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
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:
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
Laparoscopic evaluation and management of
nonpalpable testes in children. Lotan G, Klin B, Efrati
Y, Bistritzer T. World J Surg 2001; 25:
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;
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
Early experience with needleoscopic
inguinal herniorrhaphy in children. Prasad R, Lovvorn H N,
Wadie G M et al. J Pediatr Surg 2003; 38:
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:
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;
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.
Recovery after open versus laparoscopic pyloromyotomy for
pyloric stenosis: a double-blind multicentre randomised trial. Hall
N J, Pacilli M, Eaton S et al. Lancet 2009;
Pyloromyotomy for infantile pyloric stenosis has
traditionally been performed through either a right upper quadrant or
circumareolar incision. A laparoscopic approach has recently gained
popularity but its effectiveness remains unproven. The aim of this
study was to compare outcomes after open or laparoscopic pyloromyotomy for
the treatment of pyloric stenosis. An international multicentre,
double-blind, randomised controlled trial was conducted over a three year
period. Overall, 180 infants were randomly assigned to open (n=93)
or laparoscopic pyloromyotomy (n=87) with minimisation for age, weight,
gestational age at birth, bicarbonate at initial presentation feeding
type, preoperative duration of symptoms and trial centre. Infants
with a confirmed diagnosis of pyloric stenosis were eligible.
Primary outcomes were time to full enteral feeding and duration of
postoperative recovery. Participants, parents and nursing staff were
unaware of treatment. Data was analysed in an intention to treat
basis with regression analysis. Median time to achieve full enteral
feeding in the open pyloromyotomy group was 23.9 h (16.0-41.0) versus 18.5
h (12.3-12; p=0.002) in the laparoscopic group. Post operative
length of stay was 43.8 h (25.3-55.6) vs. 33.6 h (22.9-48; p=0.027).
Postoperative vomiting and intraoperative and postoperative complications
were similar between the two groups. It was concluded that both open
and laparoscopic pyloromyotomy are safe procedures for the management of
pyloric stenosis. However, laparoscopy has advantages over open
pyloromyotomy and its use should be recommended in centres with suitable