Paediatric papers

Abscess after appendicectomy in children: the role of conservative management. Okoke B O, Rampersad B, Marantos A, Abernethy L J, Losty P D, Lloyd D A. Br J Surg 1998; 85: 1111-1113.

Acute appendicitis is the commonest emergency in childhood requiring surgery. Appendicectomy is the treatment of choice and invariably has a low morbidity and mortality. Intra-abdominal abscesses are an infrequent complication, particularly seen in those with perforated appendicitis. They often result in a prolonged hospital stay or a need for readmission. Until recently open drainage was regarded as the treatment of choice. Interest has increasingly been shown in ultrasound guided percutaneous, transvaginal or transrectal drainage of abscesses with laparotomy reserved for those in inaccessible sites. Few have investigated the role of antibiotic therapy alone. The outcome of surgery in over 1000 children who underwent appendicectomy over a five year period was retrospectively reviewed. Of these children, 23 (2.2%) developed post-operative intraperitoneal abscesses (i.e. an appendix abscess not present at the time of the initial surgery). Twenty-one resolved both clinically and radiologically with antibiotic treatment. It was concluded that in children with acute appendicitis, antibiotic treatment alone is efficacious and safe as initial treatment in those who develop post-operative intraperitoneal abscesses.

Thyroid cancer in children: the Royal Marsden Hospital experience. Landau D, Vini L, Hern R A, Harmer C. Eur J Cancer 2000; 36: 214-220.

Carcinoma of the thyroid is rare in children. Most are well differentiated papillary lesions with a slightly increased female preponderance. Tumours presenting in childhood appear to behave differently to those seen later in life. They are usually more advanced with nodal and distant metastases at presentation in 60% and 10% of children respectively. Despite such advanced disease the prognosis is generally good. In this retrospective review the Royal Marsden Hospital have published their experience with 30 children (less than 16 years old) presenting with differentiated thyroid cancer over an extended time period. None had been given previous radiation therapy. The median follow up was 22 years. All patients underwent varying degrees of thyroid surgery. Those without clinical evidence of nodal metastases avoided a neck dissection. Since the last 1960s almost all patients were given adjuvant radioiodine ablation therapy. This study confirmed that the prognosis is good with a median survival of 50 years and a median time to recurrence of 7 years. The risk of recurrence was increased in children presenting less than 10 years of age. Both the use of TSH suppression with thyroxine and radioiodine ablation were associated with a reduced risk of recurrence. No child developed a second tumour as a result of the radioiodine therapy. The recommendations from this study are that all children with differentiated thyroid cancer should undergo total thyroidectomy. Radioiodine ablation should be given to all except those with small node negative tumours presenting after 10 years of age. Modified neck dissection should be considered for all with clinical evidence of node metastases. The role of external beam radiotherapy remains unclear. Patients should be followed up for life with regular measurement of serum thyroglobulin.

Surgical management of infantile hypertrophic pyloric stenosis - can it be performed by general surgeons? Maxwell-Armstrong C A, Cheng M, Reynolds J R, Holliday H W. Ann R Coll Surg Eng 2000; 82: 341-343.

Since the first reported case of infantile hypertrophic pyloric stenosis by Blair in 1717, many different surgical approaches to its management have been described. These have included gastroenterostomy, pylorectomy and extramucosal pyloroplasty. In 1912, Wilhelm Ramstedt described the pyloromyotomy that bears his name and this has become the standard surgical treatment used today. Debate exists as to whether this procedure should be performed by paediatric surgeons in a specialist centre or whether it can be safely performed in a district hospital by a general surgeon with a paediatric specialist interest. The aim of this study was to retrospectively audit the outcome of treatment of infantile hypertrophic pyloric stenosis admitted under the care of two consultant general surgeons with a paediatric surgical interest in a district general hospital. Between April 1995 and September 1998, 66 babies were operated on for pyloric stenosis. Demographics, operative details, hospital stay and complications were recorded. The median age was 37 days and the male : female ratio was 4.5 to one. The diagnosis was confirmed by a test feed and by ultrasound in most patients (n=57). Two patients had concomitant medical problems - small VSD and patent urachus. Surgery was performed by a consultant in the majority of cases (n=54). All cases were anaesthetised by a consultant paediatric anaesthetist. Perioperative complications occurred in two patients both requiring omental patches for duodenal perforation. Other complications included post-operative vomiting (n=9), wound or urinary tract infection (n=4) and incisional hernia (n=1). There was no mortality. It was concluded that the complication rate was similar to that seen in specialist centres and that infantile hypertrophic pyloric stenosis and safely be managed in a district general hospital by a general surgeon with a paediatric interest.

A prospective, randomised, double-blind, placebo-controlled trial of glyceryl trinitrate ointment in the treatment of children with anal fissure. Tander B, Guven A, Demirbag S, Ozkan Y, Cetinkursun S. J Pediatr Surg 1999; 34: 1810-1812.

Anal fissure is a common problem in children presenting with rectal bleeding, perianal discomfort, constipation and crying during defecation. Although the condition is often self-limiting it frequently recurs. It can often be managed with sitz baths, stool softeners and analgesic ointment. The treatment of intractable cases can be difficult. It has been well established that nitric oxide donors such as glyceryl trinitrate (GTN) can induce a reversible chemical sphincterotomy. Its benefit in adults has been well documented but its use in children has not been previously reported. This study was performed as a prospective, randomised, double-blind, placebo-controlled trial. Overall, 65 children with anal fissures were randomised into three groups. Each group received topical treatment either 0.2% GTN, 10% lignocaine or placebo ointment applied to the anal skin twice daily. Patients were followed up for eight weeks. Complete fissure healing occurred in 26 of 31 (84%) treated with GTN, 7 of 14 (50%) treated with lignocaine and 6 of 17 (35%) treated with placebo. overall, 94% of patients treated with GTN had complete resolution of symptoms. The differences between the study and control groups were highly significant. It was concluded that the majority of children with anal fissures are helped by topical application of GTN ointment.

Contralateral groin exploration is not justified in infants with a unilateral inguinal hernia. Ballantyne A, Jawaheer G, Munro F D. Br J Surg 2001; 88: 720-723.

Controversy exists regarding the optimal management of unilateral inguinal hernias in infants, in particular the need for contralateral groin exploration in order to detect a further patent processus vaginalis. Indications for contralateral groin exploration have been based on age, prematurity, incarceration, sex and the side of the hernia. A study of the natural history of the processus vaginalis suggests that 40% close at around the time of birth, 20% over the ensuing 2 years and the patency rate is 40% at 2 years. As the incidence of clinically apparent herniation is of an order of magnitude less than this, the presence of a patent processus is a poor criterion on which to base contralateral groin exploration. Data on the long-term risk of contralateral herniation in children is limited and there are no studies confined exclusively to infancy when the risk of development of a hernia is highest. The aim of this study was to quantify the risk of development of a clinical inguinal hernia in children who had undergone a unilateral inguinal herniotomy aged less than one year. All infants who underwent a unilateral inguinal herniotomy between January 1986 and December 1991 were studied retrospectively. Overall, 181 infants (165 boys and 16 girls) were identified. Median gestational age was 37 (range 25-42) weeks and median age at operation was 87 (range 1-365) days. The hernia was right-sided in 83% of patients. Follow-up ranged from 5 to 10 years. A contralateral hernia or hydrocele developed in 14 infants (8%). None of the hernias were incarcerated. Median time from operation to occurrence of the contralateral hernia was 18 (2-67) months. Gestational age, sex and side of the hernia did not influence the incidence of contralateral hernia development. It was concluded that the low incidence of contralateral hernia development in infants undergoing a unilateral inguinal herniotomy does not justify routine contralateral groin exploration.

Active observation of children with possible appendicitis does not increase morbidity. Kirby C P, Sparnon A L. Aust NZ J Surg 2001; 71: 412-413.

The diagnosis of acute appendicitis in childhood can be difficult with a definitive diagnosis made at the initial assessment in only 50-70% of patients. Those children for whom the diagnosis is uncertain are often submitted to a period of 'active observation' to allow improved diagnostic accuracy. However, a greater than 24 hours duration of symptoms increases the perforation rate to over 30%. The morbidity associated with perforation represents a potential risk of a prolonged period of observation. The aim of this study was to assess the morbidity associated with 'active observation' in children with uncertain appendicitis. A retrospective review was undertaken of 378 children who had an appendicectomy over a 4-year period. Active observation was associated with an overall diagnostic accuracy of 93%. The overall mean preoperative hospital time was 12 hours. The incidence of perforation was 32% with a mean preoperative hospital time of only 7 hours in this group. The overall incidence of postoperative infective complications was 4% with an incidence of 12% following perforation. It was concluded that with perforated appendicitis, convincing signs were often present at presentation and that these patients are usually not subjected to a significant delay. Active observation appears safe and is not associated with high postoperative morbidity.

Laparoscopic evaluation and management of nonpalpable testes in children. Lotan G, Klin B, Efrati Y, Bistritzer T. World J Surg 2001; 25: 1542-1545.

Cryptorchidism is the commonest disorder of male sexual differentiation affecting 1% of male infants at one year, 3% of full-term newborns and 21% of premature males. Approximately 20% of undescended testes are nonpalpable and in 20-50% of infants with a nonpalpable testis it is absent. Early investigation and treatment of nonpalpable testes is essential to decrease the incidence of infertility and to allow adequate follow up for possible testicular malignancy. The diagnostic and therapeutic management of the nonpalpable testis has changed over recent years. The main advance has been the introduction of diagnostic laparoscopy and the performance of a laparoscopic Fowler-Stephens procedure. The aim of this study was to evaluate the outcome of males with nonpalpable testes managed and treated laparoscopically over a 6-year period. Overall, 109 boys, mostly between 12 and 18 months old, were evaluated with laparoscopy. Diagnostic laparoscopy and eventual orchidectomy was performed in 50 (46%) with atrophic testes. A normal sized intra-abdominal testis was found in 59 (54%) patients. In 12 patients it was located near the vicinity of the internal inguinal ring. All patients underwent both the first and second stages of a the Fowler-Stephens procedure, except those with the testis near the internal ring. The later underwent a one-stage laparoscopically-assisted orchidopexy. Only two patients had an atrophic testis observed in the scrotum after the complete Fowler-Stephens procedure. It was concluded that the results of laparoscopic management of the non-palpable testis were good and superior in terms of morbidity, complication rate and length of hospital stay to previously reported case series.

Laparoscopic appendectomy: an unnecessary and expensive procedure in children. Little D C, Custer M D, May B H, Blalock S E, Cooney D R. J Pediatr Surg 2002; 37: 310-317.

Laparoscopic appendicectomy has been established over the last decade as a safe and reasonable alternative to open surgery in the treatment of acute appendicitis in children. However, the relative benefit of laparoscopic over open appendicectomy has not been established. Questions remain regarding the marginal advantages against the cost effectiveness of this approach. The aim of this study was to compare laparoscopic and open appendicectomy in a prospective randomised study in the treatment of acute appendicitis in children. Overall, 88 children were included in the study (43 boys and 45 girls, mean age 10.5 years). Patients were randomised to either open or laparoscopic surgery. Open appendicectomy utilised a 3-4 cm right lower quadrant muscle-splitting incision. Wounds were closed without drains. Laparoscopic appendicectomy was performed using a standard 3-trocar technique. Antibiotic prophylaxis (gentamicin, clindamycin and ampicillin) was provided. Perforated appendicitis was found in 21 (24%) of patients. Patients were discharged when afebrile and tolerating normal diet. No difference in postoperative analgesia, resumption of oral intake, length of hospitalisation, return to normal activity or morbidity was identified between the two groups. Laparoscopic appendicectomy was associated with longer operating time and increased costs. It was concluded that laparoscopic appendicectomy in children is not associated with same advantages reported in adults. Laparoscopic is more expensive and offers no advantages related to pain relief, length of hospital stay or return to normal activity.

Successful non-operative management of typhlitis in pediatric oncology patients. Schlatter M, Snyder K, Freyer D. J Pediatr Surg 2002; 37: 1151-1155.

The term typhlitis was introduced in 1970 to describe necrotising enterocolitis in terminally ill patients with acute leukaemia. The administration of chemotherapeutic agents or the development of neutropenia is usually the precipitating event. The exact aetiology is unclear but several mechanisms have been proposed. The optimal management of these patients remains to be determined. Trends have varied between operative and non-operative approaches. The aim of this paper was to retrospectively review the outcome of the non-operative management of paediatric oncology patients with typhlitis . Medical records of paediatric haematology and oncology patients treated over a 10-year period were reviewed. Twelve patients were identified. Ten patients (83%) with a CT scan suggestive of the diagnosis were treated successfully non-operatively. Management usually consisted of bowel rest, antibiotics and parenteral nutrition. Two patients (17%) in whom a CT scan was not obtained underwent surgery for presumed appendicitis and a pneumoperitoneum. Typhlitis was an incidental finding at the time of surgery. One of these patients died as a result of septic complications and was the only mortality in the series. It was concluded that paediatric oncology patients with typhilitis can be successfully managed non-operatively with bowel rest, antibiotics and parenteral nutrition. The early use of CT scanning helps to facilitate the diagnosis and may provide the ability to differentiate typhilitis from other abdominal diseases that may require surgery.

Ad libitum feeding: safely improving the cost-effectiveness of pyloromyotomy. Puapong D, Kahng D, Ko A, Applebaum H. J Pediatr Surg 2002; 37; 1667-1668.

The typical postoperative feeding regime for babies undergoing pyloromyotomy for hypertrophic pyloric stenosis has long been one of considerable complexity. Although the specifics of these protocols has varied, they have all been based on an assumption, they have all been based on an assumption that gradual advancement in both the amounts and strengths of feeds reduces the amount of postoperative vomiting. The evidence to support this theory is limited. The aim of this study was to determine as to whether an ad libitum feeding regime could reduce the length of hospital stay without an increase in morbidity. Overall, 56 patients undergoing pyloromyotomy were evaluated. The first 31 were treated with a traditional protocol and the next 25 received ad libitum feeding. Time to first full-strength feed, amount and time of any emesis and time to discharge were recorded. Hospital costs and number of readmissions were assessed. Patients in the ad libitum group had a statistically shorter postoperative stay (25 vs. 39 hours. p<0.05). More patients in the ad libitum group experienced more postoperative vomiting but this was not statistically significant. It was concluded that ad libitum feeding resulted in a significant reduction in postoperative stay. It is safe, simple and cost-effective and is not associated with an increased in postoperative morbidity.

Early experience with needleoscopic inguinal herniorrhaphy in children. Prasad R, Lovvorn H N, Wadie G M et al. J Pediatr Surg 2003; 38: 1055-1058

Laparoscopic herniorrhaphy in children is relatively new. The initial use of laparoscopy in the paediatric hernia patient was to examine the contralateral groin, either through a remotely placed port or the open processus vaginalis during open unilateral hernia surgery. More recently there have been numerous reports describing various laparoscopic techniques for paediatric inguinal hernia repair. The purpose of this study was to evaluate the safety and efficacy of a needleoscopic technique for paediatric inguinal herniorrhaphy. Twelve consecutive children older than 6 months with unilateral (n=8) or bilateral (n=4) inguinal hernia underwent needleoscopic herniorrhaphy. A 1.7 mm needle laparoscope was introduced through the umbilicus and a grasper placed laterally was used for retraction. A curved stainless steel awl was introduced percutaneously anterolateral to the internal ring and was used to pass a ligature circumferentially to complete an extraperitoneal ligation of the sac without handling the vas deferens and spermatic vessels in males. Data recorded included operating time, postoperative discomfort, recurrence and complications. The mean operating time was 23 minutes for unilateral and 46 minutes for bilateral hernias respectively. No required more than simple analgesia. There was no recurrence or complications. It was concluded that needleoscopic inguinal herniorrhaphy in children is safe and effective. The technique potential offers less risk of injury to cord structures with superior cosmetic result.

Outcome of submucosal injection of different sclerosing materials for rectal prolapse in children. Fahmy M A B, Ezzelarab S. Pediatr Surg Int 2004; 20: 353-356.

Rectal prolapse is a common problem in children living in tropical and developing countries. In this population, cystic fibrosis is rare as an aetiological factor but enterobiasis and amoebiasis are commonly associated with the condition. Injection sclerotherapy is one of the commonly used modalities, with various different materials being used. The aim of this study was to retrospectively review the medical records of all children presenting with a rectal prolapse over a three-year period in order to define possible aetiological factors and compare different treatment modalities. The records of 130 children were reviewed. Their ages ranged from 6 months to 12 years (mean = 6 years). Overall, 45 patients (35%) responded to conservative treatment and 85 (65%) required injection sclerotherapy. The sclerosing agents used were 98% ethyl alcohol (n=35), 5% phenol in almond oil (n=22) and polysaccharides (n= 28, Deflux). The follow-up period ranged from 2 months to 3 years. Clinical data and all complications were recorded. Repeated treatment was required in 30% of patients treated with 98% ethyl alcohol, but complications were uncommon. The use of 5% phenol in almond oil was associated with complications in 27% of patients (mucosal sloughing and perianal fistulae). Deflux had the lowest complication rate and long-term follow-up showed no recurrence. It was concluded that in the management of rectal prolapse in children, 5% phenol in almond oil should be avoided because of its high complication rate. Alcohol is cheap and has a low complication rate and should be considered as an alternative to Deflux.

Retrospective comparison of open versus laparoscopic pyloromyotomy. Hall N J, Ade-Ajayi N, Al-Roubaie J et al. Br J Surg 2004; 91: 1325-1329.

Infantile hypertrophic pyloric stenosis is a common condition in infancy with an incidence of 1-3 per 1000 live births. It is one of the commonest conditions requiring surgical intervention in early life. The surgical operation of choice is the pyloromyotomy in which the hypertrophic muscle is split leaving the mucosa intact. The operation has a high success rate, a low risk of complications and can be performed quickly ensuring minimal anaesthetic time. A laparoscopic approach was first described in the 1990s. Its potential advantages include shorter recovery time and improved cosmesis but us superiority over the open approach has not been demonstrated unequivocally. The aim of this paper was to report on the experiences of one institution and to identify any benefits over the open procedure. A retrospective review of all 87 pyloromyotomies conducted over a 39 month period since the first laparoscopic pyloromyotomy was performed was undertaken. Data from 39 infants who underwent laparoscopic pyloromyotomy was compared with those for 38 infants who underwent pyloromyotomy via a periumbilical incision. Patient demographics were similar between the tow groups. The operation was longer for laparoscopic pyloromyotomy than for the open procedure (median of 50 vs. 30 mins; p=0.001). There was no difference in recovery time, postoperative length of hospital stay, complication rates and postoperative analgesia requirements between the two groups. It was concluded that laparoscopic pyloromyotomy has been incorporated successfully into the authors' standard working practice. Complication rates and recovery times were similar to those achievable with the open procedure. There was no clear benefit of the laparoscopic approach.

Trends in paediatric circumcision and its complications in England between 1997 and 2003. Cathcart P, Nuttall M, van der Meulen J et al. Br J Surg 2006; 93: 885-890.

Circumcision is a common paediatric surgical procedure. The proportion of boys circumcised during childhood varies markedly by country, religion and to some extent by socioeconomic group. The only undisputed medical indications for circumcision are pathological phimosis and recurrent balanitis. Pathological phimosis can be defined as narrowing of the preputial orifice, leading to an inability to retract the foreskin. It should be distinguished from physiological phimosis, which is a normal part of penile development. It has been suggested that too many boys undergo circumcision. The aim of this study was to describe how circumcision rates have changed in England between 1997 and 2003, including data on complication rates and how age, medical indication and surgical speciality affect postoperative haemorrhage rates. Data were extracted from the Hospital Episode Statistics database of admissions to NHS hospitals in England. Patients were included in the study if an OPCS code for circumcision was present in any of the operative procedure fields of the database. Overall, 75868 boys below 15 years of age were included in the study. Circumcision rates declined by 20% between 1997 and 2003. Between 2000 and 2003, circumcision rates remained static at 2.1 per 1000 boys per year. Circumcision rates fell by 31% for boys aged 0-4 years, 9.3% for bots aged 5-9 years and increased by 7.7% in boys aged 10-14 years. Overall, 90% of circumcisions were done for phimosis and 1.2% of boys experienced a complications. It was concluded that circumcision rates in England fell up until 2000, particularly in those aged under 5 years, in who a pathological phimosis is rare. The circumcision rate remains five times higher than the reported incidence of phimosis.

Characteristics of perianal abscess and fistula-in-ano in healthy children. Serour F, Gorenstein A. World J Surg 2006; 30: 467-472.

A relatively small number of studies have been published regarding the management of perianal abscess (PA) and fistula-in-ano (FIA) in children. Pathophysiology and treatment of PA and FIA in children are controversial and several differences have been identified from the adult population. The aim of this study was to summarise one units experience about the characteristics and treatment of PA and FIA in healthy children. A retrospective review was undertaken of all children treated for PA and/or FIA older than 2 years over a 13 year period. Overall, 40 patients were identified with 37 (93%) being bots ranging from 2 to 14 years of age. At first examination, the diagnosis was PA in 36 patients and FIA in 4 patients. The primary local treatment of PA was drainage (needle aspiration in 26 patients and incision and drainage in 4 patient) and local care in 6 patients. All patients received antibiotics. Overall, 29 children (80%) had primary cure of the abscess. Evolution included recurrent abscess in 3 patients (8%) and FIA in 4 patients (11%). Crohn's disease was diagnosed in only one boy with an abscess of long duration. No patient developed a new PA in another location or a recurrent FIA. Four male patients had a FIA of long duration. One patient underwent fistulectomy. Crohn's disease was found in 3 other children and treated conservatively. It was concluded that drainage of PA by needle aspiration with antibiotic therapy was effective in children older than 2 years of age with a low rate of evolution toward a FIA. Associated pathology must be ruled out in older children with FIA.