaire. In group A, 2 bowel obstructions, 1 tight fundoplication, 1 dumping syndrome, and 3 failures of fundoplication occurred. Group B presented 1 anastomotic stricture, 1 paraesophageal hernia, and 1 bowel obstruction. CONCLUSIONS: Compared with fundoplication and gastrostomy, EGD offered better nutritional rehabilitation, reduction in respiratory infections, and improved quality of life. EGD can be rightfully chosen as a primary procedure.

A new and successful chance in surgical treatment of gastrooesophageal reflux in severely neurologically impaired children: Bianchi's procedure.

AIM: Neurologically impaired (NI) children present with neuromuscular incoordination and severe gastroesophageal reflux (GER). In these cases, Bianchi has proposed total oesophagogastric dissociation (OGD) as a primary procedure and not only after failed fundoplication. METHODS: Anthropometric and laboratory data, incidence of respiratory symptoms, days of hospitalisation, time of feeding, stool frequency and quality of life were tested preoperatively and after OGD over a 12-month period in 13 severe NI patients. RESULTS: Results are shown in Table 1. We also recorded improvement in quality of life, based on communication by the person responsible for the care of the subject, and determined by psychological interviews. CONCLUSIONS: OGD is a successful and feasible procedure and can be included as a primary definitive surgical treatment in individualised nutritional rehabilitation planning for each severe NI child.

Are preoperative parameters of unilateral pyelo-ureteric junction obstruction in children predictive of postoperative function improvement?

OBJECTIVES: Surgery on the pyelo-ureteric junction obstruction (PUJO) has long been thought to affect postoperative renal function. However, preoperative assessment of which kidneys will benefit from such surgery remains unreliable. MATERIAL AND METHODS: Pre- and postoperative data relating to renal function were obtained by renal scan for 69 patients who were operated upon for PUJO. These patients were divided into two groups: group A (improved differential renal function) and group B (unimproved or decreased differential renal function). The two groups were then compared with regard to age at operation and presence or absence of clinical symptoms. Ultrasound (anteroposterior diameter of the pelvis, parenchymal thickness) and renal scan (glomerular filtration rate, differential renal function of the affected kidney, obstructive pattern) parameters were also taken into consideration. Some variables were also made dichotomous (pelvic diameter < or > 15 mm, parenchymal thickness < or > 5 mm, differential renal function < or > 40%). Statistical correlation was sought with parametric and non-parametric tests. RESULTS: No correlation whatsoever was found between the two groups for any of the parameters under consideration, so that any attempt at logistical regression analysis failed. CONCLUSIONS: None of the currently adopted diagnostic tests can be used to indicate which renal units will benefit from surgery through an improved renal function. The presence or absence of clinical symptoms does not appear to affect renal function either. There is evidence that parents should be provided with such information when giving their informed consent to pyeloplasty.

Is preoperative laparoscopy useful for impalpable testis?

PURPOSE: Laparoscopic assessment of pelvic anatomy has gained wide popularity over the years. Today surgical treatment of impalpable testis is nearly always preceded by diagnostic laparoscopy. The actual role of such a procedure remains undefined. We performed a prospective randomized clinical trial in patients with impalpable testis to evaluate the clinical usefulness of laparoscopy before surgical exploration. MATERIALS AND METHODS: We studied pediatric, age matched patients with impalpable testis who were randomized to group 1-30 who underwent open surgery only and group 2-31 who underwent laparoscopy and open surgery. Anatomical findings, operative procedures, operative time and cost, number of recurrences and testicular volume at followup were then compared in the 2 groups. RESULTS: There were no statistically significant differences in the 2 groups for any of the considered parameters except operative cost and time, which were significantly higher in the laparoscopy group. CONCLUSIONS: Preoperative laparoscopy does not provide any significant advantage over open surgery for treating impalpable testis.

Gastroesophageal reflux in neurologically impaired children: partial or total fundoplication?

BACKGROUND: It is difficult to give guidelines when approaching gastroesophageal disease in neurologically impaired children. Indication for surgery has been increasing over recent years, but there is no consensus on the surgical technique of choice. Nothing has been written specifically comparing the results of different procedures in these patients, so far. STUDY DESIGN: We retrospectively compare the short- and long-term results of two different types of fundoplication in a series of children operated on for documented gastroesophageal reflux disease at our institution. RESULTS: One group (group A) of 27 patients, operated on between 1977 and 1993, underwent Nissen fundoplication, the other (group B), formed of 20 patients all of whom were operated on between 1993 and 1995, underwent Thai fundoplication. We compared the results in terms of positive outcome (recovery) and negative outcome (minor and major complication), computing the relative odds of group A versus group B in terms of risk of complication, and we compared the mean operative time and the length of hospital stay by means of a student's t-test analysis. CONCLUSIONS: Our results show that there is no statistical difference between the two procedures in terms of relative risk of complication and success rate. The duration of surgery and hospital stay were significantly shorter in group B. The Thal procedure can, therefore, be proposed as first choice in the management of these patients.