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Einar Arnbjörnsson, Christina Granéli, Anna Börjesson, Pernilla Stenström

Department of Pediatric Surgery, Skåne University Hospital and Institution of Clinical research, Lund University, Lund, Sweden

 

Correspondence:

Einar Arnbjörnsson

Department of Pediatric Surgery

Skåne University Hospital and Institution of Clinical Research, Lund University

Lund, Sweden

E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.  

 

Abstract

AimTo evaluate the indications for, and outcome, of appendicostomy for patients with Hirschsprungs disease (HD) who underwent transanal endorectal pull-through (TERPT).

Method: Children with HD > 4 years old who received an appendicostomy between 2005 and 2011 at a tertiary pediatric surgery center were included. Pre- and post-appendicostomy bowel function was evaluated by a bowel function score. HD-patients not receiving an appendicostomy were the controls. The study was approved by an institutional ethics committee (2010/49).

Results: Seven of 37 HD-patients received an appendicostomy. Syndromes were present in 43% of the appendicostomy and 6% of the controls (controls reported absence of fecal accidents (p=0.297). Three (60%) with appendicostomy and 14 (47%) controls, respectively, reported absence of soiling or soiling RPT.

Keywords: Hirschsprungs disease, transanal endorectal pull through, bowel function score, antegrade continence enema, appendicostomy.

 

Introduction

Hirschsprung disease (HD) is a congenital disease in which the absence of ganglion cells in the intestinal muscular layer leads to aperistalsis of the affected bowel. A common surgical treatment used for HD is transanal endorectal pull-through (TERPT) [1]. However, absence of bowel control and fecal incontinence may follow. Furthermore, patients with Down syndrome or other disorders and HD may require additional attention to their bowel function [2-5].

Fecal incontinence, constipation, and bowel obstruction are symptoms often initially treated by dietary modification, medication, and training to instill regular toilet habits. Some patients will nonetheless be unable to achieve bowel control. The inability to control bowel movements may carry a negative social impact that can be severely limiting as the child grows older [6]. In some of these patients, rectal enema treatments could be effective for achieving improved bowel function. However, some patients do not tolerate rectal enemas or would prefer to be more autonomous, in which case antegrade colonic enemas (ACE) through an appendicostomy might be an option.

Since 1990, when appendicostomy was proposed for administering an antegrade continence enema [7], there have been several reports on its benefits and disadvantages for different diagnoses [8-12]. There are various appendicostomy techniques described [7, 11, 12-17]. Appendicostomy outcomes have been reported in children mainly with spinal bifida, intractable functional constipation, or anorectal malformation [9-11]. Reports on the long-term functional results of an appendicostomy in children with HD who have undergone TERPT are reported in mixed groups of diagnosis (REF med HD), but separate evaluation could be valuable for selecting patients with HD who might benefit from an appendicostomy. The aim of this study was to evaluate the indications and outcomes of appendicostomy for antegrade enemas in patients with HD who underwent TERPT. The secondary aim was to describe how appendicostomy is used in patients with HD and parents' satisfaction with appendicostomy.

Materials and Methods

Settings

The study was performed at a tertiary center for pediatric surgery that serves a region with 1.8 million residents and 22,000 births annually.

Patients and study setting

HD was diagnosed in all the patients by rectal biopsy and anography. The study patients included all patients with HD who underwent TERPT from 2005 to 2011 and subsequent appendicostomy until 2014. The control group included patients with HD who underwent TERPT, but not appendicostomy, from 2005 to 2011 and were aged older than 4 years at follow-up. The appendicostomy-patients’ bowel symptoms before appendicostomy were recorded retrospectively from medical charts. The patients’ guardians were asked if they would come in for follow up and would consent to an interview after the appendicostomy. In an outpatient setting, they were questioned about bowel symptoms, appendicostomy use, and satisfaction with the appendicostomy. Information on the bowel symptoms of the control patients was obtained from telephone interviews or during counseling at the outpatient clinic.

Scoring of bowel symptoms

Bowel function was assessed by a bowel function scoring system with bowel function scores (BFS’s) ranging from worse to better function: 1 to 20 [18].

Bowel management program and indications for appendicostomy

All children who undergo TERPT for HD are routinely offered an individualized bowel management program at our center. Each patient’s bowel habits and symptoms are regularly checked and scored, and a BFS is recorded. The patient and family are counseled, and recommendations for obtaining improved bowel function are provided if needed.

If the patient requires enemas but neither the family nor the patient accept the rectal approach, appendicostomy is evaluated as an alternative. Another reason for appendicostomy is patient desire for greater autonomy.

The pediatric surgeon and the colorectal nurse perform repeated evaluations prior to a final decision for performing appendicostomy. The operation is only performed after a comprehensive discussion with patients and their families, which includes possible complications and failure in bowel control despite the administration of antegrade continence enemas (ACEs) through an appendicostomy. Throughout participation in the bowel management program, the family and patient regularly receive counseling by a colorectal pediatric surgeon and with a colorectal nurse as needed. The family and patient are also routinely offered psychological consultation according to the local follow-up program.

Surgical techniques: TERPT and appendicostomy

The TERPT procedure was performed in accordance with the technique described in 1998, with rectal mucosectomy, colectomy of the aganglionic segment, and normoganglionic colon pull-through performed through the anus [1]. The length of the muscular cuff was 2–3 centimeters. Focus was put on not to damage the anal canal during the operation. Colonic resection was extended to include the transition zone, and any dilated bowel was resected, along with the aganglionic bowel. The end of the proximal bowel had to demonstrate a normal frequency of mature ganglionic cells, without any signs of nerve hypertrophy, according to the pathologists’ report on a frozen section obtained during the operation. The final pathology report included a statement on positive staining for calretinin.

At our center, a laparoscopic approach was used for appendicostomy, which was carried out by 2 experienced pediatric surgeons. The laparoscopic procedure involved open access at the umbilicus with a 5-mm 30-degree laparoscope. A 5-mm laparoscopy port was introduced at the right lateral inguinal fossa, at the point selected for the appendicostomy stoma. A grasper was introduced through the port to grab the appendix and pull it out through the port hole. The tip of the appendix was then opened, and 5-10 mm of it was removed. The wall of the appendix was sutured to the skin using a V-Y plastic with absorbable sutures. Until 2009, a Foley catheter® was left in the stoma and removed after 6 weeks. After 2009, a Chait button® was placed in the stoma and either removed after 6 weeks or left in place to avoid repeat catheterizations of the stoma in very young or active children. The Chait button® was then replaced every 6 months.

Appendicostomy – complications and use

Peri- and post-operative complications of appendicostomy were retrospectively recorded from medical records. Infection was defined as a positive culture from a specimen obtained from the stoma site in combination with clinical signs of infection. A questionnaire on the use of and satisfaction with the appendicostomy was administered during follow-up counseling sessions. The questionnaire had been used in a previous study [19] and includes questions regarding time needed to administer enemas, time until the bowel was completely empty after enema administration, type of enema used, and degree of satisfaction with the appendicostomy.

Statistical analysis

Nonparametric statistics were used, since data could be skewed because of the small number of patients. This is based on the following observations: 1. Analyzing paired data as unpaired does not increase the type 1 error for the t test. 2. The WMW test is the nonparametric equivalent of the t test. P values < 0.05 were considered significant. The Fischer exact probability test 2×4 with the Freeman-Halton extension yielded the same results and was also used. All statistical analysis was performed by a statistician.

Ethics

The regional research committee approved the study (registration number 2010/49). Approval from each patient´s guardians was obtained before including the child in the study. Intention to treat was the main diagnostic strategy used for all patients. All evaluations, treatments, and procedures described in this report were the standard of care. All data were maintained as confidential in the hospital file system and were coded in the study investigators’ computers.

Results

Indications for appendicostomy

A total of 7 children with HD who underwent TERPT subsequently received an appendicostomy. Their median age at appendicostomy was 5 (2-8) years. Other patient characteristics and details on the procedure are shown in Table 1. All 7 patients had been using rectal enemas. The rectal enemas had a satisfactory effect on individual bowel management problems, but the treatment had failed in 5 of the 7 because of the following issues: low compliance secondary to anal pain (n=3); patient intolerance to enema administration (n=4), and both parent and patient psychological intolerance to rectal enemas (n=5). Indications for appendicostomy for the other 2 patients were desire for increased autonomy and easier administration and emptying while sitting on a toilet (n=2) (Table 1).

Complications associated with TERPT and appendicostomy

There were no recorded intraoperative complications during either the TERPT or the appendicostomy procedures. A laparoscopic appendicostomy was converted to open surgery for 1 patient because of intra-abdominal adhesions. Post operative no additional pull-through interventions were required, although 1 patient developed a rectourethral fistula and therefore underwent additional surgery.

A total of 6 postoperative complications after appendicostomy occurred in 4(57%) patients and included granuloma (n=1), local infection (n=2), and irritation at the site of the stoma (n=3). No pain at the site of the appendicostomy was reported. All infections were treated by oral antibiotics and/or sterile washing, and no additional surgical interventions were needed because of infection. No one still using the appendicostomy at the follow-up reported localized pain associated with the stoma.

Outcome and use of the appendicostomy

At the time of follow-up, 2 of the 7 children no longer used their appendicostomy. Both had received colostomy at 8 and 10 months respectively after the appendicostomy procedure. The reasons for colostomy were development of a recto urethral fistula in the one patient who needed a reoperation, and the other child, who also had Down syndrome, had colostomy because of severe obstructive symptoms and a painful anal stricture. The five patients still using their appendicostomy used it daily as follows: 2 children used it in the morning and evening, and 3 other children used it in the evening only. Four children used a Chait button because they preferred to avoid catheterization. The other used intermittent catheterization. All of the parents would recommend appendicostomy to other families in the same situation (Table 2).

Two children were still using diapers, 1 because of late maturity and urinary incontinence due to Down syndrome and the other because of a rare chromosomal translocation syndrome which led to concomitant urinary outlet symptoms.

None of the children with appendicostomy had been treated with botulinum toxin A injections before the procedure, because the treatment had not yet been introduced in our department at that time. Three children, all with some syndromes, had obstructive symptoms that were treated by botulinum toxin A injections after the appendicostomy. Two of them were successfully treated by the combination of ACE through the appendicostomy plus botulinum toxin A, while the third child needed a colostomy.

Bowel function scores before and after appendicostomy

The pre- and postoperative BFS of the children who received an appendicostomy are shown in Table 3, which shows that the bowel scores were significantly increased for the patients who still used their appendicostomy.

Control patients without appendicostomy

During the study period a total of 32 patients with HD were operated on with TERPT but not appendicostomy. After the exclusion of 2 patients who had migrated 30 children without appendicostomy were included in the study as controls. Their median age at the time of the study was 5.5 (4-9) years. There were no intra- or postoperative complications associated with TERPT. At follow-up, 5 patients used rectal enemas regularly because of obstructive symptoms and 2 of them also fecal incontinence. Two of these 5 patients also received botulinum toxin A injections.

Comparison of BFS between appendicostomy patients and controls

The BFS of each symptom of the children needing appendicostomy were significantly lower before appendicostomy than the BFS of the control patients (Table 4). At follow up after appendicostomy; there was no difference between the BFS of the 5 children with appendicostomy and the BFS of the control patients. Some of the BFS outcomes of the children with appendicostomy were better (Table 5).

Discussion

This study showed that ACE through an appendicostomy stoma can achieve increased bowel control for selected children with HD who have undergone TERPT. Our patients who were considered for appendicostomy and had favorable outcomes after the procedure were those with very poor bowel function, those who had low compliance with rectal enemas, and those with a syndrome. The children with an appendicostomy who continued to use it to administer ACE achieved a level of bowel control similar to the bowel control of children with HD without an appendicostomy.

To our knowledge, there are no published reports on this select group of patients with appendicostomy. Prior studies have reported data from mixed cohorts of patients with a variety of conditions, including anorectal malformations, HD, idiopathic constipation, neurological disorders such as spine bifida, and post-traumatic disorders with various indications [9-12, 13, 20]. Our aim was to clarify the indications for appendicostomy in children with HD who have undergone TERPT. The results confirmed the findings of similar studies that were performed on other types of patients; namely, that ACE through an appendicostomy is effective and improves fecal continence and patient autonomy [14, 20].

The long-term complication rate of children undergoing an appendicostomy was high (57%) but was in line with previous studies on appendicostomy in mixed diagnosis groups reporting 23–100% complications [19, 20-23]. Previously, the most frequently reported complications associated with appendicostomy were stenosis, pain during catheter insertion, and leakage [8, 21, 23]. It has been suggested that the complication rate might be decreased using a Chait cecostomy regarding infections and fistula formation [24]. It has also been speculated that younger children might have fewer complications with their appendicostomy because either the appendicular valve is continent in young children or the Chait in the appendix, which is used more frequently in young children and might be protective [19, 25]. In our study, the median age was low and the frequency of Chait button use was high, which might explain why minor complications were reported. None of our patients developed stenosis, although previous reports have indicated that this is one of the major problems emerging during the years following an appendicostomy in 15–20% of older children [8, 15]. It is possible that stoma stenosis did not develop in our patients because we left a catheter in place for at least 6 weeks after surgery, and most of these children continued to use the Chait button.

ACE had been proposed with the main purpose of improving personal control and hygiene, but it has primarily been studied in older patients [19]. However, the timing of appendicostomy and bowel control problems have not been evaluated in children with HD. Appendicostomy for ACE may seem to be an aggressive treatment for bowel management in preschool children. At our institution, we chose to perform appendicostomy in select patients with HD, independent of age, who had severe bowel management issues and who did not obtain sufficient management with conventional regimens such as dietary modifications, oral medications, and rectal enemas. This requires detailed knowledge not only of the child, but also of the child’s family. In the study cohort, all families were well informed of available treatment options and insisted upon a solution for their children’s problems. A positive finding of our study was that all guardians indicated that they would recommend appendicostomy to the family of a child with HD who had the same bowel management issues. This result agrees with a study of children with anorectal malformations who underwent the same operation [19]. Results from that study led the authors to suggest that patients should receive an appendicostomy before they reach school age to provide them with early autonomy and the possibility of being clean during the school day.

However, there have not been any valid studies that have identified the best age to perform an appendicostomy. Additional studies are required as to decide whether it is beneficial for a child to have an appendicostomy for ACE, instead of continuing rectal enemas despite a child’s dislike of the procedure. In our study, it was difficult to interpret whether improved bowel control was an effect of older age versus ACE. This issue is a consideration as the patients were older when they were assessed after ACE initiation than they were when the appendicostomy was performed. It has been suggested that many patients with HD develop improved bowel control with age. A recent study [26] has shown that after TERPT, incontinence scores, but not constipation scores, are positively correlated with follow-up duration. This result indicates that improved continence could be expected over time. Moreover, for patients with HD, appendicostomy might be used as a tool during the worst years and stopped at a later time.

We chose to use BFS because this score has been previously used for patients with HD and because it seems to consider many potential problems. However, the term constipation might be misleading and must be used and analyzed with caution. The real problem might be obstruction and bowel emptying issues. A physiological obstruction can sometimes be successfully treated by botulinum toxin A [27]. For treating obstructive symptoms, current bowel management includes botulinum toxin A injection as the first option before an appendicostomy or a colostomy.

One limitation of this study is that a small study group was assessed, with 7 of the study patients receiving an appendicostomy. Another potential limitation is that bowel function was assessed at a visit comprising an interview. The results could have been skewed to obtain a better outcome given the closeness of the patients and their families. We attempted to diminish this bias by having an independent person, who had not been previously involved in patient care, assess the BFS and appendicostomy use. However, strength of this study is that no patients were lost to follow-up and that the patients were treated at the same center where all information was also collected. All residents have access to health care free of charge at the time of need and any dropout due to socioeconomic factors is unlikely.

The bowel management program used to day differs from that used during the period of the study. The first step in the bowel management program is dietary counseling, which includes dietary modifications. If bowel symptoms are not improved, and if constipation or obstruction is the main problem, oral medications such as Loperamid are prescribed. If it turns out that the patient’s main symptom is outlet obstruction, botulinum toxin A is injected into the anal sphincter. If the patient continues to have fecal incontinence and/or constipation, the patient is introduced to the use of rectal enemas.

In conclusion, ACE administered through an appendicostomy stoma appears to improve the bowel control in some children with HD who had undergone TERPT. Using a standardized method for evaluating and selecting the patients most likely to benefit from an appendicostomy is important.

Acknowledgments

We are grateful to Fredrik Nilsson, biostatistician at the Competence Centre for Clinical Research, Skåne University Hospital, LUND, Sweden, for statistical advice. This manuscript has been edited by native English-speaking medical experts from BioMed Proofreading LLC.

Editorial editorial

Prof. Dr. Dan Osvald Lucaciu
Rehabilitation Clinic
Cluj-Napoca, Romania

 

Osteoarthritis is the most common type of arthritis, representing a degeneration of joint cartilage and subchondral bone. It is most common in knees and hips, usually affecting people over 50 years, but can also be found in younger people as well. When symptoms cannot be controlled by conservative treatment including weight reduction, physiotherapy, intraarticular injections, topical or systemic drugs, then total knee replacement is the treatment of choice. Arthroscopy is a minimally invasive procedure for diagnosing and treating joint pathologies.

There has been a great debate over the last years regarding the role of arthroscopy in knee osteoarthritis. The need for an evidence-based decision required high quality randomized control studies, which now seem to clarify the indications and contraindications of arthroscopic surgical treatment in knee osteoarthritis.

Current evidence shows that there is no difference in functional scores, pain and quality of life between groups receiving physical therapy and groups undergoing arthroscopic treatment. Moreover, there has been no difference in groups receiving arthroscopic treatment and placebo surgery for knee osteoarthritis. As a result, American Academy of Orthopaedic Surgeons strongly recommend against performing arthroscopy in patients with primary symptomatic osteoarthritis of the knee.

On the other side, we consider that arthroscopy has its indications for associated pathologies in an osteoarthritic knee. Mechanical symptoms including locking and jamming of the knee due to lose bodies, catching of the knee due to meniscal or chondral flaps, represent indications for arthroscopic surgery. It is sometimes difficult to decide whether the knee pain is due to meniscal tears, which may be managed arthroscopically, or due to osteoarthritis. A pain with acute onset, limited to medial joint line (sometimes lateral joint line) and tenderness when palpating the medial or lateral joint line usually points acute meniscal pathology. Of great importance is that surgical outcomes might only reduce mechanical symptoms and not relieve pain or reduce knee swelling. Therefore the patient needs to be well informed regarding the possible outcomes. Furthermore, we consider that degenerative meniscus pathology should not be addressed arthroscopically, due to poor results in current literature.

A great importance is the presence of sub-chondral stress fractures associated to meniscal pathology, especially in elderly. In such cases, the stress fracture can produce the pain, and not the meniscal pathology. If partial meniscectomy is performed in such cases, pain can be aggravated by the procedure. Therefore, an MRI is an examination of great importance for a thorough examination of the knee pathology to prevent wrong surgical indication.

Another indication is a limited chondral lesion, usually medial. In this setting, marrow stimulation, matrix-induced autologous chondrocyte implantation, osteochondral autograft transfer and osteochondral allograft are of great importance with good outcomes, especially in younger patients. Intraarticular soft tissue pathology can also be addressed arthroscopically in case of acute onset, for example pigmented villonodular synovitis.

As a conclusion, arthroscopy has limited indications in knee osteoarthritis, but when this minimally invasive surgery is adequately performed, it can reduce symptoms and delay the need of a total knee replacement, sometimes even prevent it. However, in most cases, conservative treatment consisting in physiotherapy can have the similar effect on symptoms compared to arthroscopic surgery. 

Mohamed Shoukry, Munther Haddad

 

Abstract

Background: Accidental ingestion of foreign bodies in young children and toddlers is common. Most will pass spontaneously without any harm. However, when foreign bodies are magnetized, significant problems can occur. Exceptionally strong magnetic pull and 2 magnets in separate parts of alimentary canal can quite easily attract, potentially causing damage to the intervening structures. We present our experience where earlier surgical intervention was required to extract magnets.

Material and methods: A review of case notes of three patients referred to a tertiary Paediatric Surgery centre during the period March 2011 to August 2014. They have completed follow up period for 2 years at least before discharge them back to GPs care successfully. Retrospective review of similar published articles on PubMed and midline.

Conclusion: Authors recommend close observation, high index of suspicion and early surgical intervention. More public and medical awareness is needed of dangers posed by these readily available objects.

Keywords:  magnetic FB, early surgical intervention, children

 

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Ahmed H. Al-Salem, Mukul Kothari

 

Abstract

Isolated extrahepatic biliary injury in children is extremely rare and there are no previous reports of such an injury or its management in newborns. We present a case of iatrogenic extrahepatic biliary injury in a newborn and describe a technique to treat it.

Keywords: biliary injury, children, iatrogenic, treatment

 

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Hemant Kumar, Ramnik Patel, Bharat More, Bala Eradi, Haitham Dagash, Ashok Rajimwale

 

Abstract

A preterm infant and twin 1 of the dichorionic diamniotic twins born at 27+3/40 weeks gestation weighting 790 grams who had on-going respiratory distress developed total gastric rupture following difficult intubation. Plain chest, abdominal and right lateral decubitus radiographs helped in diagnosis. Infant had resuscitation and underwent exploratory laparotomy, closure of massive gastric rupture and temporary gastrostomy for decompression initially and feeding later uneventfully. Neonatal gastric perforation is rare, serious and potentially lethal if not detected early and treated effectively. It could be traumatic, spontaneous or ischaemic. Our case had acute barotrauma following accidental oesophageal intubation and closed loop obstruction due to cardiac and pyloric sphincter at both ends and relatively high velocity air entering under pressure leading to anterior gastric wall blast. Primary repair of the stomach rupture with temporary gastrostomy is very useful and effective therapeutic strategy in these very sick preterm infants.

Keywords: preterm, gastric perforation, pneumoperitoneum, acute pneumoscotum, peritonitis, neonatal, gastrostomy, traumatic, iatrogenic

 

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Prashant Sadashiv Patil, Gupta Abhaya, Kothari Paras, Kekre Geeta, Deshmukh Shahaji , K Vishesh Dikshit, Apoorva Kulkarni

 

Abstract

The common perception is that children rarely develop severe forms of tuberculosis. A variety of sequelae and complications can occur in the pulmonary and extrapulmonary portions of the thorax in treated or untreated patients. Lung gangrene due to tuberculosis has been described in adult patients. However lung gangrene due to tuberculosis is rarely reported in paediatric patients. We report a case of 2 year old female child with lung gangrene and massive cavity due to tuberculosis.

Keywords: pulmonary tuberculosis, gangrene, thoracotomy, pneumothorax.

 

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Gauthamen Rajendran, Kokila Lakhoo, Arnwald Choi, Frances O’Brien

 

Abstract

Background: There is a paucity of data regarding the perioperative care in neonates.

Objective: To collect data relevant to perioperative care in a neonatal intensive care unit (NICU), with a focus on identifying key areas of clinical care around the time of surgery.

Methods: Perioperative data of neonates who underwent surgical intervention in 2013 within a UK NICU were collected retrospectively. Temperature, blood sugar levels, serum sodium levels, blood gas parameters, weight and fluids used in the perioperative period along with demographic details were collected. The data was analysed for the distribution and trend of temperature, blood sugar and parameters pertaining to fluid, electrolyte and acid-base balance in the perioperative period.

Results: Forty-eight neonatal surgical procedures in 45 neonates were studied. Median gestational age (IQR) at the time of surgery and weight before surgery were 37 (33 to 39) weeks and 2750 (1872 to 2942) grams. The number of surgical procedures for NEC, and abdominal wall defects were 14 and 11 respectively; 23 neonates had surgery for other reasons. Incidence of postoperative hypothermia was 15%. Hyperglycaemia and hypocapnia were more common post-operatively when compared to preoperative findings (63% vs 13% and 19% vs 0% respectively). Hyponatraemia was common preoperatively (42%) but the incidence remained static postoperatively. Hypernatremia was uncommon. A slow and sustained increase in blood sugar levels were noticed in preterm and NEC neonates. Statistically significant weight gain occurred in preterm neonates.

Conclusions: Pre-operative hyponatraemia and post-operative hyperglycemia and hypocapnia require attention. Preterm neonates and neonates with NEC and abdominal wall defects are the high risk groups.

Keywords: newborn, perioperative care, preterm infants, hypothermia, hyperglycemia

 

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Moustafa Hamchou, Hilal Matta, Bahjat Sahari, Adnan Swid, Ahmed Al-Salem

 

Abstract

Background: Obesity and overweight in children is increasingly common worldwide and known to be associated with morbidity. Dietary manipulation and changing their life style may prove to be effective in slightly overweight children but are not effective in obese children and those with comorbidities.

Patients and method: This is a retrospective study of all morbidly obese children who had laparoscopic sleeve gastrectomy (LSG).

Results: Over a period of 4 years (June 2012 - June 2015), 26 children (14 female: 12 male) had LSG. Their mean age was 12.6 years (10.5-15 years) and their mean BMI 47.2 (40-65). Twenty-one (80.8%) of our patients had associated comorbidities. These included sleep apnea (7 patients), hypertension (3 patients), type 2 diabetes mellitus (3 patients), bronchial asthma (4 patients), enuresis (2 patients), and foot and joint problems (2 patients). Two of our patients had Prader–Willi syndrome. The mean follow-up was 1.5 years (1 year - 3 years). The mean operative time was 120 minutes (90-150 minutes). The mean hospital stay was 4 days (3-7 days). Only one of our patients was admitted to the intensive care unit for one day observation because of severe sleep apnea. There were no major complications and no leaks. There was an overall 65.2% weight loss and 70% improvement in comorbidities. Their mean postoperative BMI was 30.75 (24-38). There was also marked improvement in quality of life, self-esteem, productivity and social functioning. There was a significant weight loss in the two patients with Prader–Willi syndrome for the first 2 years but one of them restarted to gain weight again.

Conclusions: Obesity and overweight in children is common worldwide and known to be associated with morbidity. LSG is effective in treating obese children and alleviating their comorbidities. LSG should be performed by experienced laparoscopic surgeons and long term follow-up is important as there is still concern regarding its effects on growth and maturity, and the sustainability of the weight loss.

Keywords:bariatric surgery, children, sleeve gastrectomy, weight loss

 

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Junaid Ashraf, Anna Radford

 

Abstract

AimThe aim of this article to give a concise summary of the assessment and management of neuropathic bladders as per the current literature in the paediatric age group.

Keywords: neuropathic bladder, assessment, investigation, conservative treatment, surgical management

 

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Einar Arnbjörnsson, Christina Granéli, Anna Börjesson, Pernilla Stenström

 

Abstract

AimTo evaluate the indications for, and outcome, of appendicostomy for patients with Hirschsprungs disease (HD) who underwent transanal endorectal pull-through (TERPT).

Method: Children with HD > 4 years old who received an appendicostomy between 2005 and 2011 at a tertiary pediatric surgery center were included. Pre- and post-appendicostomy bowel function was evaluated by a bowel function score. HD-patients not receiving an appendicostomy were the controls. The study was approved by an institutional ethics committee (2010/49).

Results: Seven of 37 HD-patients received an appendicostomy. Syndromes were present in 43% of the appendicostomy and 6% of the controls (controls reported absence of fecal accidents (p=0.297). Three (60%) with appendicostomy and 14 (47%) controls, respectively, reported absence of soiling or soiling RPT.

Keywords: Hirschsprungs disease, transanal endorectal pull through, bowel function score, antegrade continence enema, appendicostomy.

 

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Einar Arnbjörnsson, Christina Granéli, Anna Börjesson, Pernilla Stenström

Department of Pediatric Surgery, Skåne University Hospital and Institution of Clinical research, Lund University, Lund, Sweden

 

Correspondence:

Einar Arnbjörnsson

Department of Pediatric Surgery

Skåne University Hospital and Institution of Clinical Research, Lund University

Lund, Sweden

E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.  

 

Abstract

AimTo evaluate the indications for, and outcome, of appendicostomy for patients with Hirschsprungs disease (HD) who underwent transanal endorectal pull-through (TERPT).

Method: Children with HD > 4 years old who received an appendicostomy between 2005 and 2011 at a tertiary pediatric surgery center were included. Pre- and post-appendicostomy bowel function was evaluated by a bowel function score. HD-patients not receiving an appendicostomy were the controls. The study was approved by an institutional ethics committee (2010/49).

Results: Seven of 37 HD-patients received an appendicostomy. Syndromes were present in 43% of the appendicostomy and 6% of the controls (controls reported absence of fecal accidents (p=0.297). Three (60%) with appendicostomy and 14 (47%) controls, respectively, reported absence of soiling or soiling RPT.

Keywords: Hirschsprungs disease, transanal endorectal pull through, bowel function score, antegrade continence enema, appendicostomy.

 

Introduction

Hirschsprung disease (HD) is a congenital disease in which the absence of ganglion cells in the intestinal muscular layer leads to aperistalsis of the affected bowel. A common surgical treatment used for HD is transanal endorectal pull-through (TERPT) [1]. However, absence of bowel control and fecal incontinence may follow. Furthermore, patients with Down syndrome or other disorders and HD may require additional attention to their bowel function [2-5].

Fecal incontinence, constipation, and bowel obstruction are symptoms often initially treated by dietary modification, medication, and training to instill regular toilet habits. Some patients will nonetheless be unable to achieve bowel control. The inability to control bowel movements may carry a negative social impact that can be severely limiting as the child grows older [6]. In some of these patients, rectal enema treatments could be effective for achieving improved bowel function. However, some patients do not tolerate rectal enemas or would prefer to be more autonomous, in which case antegrade colonic enemas (ACE) through an appendicostomy might be an option.

Since 1990, when appendicostomy was proposed for administering an antegrade continence enema [7], there have been several reports on its benefits and disadvantages for different diagnoses [8-12]. There are various appendicostomy techniques described [7, 11, 12-17]. Appendicostomy outcomes have been reported in children mainly with spinal bifida, intractable functional constipation, or anorectal malformation [9-11]. Reports on the long-term functional results of an appendicostomy in children with HD who have undergone TERPT are reported in mixed groups of diagnosis (REF med HD), but separate evaluation could be valuable for selecting patients with HD who might benefit from an appendicostomy. The aim of this study was to evaluate the indications and outcomes of appendicostomy for antegrade enemas in patients with HD who underwent TERPT. The secondary aim was to describe how appendicostomy is used in patients with HD and parents' satisfaction with appendicostomy.

Materials and Methods

Settings

The study was performed at a tertiary center for pediatric surgery that serves a region with 1.8 million residents and 22,000 births annually.

Patients and study setting

HD was diagnosed in all the patients by rectal biopsy and anography. The study patients included all patients with HD who underwent TERPT from 2005 to 2011 and subsequent appendicostomy until 2014. The control group included patients with HD who underwent TERPT, but not appendicostomy, from 2005 to 2011 and were aged older than 4 years at follow-up. The appendicostomy-patients’ bowel symptoms before appendicostomy were recorded retrospectively from medical charts. The patients’ guardians were asked if they would come in for follow up and would consent to an interview after the appendicostomy. In an outpatient setting, they were questioned about bowel symptoms, appendicostomy use, and satisfaction with the appendicostomy. Information on the bowel symptoms of the control patients was obtained from telephone interviews or during counseling at the outpatient clinic.

Scoring of bowel symptoms

Bowel function was assessed by a bowel function scoring system with bowel function scores (BFS’s) ranging from worse to better function: 1 to 20 [18].

Bowel management program and indications for appendicostomy

All children who undergo TERPT for HD are routinely offered an individualized bowel management program at our center. Each patient’s bowel habits and symptoms are regularly checked and scored, and a BFS is recorded. The patient and family are counseled, and recommendations for obtaining improved bowel function are provided if needed.

If the patient requires enemas but neither the family nor the patient accept the rectal approach, appendicostomy is evaluated as an alternative. Another reason for appendicostomy is patient desire for greater autonomy.

The pediatric surgeon and the colorectal nurse perform repeated evaluations prior to a final decision for performing appendicostomy. The operation is only performed after a comprehensive discussion with patients and their families, which includes possible complications and failure in bowel control despite the administration of antegrade continence enemas (ACEs) through an appendicostomy. Throughout participation in the bowel management program, the family and patient regularly receive counseling by a colorectal pediatric surgeon and with a colorectal nurse as needed. The family and patient are also routinely offered psychological consultation according to the local follow-up program.

Surgical techniques: TERPT and appendicostomy

The TERPT procedure was performed in accordance with the technique described in 1998, with rectal mucosectomy, colectomy of the aganglionic segment, and normoganglionic colon pull-through performed through the anus [1]. The length of the muscular cuff was 2–3 centimeters. Focus was put on not to damage the anal canal during the operation. Colonic resection was extended to include the transition zone, and any dilated bowel was resected, along with the aganglionic bowel. The end of the proximal bowel had to demonstrate a normal frequency of mature ganglionic cells, without any signs of nerve hypertrophy, according to the pathologists’ report on a frozen section obtained during the operation. The final pathology report included a statement on positive staining for calretinin.

At our center, a laparoscopic approach was used for appendicostomy, which was carried out by 2 experienced pediatric surgeons. The laparoscopic procedure involved open access at the umbilicus with a 5-mm 30-degree laparoscope. A 5-mm laparoscopy port was introduced at the right lateral inguinal fossa, at the point selected for the appendicostomy stoma. A grasper was introduced through the port to grab the appendix and pull it out through the port hole. The tip of the appendix was then opened, and 5-10 mm of it was removed. The wall of the appendix was sutured to the skin using a V-Y plastic with absorbable sutures. Until 2009, a Foley catheter® was left in the stoma and removed after 6 weeks. After 2009, a Chait button® was placed in the stoma and either removed after 6 weeks or left in place to avoid repeat catheterizations of the stoma in very young or active children. The Chait button® was then replaced every 6 months.

Appendicostomy – complications and use

Peri- and post-operative complications of appendicostomy were retrospectively recorded from medical records. Infection was defined as a positive culture from a specimen obtained from the stoma site in combination with clinical signs of infection. A questionnaire on the use of and satisfaction with the appendicostomy was administered during follow-up counseling sessions. The questionnaire had been used in a previous study [19] and includes questions regarding time needed to administer enemas, time until the bowel was completely empty after enema administration, type of enema used, and degree of satisfaction with the appendicostomy.

Statistical analysis

Nonparametric statistics were used, since data could be skewed because of the small number of patients. This is based on the following observations: 1. Analyzing paired data as unpaired does not increase the type 1 error for the t test. 2. The WMW test is the nonparametric equivalent of the t test. P values < 0.05 were considered significant. The Fischer exact probability test 2×4 with the Freeman-Halton extension yielded the same results and was also used. All statistical analysis was performed by a statistician.

Ethics

The regional research committee approved the study (registration number 2010/49). Approval from each patient´s guardians was obtained before including the child in the study. Intention to treat was the main diagnostic strategy used for all patients. All evaluations, treatments, and procedures described in this report were the standard of care. All data were maintained as confidential in the hospital file system and were coded in the study investigators’ computers.

Results

Indications for appendicostomy

A total of 7 children with HD who underwent TERPT subsequently received an appendicostomy. Their median age at appendicostomy was 5 (2-8) years. Other patient characteristics and details on the procedure are shown in Table 1. All 7 patients had been using rectal enemas. The rectal enemas had a satisfactory effect on individual bowel management problems, but the treatment had failed in 5 of the 7 because of the following issues: low compliance secondary to anal pain (n=3); patient intolerance to enema administration (n=4), and both parent and patient psychological intolerance to rectal enemas (n=5). Indications for appendicostomy for the other 2 patients were desire for increased autonomy and easier administration and emptying while sitting on a toilet (n=2) (Table 1).

Complications associated with TERPT and appendicostomy

There were no recorded intraoperative complications during either the TERPT or the appendicostomy procedures. A laparoscopic appendicostomy was converted to open surgery for 1 patient because of intra-abdominal adhesions. Post operative no additional pull-through interventions were required, although 1 patient developed a rectourethral fistula and therefore underwent additional surgery.

A total of 6 postoperative complications after appendicostomy occurred in 4(57%) patients and included granuloma (n=1), local infection (n=2), and irritation at the site of the stoma (n=3). No pain at the site of the appendicostomy was reported. All infections were treated by oral antibiotics and/or sterile washing, and no additional surgical interventions were needed because of infection. No one still using the appendicostomy at the follow-up reported localized pain associated with the stoma.

Outcome and use of the appendicostomy

At the time of follow-up, 2 of the 7 children no longer used their appendicostomy. Both had received colostomy at 8 and 10 months respectively after the appendicostomy procedure. The reasons for colostomy were development of a recto urethral fistula in the one patient who needed a reoperation, and the other child, who also had Down syndrome, had colostomy because of severe obstructive symptoms and a painful anal stricture. The five patients still using their appendicostomy used it daily as follows: 2 children used it in the morning and evening, and 3 other children used it in the evening only. Four children used a Chait button because they preferred to avoid catheterization. The other used intermittent catheterization. All of the parents would recommend appendicostomy to other families in the same situation (Table 2).

Two children were still using diapers, 1 because of late maturity and urinary incontinence due to Down syndrome and the other because of a rare chromosomal translocation syndrome which led to concomitant urinary outlet symptoms.

None of the children with appendicostomy had been treated with botulinum toxin A injections before the procedure, because the treatment had not yet been introduced in our department at that time. Three children, all with some syndromes, had obstructive symptoms that were treated by botulinum toxin A injections after the appendicostomy. Two of them were successfully treated by the combination of ACE through the appendicostomy plus botulinum toxin A, while the third child needed a colostomy.

Bowel function scores before and after appendicostomy

The pre- and postoperative BFS of the children who received an appendicostomy are shown in Table 3, which shows that the bowel scores were significantly increased for the patients who still used their appendicostomy.

Control patients without appendicostomy

During the study period a total of 32 patients with HD were operated on with TERPT but not appendicostomy. After the exclusion of 2 patients who had migrated 30 children without appendicostomy were included in the study as controls. Their median age at the time of the study was 5.5 (4-9) years. There were no intra- or postoperative complications associated with TERPT. At follow-up, 5 patients used rectal enemas regularly because of obstructive symptoms and 2 of them also fecal incontinence. Two of these 5 patients also received botulinum toxin A injections.

Comparison of BFS between appendicostomy patients and controls

The BFS of each symptom of the children needing appendicostomy were significantly lower before appendicostomy than the BFS of the control patients (Table 4). At follow up after appendicostomy; there was no difference between the BFS of the 5 children with appendicostomy and the BFS of the control patients. Some of the BFS outcomes of the children with appendicostomy were better (Table 5).

Discussion

This study showed that ACE through an appendicostomy stoma can achieve increased bowel control for selected children with HD who have undergone TERPT. Our patients who were considered for appendicostomy and had favorable outcomes after the procedure were those with very poor bowel function, those who had low compliance with rectal enemas, and those with a syndrome. The children with an appendicostomy who continued to use it to administer ACE achieved a level of bowel control similar to the bowel control of children with HD without an appendicostomy.

To our knowledge, there are no published reports on this select group of patients with appendicostomy. Prior studies have reported data from mixed cohorts of patients with a variety of conditions, including anorectal malformations, HD, idiopathic constipation, neurological disorders such as spine bifida, and post-traumatic disorders with various indications [9-12, 13, 20]. Our aim was to clarify the indications for appendicostomy in children with HD who have undergone TERPT. The results confirmed the findings of similar studies that were performed on other types of patients; namely, that ACE through an appendicostomy is effective and improves fecal continence and patient autonomy [14, 20].

The long-term complication rate of children undergoing an appendicostomy was high (57%) but was in line with previous studies on appendicostomy in mixed diagnosis groups reporting 23–100% complications [19, 20-23]. Previously, the most frequently reported complications associated with appendicostomy were stenosis, pain during catheter insertion, and leakage [8, 21, 23]. It has been suggested that the complication rate might be decreased using a Chait cecostomy regarding infections and fistula formation [24]. It has also been speculated that younger children might have fewer complications with their appendicostomy because either the appendicular valve is continent in young children or the Chait in the appendix, which is used more frequently in young children and might be protective [19, 25]. In our study, the median age was low and the frequency of Chait button use was high, which might explain why minor complications were reported. None of our patients developed stenosis, although previous reports have indicated that this is one of the major problems emerging during the years following an appendicostomy in 15–20% of older children [8, 15]. It is possible that stoma stenosis did not develop in our patients because we left a catheter in place for at least 6 weeks after surgery, and most of these children continued to use the Chait button.

ACE had been proposed with the main purpose of improving personal control and hygiene, but it has primarily been studied in older patients [19]. However, the timing of appendicostomy and bowel control problems have not been evaluated in children with HD. Appendicostomy for ACE may seem to be an aggressive treatment for bowel management in preschool children. At our institution, we chose to perform appendicostomy in select patients with HD, independent of age, who had severe bowel management issues and who did not obtain sufficient management with conventional regimens such as dietary modifications, oral medications, and rectal enemas. This requires detailed knowledge not only of the child, but also of the child’s family. In the study cohort, all families were well informed of available treatment options and insisted upon a solution for their children’s problems. A positive finding of our study was that all guardians indicated that they would recommend appendicostomy to the family of a child with HD who had the same bowel management issues. This result agrees with a study of children with anorectal malformations who underwent the same operation [19]. Results from that study led the authors to suggest that patients should receive an appendicostomy before they reach school age to provide them with early autonomy and the possibility of being clean during the school day.

However, there have not been any valid studies that have identified the best age to perform an appendicostomy. Additional studies are required as to decide whether it is beneficial for a child to have an appendicostomy for ACE, instead of continuing rectal enemas despite a child’s dislike of the procedure. In our study, it was difficult to interpret whether improved bowel control was an effect of older age versus ACE. This issue is a consideration as the patients were older when they were assessed after ACE initiation than they were when the appendicostomy was performed. It has been suggested that many patients with HD develop improved bowel control with age. A recent study [26] has shown that after TERPT, incontinence scores, but not constipation scores, are positively correlated with follow-up duration. This result indicates that improved continence could be expected over time. Moreover, for patients with HD, appendicostomy might be used as a tool during the worst years and stopped at a later time.

We chose to use BFS because this score has been previously used for patients with HD and because it seems to consider many potential problems. However, the term constipation might be misleading and must be used and analyzed with caution. The real problem might be obstruction and bowel emptying issues. A physiological obstruction can sometimes be successfully treated by botulinum toxin A [27]. For treating obstructive symptoms, current bowel management includes botulinum toxin A injection as the first option before an appendicostomy or a colostomy.

One limitation of this study is that a small study group was assessed, with 7 of the study patients receiving an appendicostomy. Another potential limitation is that bowel function was assessed at a visit comprising an interview. The results could have been skewed to obtain a better outcome given the closeness of the patients and their families. We attempted to diminish this bias by having an independent person, who had not been previously involved in patient care, assess the BFS and appendicostomy use. However, strength of this study is that no patients were lost to follow-up and that the patients were treated at the same center where all information was also collected. All residents have access to health care free of charge at the time of need and any dropout due to socioeconomic factors is unlikely.

The bowel management program used to day differs from that used during the period of the study. The first step in the bowel management program is dietary counseling, which includes dietary modifications. If bowel symptoms are not improved, and if constipation or obstruction is the main problem, oral medications such as Loperamid are prescribed. If it turns out that the patient’s main symptom is outlet obstruction, botulinum toxin A is injected into the anal sphincter. If the patient continues to have fecal incontinence and/or constipation, the patient is introduced to the use of rectal enemas.

In conclusion, ACE administered through an appendicostomy stoma appears to improve the bowel control in some children with HD who had undergone TERPT. Using a standardized method for evaluating and selecting the patients most likely to benefit from an appendicostomy is important.

Acknowledgments

We are grateful to Fredrik Nilsson, biostatistician at the Competence Centre for Clinical Research, Skåne University Hospital, LUND, Sweden, for statistical advice. This manuscript has been edited by native English-speaking medical experts from BioMed Proofreading LLC.

Editorial editorial

Prof. Dr. Dan Osvald Lucaciu
Rehabilitation Clinic
Cluj-Napoca, Romania

 

Osteoarthritis is the most common type of arthritis, representing a degeneration of joint cartilage and subchondral bone. It is most common in knees and hips, usually affecting people over 50 years, but can also be found in younger people as well. When symptoms cannot be controlled by conservative treatment including weight reduction, physiotherapy, intraarticular injections, topical or systemic drugs, then total knee replacement is the treatment of choice. Arthroscopy is a minimally invasive procedure for diagnosing and treating joint pathologies.

There has been a great debate over the last years regarding the role of arthroscopy in knee osteoarthritis. The need for an evidence-based decision required high quality randomized control studies, which now seem to clarify the indications and contraindications of arthroscopic surgical treatment in knee osteoarthritis.

Current evidence shows that there is no difference in functional scores, pain and quality of life between groups receiving physical therapy and groups undergoing arthroscopic treatment. Moreover, there has been no difference in groups receiving arthroscopic treatment and placebo surgery for knee osteoarthritis. As a result, American Academy of Orthopaedic Surgeons strongly recommend against performing arthroscopy in patients with primary symptomatic osteoarthritis of the knee.

On the other side, we consider that arthroscopy has its indications for associated pathologies in an osteoarthritic knee. Mechanical symptoms including locking and jamming of the knee due to lose bodies, catching of the knee due to meniscal or chondral flaps, represent indications for arthroscopic surgery. It is sometimes difficult to decide whether the knee pain is due to meniscal tears, which may be managed arthroscopically, or due to osteoarthritis. A pain with acute onset, limited to medial joint line (sometimes lateral joint line) and tenderness when palpating the medial or lateral joint line usually points acute meniscal pathology. Of great importance is that surgical outcomes might only reduce mechanical symptoms and not relieve pain or reduce knee swelling. Therefore the patient needs to be well informed regarding the possible outcomes. Furthermore, we consider that degenerative meniscus pathology should not be addressed arthroscopically, due to poor results in current literature.

A great importance is the presence of sub-chondral stress fractures associated to meniscal pathology, especially in elderly. In such cases, the stress fracture can produce the pain, and not the meniscal pathology. If partial meniscectomy is performed in such cases, pain can be aggravated by the procedure. Therefore, an MRI is an examination of great importance for a thorough examination of the knee pathology to prevent wrong surgical indication.

Another indication is a limited chondral lesion, usually medial. In this setting, marrow stimulation, matrix-induced autologous chondrocyte implantation, osteochondral autograft transfer and osteochondral allograft are of great importance with good outcomes, especially in younger patients. Intraarticular soft tissue pathology can also be addressed arthroscopically in case of acute onset, for example pigmented villonodular synovitis.

As a conclusion, arthroscopy has limited indications in knee osteoarthritis, but when this minimally invasive surgery is adequately performed, it can reduce symptoms and delay the need of a total knee replacement, sometimes even prevent it. However, in most cases, conservative treatment consisting in physiotherapy can have the similar effect on symptoms compared to arthroscopic surgery. 

Mohamed Shoukry, Munther Haddad

 

Abstract

Background: Accidental ingestion of foreign bodies in young children and toddlers is common. Most will pass spontaneously without any harm. However, when foreign bodies are magnetized, significant problems can occur. Exceptionally strong magnetic pull and 2 magnets in separate parts of alimentary canal can quite easily attract, potentially causing damage to the intervening structures. We present our experience where earlier surgical intervention was required to extract magnets.

Material and methods: A review of case notes of three patients referred to a tertiary Paediatric Surgery centre during the period March 2011 to August 2014. They have completed follow up period for 2 years at least before discharge them back to GPs care successfully. Retrospective review of similar published articles on PubMed and midline.

Conclusion: Authors recommend close observation, high index of suspicion and early surgical intervention. More public and medical awareness is needed of dangers posed by these readily available objects.

Keywords:  magnetic FB, early surgical intervention, children

 

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Ahmed H. Al-Salem, Mukul Kothari

 

Abstract

Isolated extrahepatic biliary injury in children is extremely rare and there are no previous reports of such an injury or its management in newborns. We present a case of iatrogenic extrahepatic biliary injury in a newborn and describe a technique to treat it.

Keywords: biliary injury, children, iatrogenic, treatment

 

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Hemant Kumar, Ramnik Patel, Bharat More, Bala Eradi, Haitham Dagash, Ashok Rajimwale

 

Abstract

A preterm infant and twin 1 of the dichorionic diamniotic twins born at 27+3/40 weeks gestation weighting 790 grams who had on-going respiratory distress developed total gastric rupture following difficult intubation. Plain chest, abdominal and right lateral decubitus radiographs helped in diagnosis. Infant had resuscitation and underwent exploratory laparotomy, closure of massive gastric rupture and temporary gastrostomy for decompression initially and feeding later uneventfully. Neonatal gastric perforation is rare, serious and potentially lethal if not detected early and treated effectively. It could be traumatic, spontaneous or ischaemic. Our case had acute barotrauma following accidental oesophageal intubation and closed loop obstruction due to cardiac and pyloric sphincter at both ends and relatively high velocity air entering under pressure leading to anterior gastric wall blast. Primary repair of the stomach rupture with temporary gastrostomy is very useful and effective therapeutic strategy in these very sick preterm infants.

Keywords: preterm, gastric perforation, pneumoperitoneum, acute pneumoscotum, peritonitis, neonatal, gastrostomy, traumatic, iatrogenic

 

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Prashant Sadashiv Patil, Gupta Abhaya, Kothari Paras, Kekre Geeta, Deshmukh Shahaji , K Vishesh Dikshit, Apoorva Kulkarni

 

Abstract

The common perception is that children rarely develop severe forms of tuberculosis. A variety of sequelae and complications can occur in the pulmonary and extrapulmonary portions of the thorax in treated or untreated patients. Lung gangrene due to tuberculosis has been described in adult patients. However lung gangrene due to tuberculosis is rarely reported in paediatric patients. We report a case of 2 year old female child with lung gangrene and massive cavity due to tuberculosis.

Keywords: pulmonary tuberculosis, gangrene, thoracotomy, pneumothorax.

 

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Gauthamen Rajendran, Kokila Lakhoo, Arnwald Choi, Frances O’Brien

 

Abstract

Background: There is a paucity of data regarding the perioperative care in neonates.

Objective: To collect data relevant to perioperative care in a neonatal intensive care unit (NICU), with a focus on identifying key areas of clinical care around the time of surgery.

Methods: Perioperative data of neonates who underwent surgical intervention in 2013 within a UK NICU were collected retrospectively. Temperature, blood sugar levels, serum sodium levels, blood gas parameters, weight and fluids used in the perioperative period along with demographic details were collected. The data was analysed for the distribution and trend of temperature, blood sugar and parameters pertaining to fluid, electrolyte and acid-base balance in the perioperative period.

Results: Forty-eight neonatal surgical procedures in 45 neonates were studied. Median gestational age (IQR) at the time of surgery and weight before surgery were 37 (33 to 39) weeks and 2750 (1872 to 2942) grams. The number of surgical procedures for NEC, and abdominal wall defects were 14 and 11 respectively; 23 neonates had surgery for other reasons. Incidence of postoperative hypothermia was 15%. Hyperglycaemia and hypocapnia were more common post-operatively when compared to preoperative findings (63% vs 13% and 19% vs 0% respectively). Hyponatraemia was common preoperatively (42%) but the incidence remained static postoperatively. Hypernatremia was uncommon. A slow and sustained increase in blood sugar levels were noticed in preterm and NEC neonates. Statistically significant weight gain occurred in preterm neonates.

Conclusions: Pre-operative hyponatraemia and post-operative hyperglycemia and hypocapnia require attention. Preterm neonates and neonates with NEC and abdominal wall defects are the high risk groups.

Keywords: newborn, perioperative care, preterm infants, hypothermia, hyperglycemia

 

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Moustafa Hamchou, Hilal Matta, Bahjat Sahari, Adnan Swid, Ahmed Al-Salem

 

Abstract

Background: Obesity and overweight in children is increasingly common worldwide and known to be associated with morbidity. Dietary manipulation and changing their life style may prove to be effective in slightly overweight children but are not effective in obese children and those with comorbidities.

Patients and method: This is a retrospective study of all morbidly obese children who had laparoscopic sleeve gastrectomy (LSG).

Results: Over a period of 4 years (June 2012 - June 2015), 26 children (14 female: 12 male) had LSG. Their mean age was 12.6 years (10.5-15 years) and their mean BMI 47.2 (40-65). Twenty-one (80.8%) of our patients had associated comorbidities. These included sleep apnea (7 patients), hypertension (3 patients), type 2 diabetes mellitus (3 patients), bronchial asthma (4 patients), enuresis (2 patients), and foot and joint problems (2 patients). Two of our patients had Prader–Willi syndrome. The mean follow-up was 1.5 years (1 year - 3 years). The mean operative time was 120 minutes (90-150 minutes). The mean hospital stay was 4 days (3-7 days). Only one of our patients was admitted to the intensive care unit for one day observation because of severe sleep apnea. There were no major complications and no leaks. There was an overall 65.2% weight loss and 70% improvement in comorbidities. Their mean postoperative BMI was 30.75 (24-38). There was also marked improvement in quality of life, self-esteem, productivity and social functioning. There was a significant weight loss in the two patients with Prader–Willi syndrome for the first 2 years but one of them restarted to gain weight again.

Conclusions: Obesity and overweight in children is common worldwide and known to be associated with morbidity. LSG is effective in treating obese children and alleviating their comorbidities. LSG should be performed by experienced laparoscopic surgeons and long term follow-up is important as there is still concern regarding its effects on growth and maturity, and the sustainability of the weight loss.

Keywords:bariatric surgery, children, sleeve gastrectomy, weight loss

 

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Junaid Ashraf, Anna Radford

 

Abstract

AimThe aim of this article to give a concise summary of the assessment and management of neuropathic bladders as per the current literature in the paediatric age group.

Keywords: neuropathic bladder, assessment, investigation, conservative treatment, surgical management

 

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Einar Arnbjörnsson, Christina Granéli, Anna Börjesson, Pernilla Stenström

 

Abstract

AimTo evaluate the indications for, and outcome, of appendicostomy for patients with Hirschsprungs disease (HD) who underwent transanal endorectal pull-through (TERPT).

Method: Children with HD > 4 years old who received an appendicostomy between 2005 and 2011 at a tertiary pediatric surgery center were included. Pre- and post-appendicostomy bowel function was evaluated by a bowel function score. HD-patients not receiving an appendicostomy were the controls. The study was approved by an institutional ethics committee (2010/49).

Results: Seven of 37 HD-patients received an appendicostomy. Syndromes were present in 43% of the appendicostomy and 6% of the controls (controls reported absence of fecal accidents (p=0.297). Three (60%) with appendicostomy and 14 (47%) controls, respectively, reported absence of soiling or soiling RPT.

Keywords: Hirschsprungs disease, transanal endorectal pull through, bowel function score, antegrade continence enema, appendicostomy.

 

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Einar Arnbjörnsson, Christina Granéli, Anna Börjesson, Pernilla Stenström

Department of Pediatric Surgery, Skåne University Hospital and Institution of Clinical research, Lund University, Lund, Sweden

 

Correspondence:

Einar Arnbjörnsson

Department of Pediatric Surgery

Skåne University Hospital and Institution of Clinical Research, Lund University

Lund, Sweden

E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.  

 

Abstract

AimTo evaluate the indications for, and outcome, of appendicostomy for patients with Hirschsprungs disease (HD) who underwent transanal endorectal pull-through (TERPT).

Method: Children with HD > 4 years old who received an appendicostomy between 2005 and 2011 at a tertiary pediatric surgery center were included. Pre- and post-appendicostomy bowel function was evaluated by a bowel function score. HD-patients not receiving an appendicostomy were the controls. The study was approved by an institutional ethics committee (2010/49).

Results: Seven of 37 HD-patients received an appendicostomy. Syndromes were present in 43% of the appendicostomy and 6% of the controls (controls reported absence of fecal accidents (p=0.297). Three (60%) with appendicostomy and 14 (47%) controls, respectively, reported absence of soiling or soiling RPT.

Keywords: Hirschsprungs disease, transanal endorectal pull through, bowel function score, antegrade continence enema, appendicostomy.

 

Introduction

Hirschsprung disease (HD) is a congenital disease in which the absence of ganglion cells in the intestinal muscular layer leads to aperistalsis of the affected bowel. A common surgical treatment used for HD is transanal endorectal pull-through (TERPT) [1]. However, absence of bowel control and fecal incontinence may follow. Furthermore, patients with Down syndrome or other disorders and HD may require additional attention to their bowel function [2-5].

Fecal incontinence, constipation, and bowel obstruction are symptoms often initially treated by dietary modification, medication, and training to instill regular toilet habits. Some patients will nonetheless be unable to achieve bowel control. The inability to control bowel movements may carry a negative social impact that can be severely limiting as the child grows older [6]. In some of these patients, rectal enema treatments could be effective for achieving improved bowel function. However, some patients do not tolerate rectal enemas or would prefer to be more autonomous, in which case antegrade colonic enemas (ACE) through an appendicostomy might be an option.

Since 1990, when appendicostomy was proposed for administering an antegrade continence enema [7], there have been several reports on its benefits and disadvantages for different diagnoses [8-12]. There are various appendicostomy techniques described [7, 11, 12-17]. Appendicostomy outcomes have been reported in children mainly with spinal bifida, intractable functional constipation, or anorectal malformation [9-11]. Reports on the long-term functional results of an appendicostomy in children with HD who have undergone TERPT are reported in mixed groups of diagnosis (REF med HD), but separate evaluation could be valuable for selecting patients with HD who might benefit from an appendicostomy. The aim of this study was to evaluate the indications and outcomes of appendicostomy for antegrade enemas in patients with HD who underwent TERPT. The secondary aim was to describe how appendicostomy is used in patients with HD and parents' satisfaction with appendicostomy.

Materials and Methods

Settings

The study was performed at a tertiary center for pediatric surgery that serves a region with 1.8 million residents and 22,000 births annually.

Patients and study setting

HD was diagnosed in all the patients by rectal biopsy and anography. The study patients included all patients with HD who underwent TERPT from 2005 to 2011 and subsequent appendicostomy until 2014. The control group included patients with HD who underwent TERPT, but not appendicostomy, from 2005 to 2011 and were aged older than 4 years at follow-up. The appendicostomy-patients’ bowel symptoms before appendicostomy were recorded retrospectively from medical charts. The patients’ guardians were asked if they would come in for follow up and would consent to an interview after the appendicostomy. In an outpatient setting, they were questioned about bowel symptoms, appendicostomy use, and satisfaction with the appendicostomy. Information on the bowel symptoms of the control patients was obtained from telephone interviews or during counseling at the outpatient clinic.

Scoring of bowel symptoms

Bowel function was assessed by a bowel function scoring system with bowel function scores (BFS’s) ranging from worse to better function: 1 to 20 [18].

Bowel management program and indications for appendicostomy

All children who undergo TERPT for HD are routinely offered an individualized bowel management program at our center. Each patient’s bowel habits and symptoms are regularly checked and scored, and a BFS is recorded. The patient and family are counseled, and recommendations for obtaining improved bowel function are provided if needed.

If the patient requires enemas but neither the family nor the patient accept the rectal approach, appendicostomy is evaluated as an alternative. Another reason for appendicostomy is patient desire for greater autonomy.

The pediatric surgeon and the colorectal nurse perform repeated evaluations prior to a final decision for performing appendicostomy. The operation is only performed after a comprehensive discussion with patients and their families, which includes possible complications and failure in bowel control despite the administration of antegrade continence enemas (ACEs) through an appendicostomy. Throughout participation in the bowel management program, the family and patient regularly receive counseling by a colorectal pediatric surgeon and with a colorectal nurse as needed. The family and patient are also routinely offered psychological consultation according to the local follow-up program.

Surgical techniques: TERPT and appendicostomy

The TERPT procedure was performed in accordance with the technique described in 1998, with rectal mucosectomy, colectomy of the aganglionic segment, and normoganglionic colon pull-through performed through the anus [1]. The length of the muscular cuff was 2–3 centimeters. Focus was put on not to damage the anal canal during the operation. Colonic resection was extended to include the transition zone, and any dilated bowel was resected, along with the aganglionic bowel. The end of the proximal bowel had to demonstrate a normal frequency of mature ganglionic cells, without any signs of nerve hypertrophy, according to the pathologists’ report on a frozen section obtained during the operation. The final pathology report included a statement on positive staining for calretinin.

At our center, a laparoscopic approach was used for appendicostomy, which was carried out by 2 experienced pediatric surgeons. The laparoscopic procedure involved open access at the umbilicus with a 5-mm 30-degree laparoscope. A 5-mm laparoscopy port was introduced at the right lateral inguinal fossa, at the point selected for the appendicostomy stoma. A grasper was introduced through the port to grab the appendix and pull it out through the port hole. The tip of the appendix was then opened, and 5-10 mm of it was removed. The wall of the appendix was sutured to the skin using a V-Y plastic with absorbable sutures. Until 2009, a Foley catheter® was left in the stoma and removed after 6 weeks. After 2009, a Chait button® was placed in the stoma and either removed after 6 weeks or left in place to avoid repeat catheterizations of the stoma in very young or active children. The Chait button® was then replaced every 6 months.

Appendicostomy – complications and use

Peri- and post-operative complications of appendicostomy were retrospectively recorded from medical records. Infection was defined as a positive culture from a specimen obtained from the stoma site in combination with clinical signs of infection. A questionnaire on the use of and satisfaction with the appendicostomy was administered during follow-up counseling sessions. The questionnaire had been used in a previous study [19] and includes questions regarding time needed to administer enemas, time until the bowel was completely empty after enema administration, type of enema used, and degree of satisfaction with the appendicostomy.

Statistical analysis

Nonparametric statistics were used, since data could be skewed because of the small number of patients. This is based on the following observations: 1. Analyzing paired data as unpaired does not increase the type 1 error for the t test. 2. The WMW test is the nonparametric equivalent of the t test. P values < 0.05 were considered significant. The Fischer exact probability test 2×4 with the Freeman-Halton extension yielded the same results and was also used. All statistical analysis was performed by a statistician.

Ethics

The regional research committee approved the study (registration number 2010/49). Approval from each patient´s guardians was obtained before including the child in the study. Intention to treat was the main diagnostic strategy used for all patients. All evaluations, treatments, and procedures described in this report were the standard of care. All data were maintained as confidential in the hospital file system and were coded in the study investigators’ computers.

Results

Indications for appendicostomy

A total of 7 children with HD who underwent TERPT subsequently received an appendicostomy. Their median age at appendicostomy was 5 (2-8) years. Other patient characteristics and details on the procedure are shown in Table 1. All 7 patients had been using rectal enemas. The rectal enemas had a satisfactory effect on individual bowel management problems, but the treatment had failed in 5 of the 7 because of the following issues: low compliance secondary to anal pain (n=3); patient intolerance to enema administration (n=4), and both parent and patient psychological intolerance to rectal enemas (n=5). Indications for appendicostomy for the other 2 patients were desire for increased autonomy and easier administration and emptying while sitting on a toilet (n=2) (Table 1).

Complications associated with TERPT and appendicostomy

There were no recorded intraoperative complications during either the TERPT or the appendicostomy procedures. A laparoscopic appendicostomy was converted to open surgery for 1 patient because of intra-abdominal adhesions. Post operative no additional pull-through interventions were required, although 1 patient developed a rectourethral fistula and therefore underwent additional surgery.

A total of 6 postoperative complications after appendicostomy occurred in 4(57%) patients and included granuloma (n=1), local infection (n=2), and irritation at the site of the stoma (n=3). No pain at the site of the appendicostomy was reported. All infections were treated by oral antibiotics and/or sterile washing, and no additional surgical interventions were needed because of infection. No one still using the appendicostomy at the follow-up reported localized pain associated with the stoma.

Outcome and use of the appendicostomy

At the time of follow-up, 2 of the 7 children no longer used their appendicostomy. Both had received colostomy at 8 and 10 months respectively after the appendicostomy procedure. The reasons for colostomy were development of a recto urethral fistula in the one patient who needed a reoperation, and the other child, who also had Down syndrome, had colostomy because of severe obstructive symptoms and a painful anal stricture. The five patients still using their appendicostomy used it daily as follows: 2 children used it in the morning and evening, and 3 other children used it in the evening only. Four children used a Chait button because they preferred to avoid catheterization. The other used intermittent catheterization. All of the parents would recommend appendicostomy to other families in the same situation (Table 2).

Two children were still using diapers, 1 because of late maturity and urinary incontinence due to Down syndrome and the other because of a rare chromosomal translocation syndrome which led to concomitant urinary outlet symptoms.

None of the children with appendicostomy had been treated with botulinum toxin A injections before the procedure, because the treatment had not yet been introduced in our department at that time. Three children, all with some syndromes, had obstructive symptoms that were treated by botulinum toxin A injections after the appendicostomy. Two of them were successfully treated by the combination of ACE through the appendicostomy plus botulinum toxin A, while the third child needed a colostomy.

Bowel function scores before and after appendicostomy

The pre- and postoperative BFS of the children who received an appendicostomy are shown in Table 3, which shows that the bowel scores were significantly increased for the patients who still used their appendicostomy.

Control patients without appendicostomy

During the study period a total of 32 patients with HD were operated on with TERPT but not appendicostomy. After the exclusion of 2 patients who had migrated 30 children without appendicostomy were included in the study as controls. Their median age at the time of the study was 5.5 (4-9) years. There were no intra- or postoperative complications associated with TERPT. At follow-up, 5 patients used rectal enemas regularly because of obstructive symptoms and 2 of them also fecal incontinence. Two of these 5 patients also received botulinum toxin A injections.

Comparison of BFS between appendicostomy patients and controls

The BFS of each symptom of the children needing appendicostomy were significantly lower before appendicostomy than the BFS of the control patients (Table 4). At follow up after appendicostomy; there was no difference between the BFS of the 5 children with appendicostomy and the BFS of the control patients. Some of the BFS outcomes of the children with appendicostomy were better (Table 5).

Discussion

This study showed that ACE through an appendicostomy stoma can achieve increased bowel control for selected children with HD who have undergone TERPT. Our patients who were considered for appendicostomy and had favorable outcomes after the procedure were those with very poor bowel function, those who had low compliance with rectal enemas, and those with a syndrome. The children with an appendicostomy who continued to use it to administer ACE achieved a level of bowel control similar to the bowel control of children with HD without an appendicostomy.

To our knowledge, there are no published reports on this select group of patients with appendicostomy. Prior studies have reported data from mixed cohorts of patients with a variety of conditions, including anorectal malformations, HD, idiopathic constipation, neurological disorders such as spine bifida, and post-traumatic disorders with various indications [9-12, 13, 20]. Our aim was to clarify the indications for appendicostomy in children with HD who have undergone TERPT. The results confirmed the findings of similar studies that were performed on other types of patients; namely, that ACE through an appendicostomy is effective and improves fecal continence and patient autonomy [14, 20].

The long-term complication rate of children undergoing an appendicostomy was high (57%) but was in line with previous studies on appendicostomy in mixed diagnosis groups reporting 23–100% complications [19, 20-23]. Previously, the most frequently reported complications associated with appendicostomy were stenosis, pain during catheter insertion, and leakage [8, 21, 23]. It has been suggested that the complication rate might be decreased using a Chait cecostomy regarding infections and fistula formation [24]. It has also been speculated that younger children might have fewer complications with their appendicostomy because either the appendicular valve is continent in young children or the Chait in the appendix, which is used more frequently in young children and might be protective [19, 25]. In our study, the median age was low and the frequency of Chait button use was high, which might explain why minor complications were reported. None of our patients developed stenosis, although previous reports have indicated that this is one of the major problems emerging during the years following an appendicostomy in 15–20% of older children [8, 15]. It is possible that stoma stenosis did not develop in our patients because we left a catheter in place for at least 6 weeks after surgery, and most of these children continued to use the Chait button.

ACE had been proposed with the main purpose of improving personal control and hygiene, but it has primarily been studied in older patients [19]. However, the timing of appendicostomy and bowel control problems have not been evaluated in children with HD. Appendicostomy for ACE may seem to be an aggressive treatment for bowel management in preschool children. At our institution, we chose to perform appendicostomy in select patients with HD, independent of age, who had severe bowel management issues and who did not obtain sufficient management with conventional regimens such as dietary modifications, oral medications, and rectal enemas. This requires detailed knowledge not only of the child, but also of the child’s family. In the study cohort, all families were well informed of available treatment options and insisted upon a solution for their children’s problems. A positive finding of our study was that all guardians indicated that they would recommend appendicostomy to the family of a child with HD who had the same bowel management issues. This result agrees with a study of children with anorectal malformations who underwent the same operation [19]. Results from that study led the authors to suggest that patients should receive an appendicostomy before they reach school age to provide them with early autonomy and the possibility of being clean during the school day.

However, there have not been any valid studies that have identified the best age to perform an appendicostomy. Additional studies are required as to decide whether it is beneficial for a child to have an appendicostomy for ACE, instead of continuing rectal enemas despite a child’s dislike of the procedure. In our study, it was difficult to interpret whether improved bowel control was an effect of older age versus ACE. This issue is a consideration as the patients were older when they were assessed after ACE initiation than they were when the appendicostomy was performed. It has been suggested that many patients with HD develop improved bowel control with age. A recent study [26] has shown that after TERPT, incontinence scores, but not constipation scores, are positively correlated with follow-up duration. This result indicates that improved continence could be expected over time. Moreover, for patients with HD, appendicostomy might be used as a tool during the worst years and stopped at a later time.

We chose to use BFS because this score has been previously used for patients with HD and because it seems to consider many potential problems. However, the term constipation might be misleading and must be used and analyzed with caution. The real problem might be obstruction and bowel emptying issues. A physiological obstruction can sometimes be successfully treated by botulinum toxin A [27]. For treating obstructive symptoms, current bowel management includes botulinum toxin A injection as the first option before an appendicostomy or a colostomy.

One limitation of this study is that a small study group was assessed, with 7 of the study patients receiving an appendicostomy. Another potential limitation is that bowel function was assessed at a visit comprising an interview. The results could have been skewed to obtain a better outcome given the closeness of the patients and their families. We attempted to diminish this bias by having an independent person, who had not been previously involved in patient care, assess the BFS and appendicostomy use. However, strength of this study is that no patients were lost to follow-up and that the patients were treated at the same center where all information was also collected. All residents have access to health care free of charge at the time of need and any dropout due to socioeconomic factors is unlikely.

The bowel management program used to day differs from that used during the period of the study. The first step in the bowel management program is dietary counseling, which includes dietary modifications. If bowel symptoms are not improved, and if constipation or obstruction is the main problem, oral medications such as Loperamid are prescribed. If it turns out that the patient’s main symptom is outlet obstruction, botulinum toxin A is injected into the anal sphincter. If the patient continues to have fecal incontinence and/or constipation, the patient is introduced to the use of rectal enemas.

In conclusion, ACE administered through an appendicostomy stoma appears to improve the bowel control in some children with HD who had undergone TERPT. Using a standardized method for evaluating and selecting the patients most likely to benefit from an appendicostomy is important.

Acknowledgments

We are grateful to Fredrik Nilsson, biostatistician at the Competence Centre for Clinical Research, Skåne University Hospital, LUND, Sweden, for statistical advice. This manuscript has been edited by native English-speaking medical experts from BioMed Proofreading LLC.

Editorial editorial

Prof. Dr. Dan Osvald Lucaciu
Rehabilitation Clinic
Cluj-Napoca, Romania

 

Osteoarthritis is the most common type of arthritis, representing a degeneration of joint cartilage and subchondral bone. It is most common in knees and hips, usually affecting people over 50 years, but can also be found in younger people as well. When symptoms cannot be controlled by conservative treatment including weight reduction, physiotherapy, intraarticular injections, topical or systemic drugs, then total knee replacement is the treatment of choice. Arthroscopy is a minimally invasive procedure for diagnosing and treating joint pathologies.

There has been a great debate over the last years regarding the role of arthroscopy in knee osteoarthritis. The need for an evidence-based decision required high quality randomized control studies, which now seem to clarify the indications and contraindications of arthroscopic surgical treatment in knee osteoarthritis.

Current evidence shows that there is no difference in functional scores, pain and quality of life between groups receiving physical therapy and groups undergoing arthroscopic treatment. Moreover, there has been no difference in groups receiving arthroscopic treatment and placebo surgery for knee osteoarthritis. As a result, American Academy of Orthopaedic Surgeons strongly recommend against performing arthroscopy in patients with primary symptomatic osteoarthritis of the knee.

On the other side, we consider that arthroscopy has its indications for associated pathologies in an osteoarthritic knee. Mechanical symptoms including locking and jamming of the knee due to lose bodies, catching of the knee due to meniscal or chondral flaps, represent indications for arthroscopic surgery. It is sometimes difficult to decide whether the knee pain is due to meniscal tears, which may be managed arthroscopically, or due to osteoarthritis. A pain with acute onset, limited to medial joint line (sometimes lateral joint line) and tenderness when palpating the medial or lateral joint line usually points acute meniscal pathology. Of great importance is that surgical outcomes might only reduce mechanical symptoms and not relieve pain or reduce knee swelling. Therefore the patient needs to be well informed regarding the possible outcomes. Furthermore, we consider that degenerative meniscus pathology should not be addressed arthroscopically, due to poor results in current literature.

A great importance is the presence of sub-chondral stress fractures associated to meniscal pathology, especially in elderly. In such cases, the stress fracture can produce the pain, and not the meniscal pathology. If partial meniscectomy is performed in such cases, pain can be aggravated by the procedure. Therefore, an MRI is an examination of great importance for a thorough examination of the knee pathology to prevent wrong surgical indication.

Another indication is a limited chondral lesion, usually medial. In this setting, marrow stimulation, matrix-induced autologous chondrocyte implantation, osteochondral autograft transfer and osteochondral allograft are of great importance with good outcomes, especially in younger patients. Intraarticular soft tissue pathology can also be addressed arthroscopically in case of acute onset, for example pigmented villonodular synovitis.

As a conclusion, arthroscopy has limited indications in knee osteoarthritis, but when this minimally invasive surgery is adequately performed, it can reduce symptoms and delay the need of a total knee replacement, sometimes even prevent it. However, in most cases, conservative treatment consisting in physiotherapy can have the similar effect on symptoms compared to arthroscopic surgery. 

Mohamed Shoukry, Munther Haddad

 

Abstract

Background: Accidental ingestion of foreign bodies in young children and toddlers is common. Most will pass spontaneously without any harm. However, when foreign bodies are magnetized, significant problems can occur. Exceptionally strong magnetic pull and 2 magnets in separate parts of alimentary canal can quite easily attract, potentially causing damage to the intervening structures. We present our experience where earlier surgical intervention was required to extract magnets.

Material and methods: A review of case notes of three patients referred to a tertiary Paediatric Surgery centre during the period March 2011 to August 2014. They have completed follow up period for 2 years at least before discharge them back to GPs care successfully. Retrospective review of similar published articles on PubMed and midline.

Conclusion: Authors recommend close observation, high index of suspicion and early surgical intervention. More public and medical awareness is needed of dangers posed by these readily available objects.

Keywords:  magnetic FB, early surgical intervention, children

 

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Ahmed H. Al-Salem, Mukul Kothari

 

Abstract

Isolated extrahepatic biliary injury in children is extremely rare and there are no previous reports of such an injury or its management in newborns. We present a case of iatrogenic extrahepatic biliary injury in a newborn and describe a technique to treat it.

Keywords: biliary injury, children, iatrogenic, treatment

 

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Hemant Kumar, Ramnik Patel, Bharat More, Bala Eradi, Haitham Dagash, Ashok Rajimwale

 

Abstract

A preterm infant and twin 1 of the dichorionic diamniotic twins born at 27+3/40 weeks gestation weighting 790 grams who had on-going respiratory distress developed total gastric rupture following difficult intubation. Plain chest, abdominal and right lateral decubitus radiographs helped in diagnosis. Infant had resuscitation and underwent exploratory laparotomy, closure of massive gastric rupture and temporary gastrostomy for decompression initially and feeding later uneventfully. Neonatal gastric perforation is rare, serious and potentially lethal if not detected early and treated effectively. It could be traumatic, spontaneous or ischaemic. Our case had acute barotrauma following accidental oesophageal intubation and closed loop obstruction due to cardiac and pyloric sphincter at both ends and relatively high velocity air entering under pressure leading to anterior gastric wall blast. Primary repair of the stomach rupture with temporary gastrostomy is very useful and effective therapeutic strategy in these very sick preterm infants.

Keywords: preterm, gastric perforation, pneumoperitoneum, acute pneumoscotum, peritonitis, neonatal, gastrostomy, traumatic, iatrogenic

 

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Prashant Sadashiv Patil, Gupta Abhaya, Kothari Paras, Kekre Geeta, Deshmukh Shahaji , K Vishesh Dikshit, Apoorva Kulkarni

 

Abstract

The common perception is that children rarely develop severe forms of tuberculosis. A variety of sequelae and complications can occur in the pulmonary and extrapulmonary portions of the thorax in treated or untreated patients. Lung gangrene due to tuberculosis has been described in adult patients. However lung gangrene due to tuberculosis is rarely reported in paediatric patients. We report a case of 2 year old female child with lung gangrene and massive cavity due to tuberculosis.

Keywords: pulmonary tuberculosis, gangrene, thoracotomy, pneumothorax.

 

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Gauthamen Rajendran, Kokila Lakhoo, Arnwald Choi, Frances O’Brien

 

Abstract

Background: There is a paucity of data regarding the perioperative care in neonates.

Objective: To collect data relevant to perioperative care in a neonatal intensive care unit (NICU), with a focus on identifying key areas of clinical care around the time of surgery.

Methods: Perioperative data of neonates who underwent surgical intervention in 2013 within a UK NICU were collected retrospectively. Temperature, blood sugar levels, serum sodium levels, blood gas parameters, weight and fluids used in the perioperative period along with demographic details were collected. The data was analysed for the distribution and trend of temperature, blood sugar and parameters pertaining to fluid, electrolyte and acid-base balance in the perioperative period.

Results: Forty-eight neonatal surgical procedures in 45 neonates were studied. Median gestational age (IQR) at the time of surgery and weight before surgery were 37 (33 to 39) weeks and 2750 (1872 to 2942) grams. The number of surgical procedures for NEC, and abdominal wall defects were 14 and 11 respectively; 23 neonates had surgery for other reasons. Incidence of postoperative hypothermia was 15%. Hyperglycaemia and hypocapnia were more common post-operatively when compared to preoperative findings (63% vs 13% and 19% vs 0% respectively). Hyponatraemia was common preoperatively (42%) but the incidence remained static postoperatively. Hypernatremia was uncommon. A slow and sustained increase in blood sugar levels were noticed in preterm and NEC neonates. Statistically significant weight gain occurred in preterm neonates.

Conclusions: Pre-operative hyponatraemia and post-operative hyperglycemia and hypocapnia require attention. Preterm neonates and neonates with NEC and abdominal wall defects are the high risk groups.

Keywords: newborn, perioperative care, preterm infants, hypothermia, hyperglycemia

 

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Moustafa Hamchou, Hilal Matta, Bahjat Sahari, Adnan Swid, Ahmed Al-Salem

 

Abstract

Background: Obesity and overweight in children is increasingly common worldwide and known to be associated with morbidity. Dietary manipulation and changing their life style may prove to be effective in slightly overweight children but are not effective in obese children and those with comorbidities.

Patients and method: This is a retrospective study of all morbidly obese children who had laparoscopic sleeve gastrectomy (LSG).

Results: Over a period of 4 years (June 2012 - June 2015), 26 children (14 female: 12 male) had LSG. Their mean age was 12.6 years (10.5-15 years) and their mean BMI 47.2 (40-65). Twenty-one (80.8%) of our patients had associated comorbidities. These included sleep apnea (7 patients), hypertension (3 patients), type 2 diabetes mellitus (3 patients), bronchial asthma (4 patients), enuresis (2 patients), and foot and joint problems (2 patients). Two of our patients had Prader–Willi syndrome. The mean follow-up was 1.5 years (1 year - 3 years). The mean operative time was 120 minutes (90-150 minutes). The mean hospital stay was 4 days (3-7 days). Only one of our patients was admitted to the intensive care unit for one day observation because of severe sleep apnea. There were no major complications and no leaks. There was an overall 65.2% weight loss and 70% improvement in comorbidities. Their mean postoperative BMI was 30.75 (24-38). There was also marked improvement in quality of life, self-esteem, productivity and social functioning. There was a significant weight loss in the two patients with Prader–Willi syndrome for the first 2 years but one of them restarted to gain weight again.

Conclusions: Obesity and overweight in children is common worldwide and known to be associated with morbidity. LSG is effective in treating obese children and alleviating their comorbidities. LSG should be performed by experienced laparoscopic surgeons and long term follow-up is important as there is still concern regarding its effects on growth and maturity, and the sustainability of the weight loss.

Keywords:bariatric surgery, children, sleeve gastrectomy, weight loss

 

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Junaid Ashraf, Anna Radford

 

Abstract

AimThe aim of this article to give a concise summary of the assessment and management of neuropathic bladders as per the current literature in the paediatric age group.

Keywords: neuropathic bladder, assessment, investigation, conservative treatment, surgical management

 

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Einar Arnbjörnsson, Christina Granéli, Anna Börjesson, Pernilla Stenström

 

Abstract

AimTo evaluate the indications for, and outcome, of appendicostomy for patients with Hirschsprungs disease (HD) who underwent transanal endorectal pull-through (TERPT).

Method: Children with HD > 4 years old who received an appendicostomy between 2005 and 2011 at a tertiary pediatric surgery center were included. Pre- and post-appendicostomy bowel function was evaluated by a bowel function score. HD-patients not receiving an appendicostomy were the controls. The study was approved by an institutional ethics committee (2010/49).

Results: Seven of 37 HD-patients received an appendicostomy. Syndromes were present in 43% of the appendicostomy and 6% of the controls (controls reported absence of fecal accidents (p=0.297). Three (60%) with appendicostomy and 14 (47%) controls, respectively, reported absence of soiling or soiling RPT.

Keywords: Hirschsprungs disease, transanal endorectal pull through, bowel function score, antegrade continence enema, appendicostomy.

 

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