Gasless Trans-Umbilical Laparoscopically-Assisted Appendectomy in the Pediatric Population: An Early Experience

Background: The aim of this study is to determine the feasibility and safety of the single-port gasless trans-umbilical laparoscopically-assisted appendectomy in the pediatric age group at a single center in a tertiary university hospital in Jordan. Methods: Between April 2018 and July 2019, the surgical records of all patients aged between 0 and 13 years treated with trans-umbilical laparoscopic-assisted appendectomy TULAA for a suspected appendicitis following a clinical, laboratory and ultrasound findings were reviewed retrospectively. Baseline characteristics, white blood cell count, operative time, intraoperative findings, need for additional trocars or for conversion, length of hospital stay and surgical complications were reported.Results: 36 cases were included in the study, 23 (64%) were completed successfully using the gasless TULAA technique. Gas insufflation was needed in 10 (28%) cases and only 3 (8%) had to be converted to the three-port laparoscopic appendectomy technique. There was no significant difference between the gaseous and gasless groups in terms of baseline characteristics, BMI, surgery duration, postoperative recovery period or length of stay. However, the group of patients who needed gas insufflation to complete the procedure had a higher white blood cell count compared to the gasless group. The surgery was completed successfully by senior general surgery residents in 27 (75%) cases while the consultant’s intervention was needed in the remaining cases. The gasless TULAA group were less likely to require complex analgesia (i.e., IV analgesia) compared to the gasless group (OR=0.683).Conclusions: Gasless TULAA is a feasible procedure that can be performed safely by surgical residents as an initial approach for all grades of acute appendicitis in the pediatric age group

The Prevalence of Nocturnal Enuresis among Patients with Vesicoureteral Reflux

Background: To identify the prevalence and other associated factors of nocturnal enuresis in children with vesicoureteral reflux undergoing surgical interventions.Methods: This is a cross-sectional study were the medical records of 40 children with confirmed vesicoureteral reflux were reviewed. Additionally, parents were asked to fill out a questionnaire inquiring about presence, onset & course of nocturnal enuresis as has been defined according to ICD-10.Results: Among the 40 children, 22 children (55%) had nocturnal enuresis before any surgical intervention. However; gender, family history of bedwetting, renal hydronephrosis on ultrasound, positive urine culture, and pre-op creatinine level were found to have statistically insignificant association with nocturnal enuresis. After surgical management only 13 (32.5%) children experienced nocturnal enuresis.Conclusion: This study can conclude that there is a weak correlation between NE and VUR in patients undergoing surgical intervention. Also, the surgical management of VUR did not significantly affect the prevalence of NE. However, it is an essential problem for both families and children in Jordan for which specific guidelines should be developed

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030