Surgical Procedures In Children Research Articles

Effect of Mother’s Voice on Postoperative Pain Pediatric in Tonsillectomy Surgery

Introduction: Tonsillectomy is a painful but common surgical procedure in children whichrequires adequate pain relief to facilitate the recovery process. One of the main roles of nurses is to use non pharmacological treatment of pain. Therefore, the present study aimed at determining the effects of mother’s voice on pediatrics’ pain in tonsillectomy surgery.

Rates and risk factors of unplanned 30-day readmission following general and thoracic pediatric surgical procedures

Background/PurposePostoperative unplanned readmissions are costly and decrease patient satisfaction; however, little is known about this complication in pediatric surgery. The purpose of this study was to determine rates and predictors of unplanned readmission in a multi-institutional cohort of pediatric surgical patients. MethodsUnplanned 30-day readmissions following general and thoracic surgical procedures in children <18 were identified from the 2012–2014 National Surgical Quality Improvement Program- Pediatric. Time-dependent rates of readmission per 30 person–days were determined to account for varied postoperative length of stay (pLOS). Patients were randomly divided into 70% derivation and 30% validation cohorts which were used for creation and validation of a risk model for readmission. ResultsReadmission occurred in 1948 (3.6%) of 54,870 children for a rate of 4.3% per 30 person–days. Adjusted predictors of readmission included hepatobiliary procedures, increased wound class, operative duration, complications, and pLOS. The predictive model discriminated well in the derivation and validation cohorts (AUROC 0.710 and 0.701) with good calibration between observed and expected readmission events in both cohorts (p>.05). ConclusionsUnplanned readmission occurs less frequently in pediatric surgery than what is described in adults, calling into question its use as a quality indicator in this population. Factors that predict readmission including type of procedure, complications, and pLOS can be used to identify at-risk children and develop prevention strategies. Level of evidenceIII.

Assessment of risk factors for cerebral oxygen desaturation during neonatal and infant general anesthesia: an observational, prospective study.

BackgroundCerebral oxygen saturation (rSO2c) decrease from baseline greater than 20 % during infant cardiac surgery was associated with postoperative neurologic changes and neurodevelopmental impairment at 1 year of age. So far, there is no sufficient evidence to support the routine monitoring of rSO2c during general surgical procedures in children. We aimed to find out the frequency of cerebral desaturation 20 % or more from baseline and to identify possible predictors of change in cerebral oxygen saturation during neonatal and infant general surgery.MethodsForty-four infants up to 3 months of age were recruited. Before induction of anesthesia, two pediatric cerebral sensors were placed bilaterally to the forehead region and monitoring of regional cerebral saturation of oxygen was started and continued throughout the surgery. Simultaneously, mean arterial blood pressure (MAP), pulse oximetry (SpO2), heart rate (HR), endtidal CO2, expired fraction of sevoflurane and rectal temperature were recorded. The main outcome measure was rSO2c value drop-off ≥20 % from baseline. Mann-Whitney U-test, chi-squared test, simple and multiple linear regression models were used for statistical analysis.ResultsForty-three infants were analyzed. Drop-off ≥20 % in rSO2c from baseline occurred in 8 (18.6 %) patients. There were no differences in basal rSO2c, SpO2, HR, endtidal CO2, expired fraction of sevoflurane and rectal temperature between patients with and without desaturation 20 % or more from baseline. But the two groups differed with regard to gestation, preoperative mechanical ventilation and the use of vasoactive medications and red blood cell transfusions during surgery. Simple linear regression model showed, that gestation, age, preoperative mechanical ventilation and mean arterial pressure corresponding to minimal rSO2c value during anesthesia (MAPminrSO2c) were associated with a change in rSO2c values. Multiple regression model including all above mentioned variables, revealed that only MAPminrSO2c was predictive for a change in rSO2c values (β (95 % confidence interval) -0.28 (−0.52–(−0.04)) p = 0.02).ConclusionsCerebral oxygen desaturation ≥20 % from baseline occurred in almost one fifth of patients. Although different perioperative factors can predispose to cerebral oxygenation changes, arterial blood pressure seems to be the most important. Gestation as another possible risk factor needs further investigation.Trial registrationThe international registration number NCT02423369. Retrospectively registered on April 2015.Electronic supplementary materialThe online version of this article (doi:10.1186/s12871-016-0274-2) contains supplementary material, which is available to authorized users.

Postoperative Complications in Children With Crohn Disease Treated With Infliximab.

Infliximab (IFX) has become a mainstay of therapy for children with Crohn disease (CD). Despite medical advances, many children with CD, however, still require operative interventions. The risk of complications following resection in children treated with IFX remains largely unknown. We compare surgical outcomes stratified by IFX therapy in a cohort of children with CD who require bowel resection. We reviewed the postoperative complications in 123 children with CD who underwent bowel resection with primary anastomosis at our institution between 1977 and 2011. Demographics, medications, types of operations, and inpatient courses were analyzed. Complications and length of stay were compared based on medical therapy. Overall, the postoperative complication rate was 13%. Of the 123 surgical cases, 24 children had received IFX before their operation. In the children treated with IFX, we identified 3 major complications, including anastomotic leak, acute renal failure, and intraabdominal abscess. There were 9 major complications in the non-IFX group, including infections (2), intraabdominal abscesses (2), bowel obstruction, shock, supraventricular tachycardia, phlegmon, and anastomotic stricture. No significant differences in complication rates or postoperative lengths of stay were identified between those who did or did not receive IFX. In this cohort, surgical procedures in children and young adults treated with IFX were not associated with an increased number of complications or prolonged length of stay. Given that postoperative complications are infrequent in children, larger multicenter studies may be required to determine whether IFX therapy increases the risk of surgical complications in pediatric CD.

Safety and cost-effectiveness of port removal outside of the operating room among pediatric patients

PurposeThe current emphasis on fiscally responsible health spending in the era of the Affordable Care Act and other health care reform necessitates cost-conscious delivery of care. “Value” in health care is defined as the quality of care divided by the cost. As such, health systems optimize value by providing the most cost-effective care possible without sacrificing safety or outcomes. Elective, minimal risk surgical procedures in children may be value-enhanced by moving from an operating room (OR) to a more cost-efficient setting. The purpose of this study was to assess the safety and cost of performing the removal of implantable central venous access devices (“ports”) in locations other than the main OR. MethodsWe compared port removal at three sites: 1. Main OR, 2. Satellite OR, and 3. Clinic Procedure Room. This was a mixed-methods study including a retrospective review of medical records and prospective observation/interviewing. To calculate cost without the inherent biases of hospital charges, costs, and payments, we utilized the methodology of time-driven activity based costing. Specifically, we recorded time spent by the patient in hospital facilities and with health care personnel. This duration was then weighted with the hourly cost of each health care professional and hospital space. The Mann–Whitney U test compared time and cost across the three sites. Overall cost at each site was divided by overall cost at the referent site (Main OR) to obtain a ratio of cost savings. ResultsA total of 120 patients (40 per site) were included in the analysis. Demographic and clinical factors were not significantly different between sites. No complication occurred with port removal at any site. Time of the entire care episode was significantly decreased in the Clinic (median 161min, 95% confidence interval [CI] 134–188min), compared to the Main OR (median 235min, 95% confidence interval [CI] 209–251min) or Satellite OR (median 228min, 95% confidence interval [CI] 211–245min). Overall cost was decreased by 25% (95% CI: 13–34%) at the Clinic and by 6% (95% CI: −2–11%) at the Satellite OR, compared to the Main OR (referent, P<0.01). ConclusionIn our study, port removal in the Clinic Procedure Room was not associated with increased risk of negative outcomes. Shifting port removal from the Main OR to the Clinic may result in substantial cost savings.

Prevalence of Diagnosed Sleep Disorders and Related Diagnostic and Surgical Procedures in Children with Autism Spectrum Disorders.

Sleep disorders are common and important comorbid conditions in children with autism spectrum disorder (ASD) and can contribute to cognitive and behavioral problems. Sleep-disordered breathing (SDB) is a diagnosable and treatable cause of behavioral problems in children. We aimed to quantify the relative risk for children with ASD versus controls of being diagnosed with sleep disorders including SDB and undergoing related diagnostic and surgical procedures. This retrospective case-cohort study included 48,762 children with ASD aged 2 to 18 years enrolled in the military health system (MHS) from 2000 to 2013. Children with ASD were matched 1:5 by birthdate, sex, and enrollment time to children without an ASD diagnosis. The MHS database was queried for International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for sleep disorders or ICD-9-CM and Current Procedural Terminology codes for diagnostic and surgical procedures. Relative risks (RR) and 95% confidence intervals (CI) were determined with binary Poisson regression conditional on the match and adjusting for confounders. Children with ASD were at higher risk of receiving any sleep disorder diagnosis (RR: 1.97 [95% CI, 1.91-2.02]) including SDB (RR: 1.96 [95% CI, 1.88-2.05]). Children with ASD also were at increased risk of undergoing polysomnography (RR: 3.74 [95% CI, 3.56-3.93]) and sleep disorder-related surgery (RR: 1.50 [95% CI, 1.46-1.54]). Children with ASD are more likely to be given a sleep disorder diagnosis including SDB and are more likely to undergo related diagnostic and surgical procedures compared with controls without ASD.

The Effect of Systemic Magnesium on Postsurgical Pain in Children Undergoing Tonsillectomies: A Double-Blinded, Randomized, Placebo-Controlled Trial.

Tonsillectomy is a frequently performed surgical procedure in children; however, few multimodal analgesic strategies have been shown to improve postsurgical pain in this patient population. Systemic magnesium infusions have been shown to reliably improve postoperative pain in adults, but their effects in pediatric surgical patients remain to be determined. In the current investigation, our main objective was to evaluate the use of systemic magnesium to improve postoperative pain in pediatric patients undergoing tonsillectomy. We hypothesized that children who received systemic magnesium infusions would have less post-tonsillectomy pain than the children who received saline infusions. The study was a prospective, randomized, double-blinded, clinical trial. Subjects were randomly assigned using a computer-generated table of random numbers to 1 of the 2 intervention groups: systemic magnesium infusion (initial loading dose 30 mg/kg given over 15 minutes followed by a continuous magnesium infusion 10 mg/kg/h) and the same volume of saline. The primary outcome was pain scores in the postanesthesia care unit (PACU) measured by FLACC (Face, Legs, Activity, Cry, Consolability) pain scores. Pain reduction was measured by the decrement in the area under the pain scale versus 90-minute postoperative time curve using the trapezoidal method. Secondary outcomes included opioid consumption in the PACU, emergence delirium scores (measured by the pediatric anesthesia emergence delirium scale), and parent satisfaction. Sixty subjects were randomly assigned and 60 completed the study. The area under pain scores (up to 90 minutes) was not different between the study groups, median (interquartile range [IQR]) of 30 (0-120) score × min and 45 (0-135) score × min for the magnesium and control groups, respectively (P = 0.74). Similarly, there was no clinically significant difference in the morphine consumption in the PACU between the magnesium group, median (IQR) of 2.0 (0-4.44) mg IV morphine, compared with the control, median (IQR) of 2.5 (0-4.99) mg IV morphine (P = 0.25). The serum level of magnesium was significantly lower in the control group than in the treatment group at the end of the surgery (P < 0.001). Despite a large number of studies demonstrating the efficacy of systemic magnesium for preventing postsurgical pain in adults, we could not find evidence for a significant clinical benefit of systemic magnesium infusion in children undergoing tonsillectomies. Our findings reiterate the importance of validating multimodal analgesic strategies in children that have been demonstrated to be effective in the adult population.

Tramadol wound infiltration is not different from intravenous tramadol in children: a randomized controlled trial

Study ObjectiveThe purpose of this trial was to assess if tramadol wound infiltration is superior to intravenous (IV) tramadol after minor surgical procedures in children because tramadol seems to have local anesthetic–like effect. DesignRandomized double-blind controlled trial. SettingPostanesthesia care unit. PatientsForty children, American Society of Anesthesiologists physical status I or II, scheduled to elective inguinal hernia repair. InterventionsChildren were randomly distributed in 1 of 2 groups: IV tramadol (group 1) or subcutaneous infiltration with tramadol (group 2). At the end of the surgery, group 1 received 2 mg/kg tramadol (3 mL) by IV route and 3-mL saline into the surgical wound; group 2 received 2 mg/kg tramadol (3 mL) into the surgical wound and 3-mL saline by IV route. MeasurementsIn the postanesthesia care unit, patients were evaluated for pain intensity, nausea and vomiting, time to first rescue medication, and total rescue morphine and dipyrone consumption. Main ResultsPain scores measured during the postanesthesia recovery time were similar between groups. Time to first rescue medication was shorter, but not statistically significant in the IV group. The total dose of rescue morphine and dipyrone was also similar between groups. ConclusionsWe concluded that tramadol was effective in reducing postoperative pain in children, and there was no difference in pain intensity, nausea and vomiting, or somnolence regarding IV route or wound infiltration.

Coeliac trunk and common hepatic artery variations in children: an analysis with computed tomography angiography.

Understanding the coeliac trunk (CeT) and hepatic artery anatomy is important not only in preventing iatrogenic injuries but also in planning surgical procedures in children. Therefore, the aim of this study is to analyse the prevalence of CeT and common hepatic artery (CHA) variations in the paediatric population. One hundred and seventy-four children who underwent abdominal multidetector computed tomography (MDCT) angiography, either because of trauma or liver transplantation, were analysed retrospectively. The patterns of CeT, CHA and their variant branches were revealed and compared with previous studies involving adults. A total of 157 (90.2%) of the 174 patients had normal CeT anatomy, whereas 17 (9.8%) had variations. Five types of CeT variations were identified according to Song's classification in which 'hepatosplenic trunk + left gastric artery + superior mesenteric artery' was the most prevalent. One hundred-twelve (64.4%) of the 174 patients had normal CHA anatomy; however, 62 (35.6%) had variations. Six types of CHA variations were identified according to Michel's and Hiatt's classification. The most common was 'replaced left hepatic artery originating from left gastric artery'. The prevalences of CeT and hepatic artery variations are high in children, as they are in older patients. Awareness of these variations is important in terms of avoiding iatrogenic injury and in promoting surgical procedure planning for liver transplantation or abdominal tumour surgery.

Links and risks associated with adenotonsillectomy and obesity.

Adenotonsillectomy (A&T) is a very common surgical procedure in children. Over the past 20 years the principal indication for A&T in children has changed from recurrent adenotonsillitis to obstructive sleep apnea. The physiopathology of obstructive sleep apnea syndrome (OSAS) is multifactorial and obesity has been shown to be one of the main factors correlated with its occurrence. On the other hand, the prevalence and severity of childhood obesity have become a veritable epidemic problem in the past 30 years. So the increasing prevalence of obesity in children and high prevalence of obstructive sleep apnea in obese children implies that an increasing number of these children will present for A&T. Due to more prevalent anatomical alterations of the oronasopharyngeal airways, it is often difficult to predict operation success in obese children. However, previous studies supports that although the risk of presence of residual symptoms of OSAS and airway-related perioperative complication in obese may be more than nonobese group, A&T is effective to reduce obstructive symptoms and improve quality of life in obese children with OSAS.

Contemporary Guidelines for Tympanostomy Tube Placement

Although tympanostomy tube placement has been one of the most common surgical procedures in children in the USA for many years, clinical practice guidelines were not developed until recently. In 2013, the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) published a clinical practice guideline based on an extensive literature review to address specific indications for surgery. These clinical practice guidelines focus primarily on chronic otitis media with effusion and recurrent acute otitis media and provide an evidence-based framework for decision-making strategies. Although a useful tool to assist in clinical decision-making, it is important to keep in mind that individual patient considerations and circumstances must also be taken into account when making treatment decisions. Otherwise, healthy children with minimal risk of developmental delays should be given a generous observation period prior to offering tympanostomy tube placement; higher-risk children should undergo more prompt surgical intervention.

Risk of venous thromboembolism in children after general surgery

Background/purposeThe purpose of the study was to determine absolute and relative rates of venous thromboembolism (VTE) following general surgical procedures in children compared to the general population. MethodsWe analyzed data from all patients under the age of 18years in the Clinical Practice Research Datalink, linked to Hospital Episode Statistics from England (2001–2011) undergoing a general surgical procedure and population controls. Crude rates of VTE and adjusted hazard ratios were calculated using Cox regression. ResultsWe identified 15,637 children who had a surgical procedure with 161,594 controls. Six children undergoing surgery had a VTE diagnosed in the year after compared to five children in the population cohort. The overall rate of VTE following surgery was 0.4 per 1000 person years (pyrs) (95% confidence interval [CI] 0.15–0.88) compared to 0.04 per 1000 pyrs (95% CI 0.02–0.09) in the population cohort. This represented a 9 fold increase in risk compared to the population cohort (adjusted hazard ratio [HR] 8.80; 95% CI 2.59–29.94). ConclusionsChildren are at increased risk for VTE following general surgical procedures compared to the general population however the absolute risk is small and given this the benefits of thromboprophylaxis need to be balanced against the risk of complications following its use.

Robotic surgical procedures in children

Robotic surgical procedures in children

Variability in noncardiac surgical procedures in children with congenital heart disease

BackgroundThe purpose of this study was to examine the volume and variability of noncardiac surgeries performed in children with congenital heart disease (CHD) requiring cardiac surgery in the first year of life. MethodsPatients who underwent cardiac surgery by 1year of age and had a minimum 5-year follow-up at 22 of the hospitals contributing to the Pediatric Health Information System database between 2004 and 2012 were included. Frequencies of noncardiac surgical procedures by age 5years were determined and categorized by subspecialty. Patients were stratified according to their maximum RACHS-1 (Risk Adjustment in Congenital Heart Surgery) category. The proportions of patients across hospitals who had a noncardiac surgical procedure for each subspecialty were compared using logistic mixed effects models. Results8857 patients underwent congenital heart surgery during the first year of life, 3621 (41%) of whom had 13,894 noncardiac surgical procedures by 5years. Over half of all procedures were in general surgery (4432; 31.9%) or otolaryngology (4002; 28.8%). There was significant variation among hospitals in the proportion of CHD patients having noncardiac surgical procedures. Compared to children in the low risk group (RACHS-1 categories 1–3), children in the high-risk group (categories 4–6) were more likely to have general, dental, orthopedic, and thoracic procedures. ConclusionsChildren with CHD requiring cardiac surgery frequently also undergo noncardiac surgical procedures; however, considerable variability in the frequency of these procedures exists across hospitals. This suggests a lack of uniformity in indications used for surgical intervention. Further research should aim to better standardize care for this complex patient population.

Risk factors for acute pulmonary edema after adenotonsillectomy in children.

Adenotonsillectomy is a common surgical procedure in children. Acute pulmonary edema after this procedure is a rare complication but may be fatal. The factors associated with pulmonary edema after adenotonsillectomy were studied. All consecutive patients with an age of less than 15 years who underwent adenotonsillectomy at Chiang Mai University Hospital were enrolled. The study period was from January 2004 to December 2008. Clinical factors were retrospectively retrieved from medical records. Factors associated with acute pulmonary edema after adenotonsillectomy were computed using multiple logistic regression analysis. There were 216 patients who underwent adenotonsillectomy due to airway obstruction during the study period. Five patients were excluded due to incomplete data. Of those included, 129 patients (61.1%) were male with mean age of 6.6 (SD 3.2) years. Four significant factors associated with the development of post-operative pulmonary edema after the adenotonsillectomy were procedure, age, obesity, and pulmonary hypertension. Factors associated with acute pulmonary edema after adenotonsillectomy in children were adenotonsillectomy procedure, young age, obesity, or having pulmonary hypertension. Clinicians should be aware of these risk factors while performing adenotonsillectomy in children.

The Analgesic Efficacy of Preoperative Oral Ibuprofen and Acetaminophen in Children Undergoing Adenotonsillectomy: A Randomized Clinical Trial

Background:Adenotonsillectomy is one of the most common surgical procedures in children. Several complications and morbidities are common after nasal surgeries and the most common is pain. Several techniques have been employed to reduce the severity of postoperative pain. One of the preoperative techniques is pre-emptive analgesia through preventive central hypersensitization. This technique is performed by applying analgesic methods before the onset of nociceptive stimuli, consequently decreasing postoperative analgesics requirements.Objectives:Preoperative oral drug administration for pain analgesia is performed in several methods. The aim of this study was to compare the analgesic effects of preoperatively administration of oral acetaminophen and ibuprofen.Patients and Methods:In a double-blinded, randomized placebo-controlled study, sixty 4-12 years old ASA I or II children scheduled for elective adenotonsillectomy, were assigned to receive either acetaminophen 15 mg/kg, ibuprofen 10 mg/kg or placebo 30 minutes before the operation. Postoperative pain was assessed using the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS), upon arrival to the post anesthetic care unit (PACU) and ward. Findings were analyzed by SPSS version 17 using variance analysis and Tukey’s test.Results:The average pain intensities were significantly lower in acetaminophen group based on the CHEOPS in both PACU and ward compared to ibuprofen or placebo groups; but there was no difference in pain intensity between the ibuprofen and placebo groups. Pain intensity in PACU in Acetaminophen group was 7.05 ± 0.64 vs. 8.38 ± 1.20 in placebo group and 8.14 ± 0.85 in ibuprofen group, pain intensity in ward in the acetaminophen group was 6.0.87 ± 0.85in the acetaminophen group, vs. 8.04 ± 1.02 in placebo group, and 7.78 ± 0.78 in ibuprofen group.Conclusions:This study showed that administration of oral acetaminophen 30 minutes preoperatively, resulted in significantly lower pain intensity in children undergoing adenotonsillectomy in PACU and ward, compared to ibuprofen and placebo.

EComment. Is the maintenance of haemostasis possible without fibrinogen?

Although fibrinogen is a key factor in thrombosis, its role in the pathogenesis of haemostatic disturbances after cardiac surgery is often underestimated. Therefore we were glad to read the article by Gielen et al. [1]. Apparently during the postoperative period, decrease in fibrinogen often coincides with the deficiency of other clotting factors and platelet dysfunction, and the level of postoperative blood loss does not depend only on the fibrinogen concentration. Thus, there are no linear connections between blood loss and the level of fibrinogen. However, we cannot underestimate the contribution of this clotting factor in the mechanical stability of clots, which also depends on platelets, coagulation factor XIII and von Willebrand factor. The deficiency of those factors, primarily fibrinogen, leads to the decrease in the fibrin monomer and its polymerization, which further results in delayed thrombus formation along with increase of fibrinolysis sensitivity and blood loss. Based on thromboelastography data, a feedback loop exists between the fibrinogen level and maximum lysis [2]. Therefore, the fibrinogen level serves as an integral value of the formation and stabilization of the clot. It is necessary to note that the velocity of fibrin formation may be affected by the absolute quantity of fibrinogen and its concentration, therefore hypofibrinogenaemia may be the result either of fibrinogen loss or haemodilution. The main target of haemodilution is the formation and stability of the clot, but not the thrombin formation [3]. We tested the connection between pre- and postoperative coagulation values and the level of blood loss after cardiac surgical procedures in children. For patients with congenital heart disease, we consider a threshold fibrinogen concentration of 2.5 g/l to be necessary for prevention of bleeding. In cases with lower concentrations of fibrinogen, we observed postoperative blood losses of 0.75 ml/kg/h to 1.27 ml/kg/h [4]. Hypofibrinogenaemia in children may be caused by hypotrophy due to social (early artificial feeding) and medical factors, impaired hepatic protein synthesis, and a decrease in terminal elimination half-life in cyanotic patients. A postoperative level of fibrinogen less than 2 g/l led to blood loss of 0.61 to 0.85 ml/kg/h [2]. Indeed, there is insufficient evidence to prove that the use of fibrinogen concentrate after cardiac surgery is successful. However, a controlled replacement therapy of blood loss via the use of fibrinogen concentrate in hypofibrinogenaemia is efficient and abolishes the deficiency of other haemostasis components without the risk of thrombosis development. On the other hand, based on stoichiometry, a possible way to circumvent a low level of fibrinogen concentration may be the optimization of the circulating blood volume via the application of ultrafiltration. Conflict of interest: none declared

Management of Refractory Tympanostomy Tube Otorrhea with Ear Wicks

Objectives: Report our experience with ear wicks for the treatment of chronic tympanostomy tube otorrhea, failing to improve with oral and/or topical antibiotics. Methods: Retrospective review of 7 children with tympanostomy tubes and recurrent otorrhea failing medical management in 2012 at a tertiary care center. We describe the outcomes of patients after wick placement and Ciprodex ear drops. Results: The average age of patients in this study is 30 months (21-48months). The average age of tympanostomy tube insertion was 17 months (8-32 months). All patients had Armstrong grommet tubes placed. Three patients found effusions during time of insertion. All children failed previous topical and/or oral antibiotic treatment. An ear wick was placed during the clinic visit, and ciprodex drops were continued. Wicks were removed in approximately one week. Culture results showed 4 patients had Methicillin-resistant Staphylococcus aureus and 3 had Pseudomonas aeruginosa. After wick placement, 7/7 (100%) patients’ otorrhea resolved. One patient had recurrent otorrhea at further follow-up visit. Conclusions: Tympanostomy tube placement is one of the most common surgical procedures in children. Refractory otorrhea continues to be a complication that has a negative effect on patient quality of life and remains a challenge to treat. It can be difficult to adequately deliver topical therapy to young children. Placement of an ear wick improves topical delivery to the ear and may eradicate otorrhea in patients who failed prior topical and oral antibiotics.

Systematic reviews of surgical procedures in children: Quantity, coverage and quality

Systematic reviews have the potential to map those areas where children are under-represented in surgical research. We aimed to describe and evaluate the quantity, coverage and the quality of conduct and reporting of systematic reviews of surgical procedures in children. We searched four biomedical databases, a systematic review register, reference lists and conducted hand searching to identify relevant reviews. Two reviewers worked independently to critically appraise included studies and abstract data. We assessed reporting quality using the preferred reporting items for systematic reviews and meta-analysis statement and methodological quality using the Assessment of Multiple SysTemAtic Reviews tool. Fifteen systematic reviews were identified, representing 0.01% of all paediatric surgical citations in MEDLINE and Embase. Thirteen of the reviews were Cochrane reviews, and most reviews (12/15) addressed subspecialty interests such as otorhinolaryngology. The median number of included trials per systematic review was four (interquartile range 1 to 9.5), the median number of primary outcomes was 5.5 (interquartile range 3.5 to 7.5). In general, reporting and methodological quality was good although there were several omissions, particularly around completeness of reporting of statistical methods used, and utilisation of quality assessments in analyses. Outcomes were often not clearly defined and descriptions of procedures lacked sufficient detail to determine the similarities and differences among surgical procedures within the contributing trials. Systematic reviews of surgical procedures in children are rarely published. To improve the evidence base and guide research agendas, more systematic reviews should be conducted, using standard guidelines for conduct and reporting.

Totally Transanal LESS Pull-Through Colectomy: A Novel Approach for Avoiding Abdominal Wall Incision in Children with Long-Segment Intestinal Aganglionosis

Abstract Introduction: Minimally invasive surgery in children with long-segment intestinal aganglionosis aims to reduce the number of abdominal wall incisions. Conventional laparoscopic and laparoendoscopic single-site (LESS) surgeries fulfill this goal. In children, natural orifice translumenal endoscopic surgery (NOTES™; American Society for Gastrointestinal Endoscopy [Oak Brook, IL] and Society for American Gastrointestinal and Endoscopic Surgeons [Los Angeles, CA]) has been limited because of fear of access site complications. We present a novel technique of totally transanal LESS pull-through colectomy (TLPC), avoiding abdominal wall incision, which combines LESS technology and the NOTES approach. Two boys and one girl (2.5 months, 6 months, and 5 years of age, respectively) with sigmoid and transverse colon aganglionosis underwent surgery. The TLPC procedure consisted of an endorectal technique with submucosal dissection starting 1 cm orally from the dentate line to above the peritoneal reflection, where the rectal muscle was divided circumferentially. After ligation of the rectal mucosa, the proximal bowel was replaced into the abdominal cavity, and a TriPort(®) (Olympus Surgical Technologies Europe, Hamburg, Germany) was introduced transanally. Mesenterial resection of the aganglionic bowel was accomplished via transanal LESS until the normoganglionic colon segment was reached and pulled down to the site of anastomosis. After removal of the port, a conventional pull-through procedure was performed. All children displayed normal bowel movements and were complication-free during the follow-up period of up to 7 months. TLPC combines the minimally invasive LESS surgery with the scarless concept of NOTES and allows resection of long-segment aganglionosis without abdominal incision. TLPC is a safe, effective, and feasible surgical procedure in children with long-segment intestinal aganglionosis.