Laparoscopic Hernia Repair in Infancy and Childhood; Evaluation of Two Different Techniques

Background/Purpose: There are many techniques available for laparoscopic hernia repair in infancy and childhood. The objective of this study is to compare two different laparoscopic techniques as regards operative time, recurrence rate, hydrocele formation and post operative cosmetic results. Materials & Methods: A prospective randomized controlled study was carried out in the Pediatric Surgery Unit of Al- Azhar University Hospitals, over three years period. ne-hundred and fifty patients with congenital inguinal hernia were randomized into two equals groups; (n = 75). Group A was subjected to purse-string suture around the internal inguinal ring (IIR) using two needle holders (TNH). Group B was subjected to laparoscopic hernia repair of inguinal hernia by Reverdin Needle (RN). Inclusion criteria included; bilateral inguinal hernia, recurrent hernia, hernia in obese child, incarcerated hernia and hernia on ipsilateral with questionable contralateral side. Exclusion criteria included; unilateral inguinal hernia, and hernia with undescended testicles. The main outcome measurements were; operative time, hospital stay, postoperative hydrocele formation, recurrence rate, and cosmetic results. Results: There were no significant differences as regard age, sex and mode of presentation between both groups. All cases were completed successfully without conversion. There were significant statistical differences in the operative time between the studied groups, while there were no significant statistical differences in the hospital stay, post operative hydrocele formation and recurrence rate. The cosmetic result is excellent in group B. Conclusion: Laparoscopic hernia repair by RN is an effective line of hernia repair in infancy and childhood. It resulted in marked reduction of operative time and excellent cosmetic results with low recurrence. Index Word: Laparoscopic, Reverdin Needle, Purse-string, Intracorporeal sutures

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

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 middle-income 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 low-income 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 low-income, 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

Divergent trends in ecosystem services under different climate-management futures in a fire-prone forest landscape

While ecosystem services and climate change are often examined independently, quantitative assessments integrating these fields are needed to inform future land management decisions. Using climate-informed state-and-transition simulations, we examined projected trends and trade-offs for a suite of ecosystem services under four climate change scenarios and two management scenarios (active management emphasizing fuel treatments and no management other than fire suppression) in a fire-prone landscape of dry and moist mixed-conifer forests in central Oregon, USA. Focal ecosystem services included fire potential (regulating service), timber volume (provisioning service), and potential wildlife habitat (supporting service). Projections without climate change suggested active management in dry mixed-conifer forests would create more open forest structures, reduce crown fire potential, and maintain timber stocks, while in moist mixed-conifer forests, active management would reduce crown fire potential but at the expense of timber stocks. When climate change was considered, however, trends in most ecosystem services changed substantially, with large increases in wildfire area predominating broad-scale trends in outputs, regardless of management approach (e.g., strong declines in timber stocks and habitat for closed-forest wildlife species). Active management still had an influence under a changing climate, but as a moderator of the strong climate-driven trends rather than being a principal driver of ecosystem service outputs. These results suggest projections of future ecosystem services that do not consider climate change may result in unrealistic expectations of benefits