Carolyn Wayne

Surgical versus conservative management of congenital pulmonary airway malformation in children: A systematic review and meta-analysis

BACKGROUND The ideal management of infants born with asymptomatic congenital pulmonary airway malformation (CPAM) is controversial. We performed a systematic review and meta-analysis comparing elective resection versus expectant management. METHODS We searched CENTRAL, MEDLINE, EMBASE, CINAHL, and PubMed for studies describing the management of asymptomatic CPAM and reporting on postoperative morbidity, mortality, and length of hospital stay (LOS). We performed meta-analyses when possible and provide a narrative summary of results. RESULTS One nonrandomized prospective and eight retrospective studies met our inclusion criteria. Out of 168 patients, 70 underwent surgery before symptoms developed with seven experiencing postoperative complications (10.0%); 63 developed symptoms while being managed expectantly and subsequently underwent surgery with 20 complications (31.8%). Thirty-five patients continued to be followed nonsurgically (three months to nine years of follow-up). Morbidity was higher with surgery after symptom development (6 studies; odds ratio 4.59, 95% confidence interval (CI) 1.40 to 15.11, P<0.01); there was no difference in LOS (3 studies; mean difference 4.96, 95% CI -1.75 to 11.67, P=0.15). There were no related deaths. CONCLUSIONS Elective resection of asymptomatic CPAM lesions is safe and prevents the risk of symptom development, which may result in a more complicated surgery and recovery.

Minimally invasive versus open repair of Bochdalek hernia: a meta-analysis

BACKGROUND Diaphragmatic hernia can be repaired by open or minimally invasive surgery (MIS), although it is unclear which technique has better outcomes. Our objective was to compare the outcomes of these procedures in a systematic review and meta-analysis. METHODS We sought all publications describing both techniques through MEDLINE, Embase, and CENTRAL. Our primary outcome of interest was recurrence. We conducted statistical analyses using Review Manager 5.2. RESULTS We did not identify any randomized controlled trials. Our pooled estimate of results from 10 studies showed that total recurrence was higher after MIS (OR: 2.81 [1.73, 4.56], p<0.001). Subgroup analyses indicated higher recurrence after MIS for patch repairs (OR: 4.29 [2.13, 8.67], p<0.001), but not for primary repairs. Operative time was longer for MIS (MD: 55.25 [40.21, 70.28], p<0.001), while postoperative ventilator time and postoperative mortality were higher after open surgery (MD: 1.33 [0.05, 2.62], p= 0.04; OR: 7.54 [3.36, 16.90], p<0.001, respectively). CONCLUSIONS Recurrence rate is higher after MIS than open repair when a patch is used. Operative time is also longer with MIS. Poorer outcomes after open surgery may be a result of selection bias rather than surgical technique. Surgeons should carefully consider the potential morbidity associated with MIS when deciding on a repair method.

What is the ideal surgical approach for intra-abdominal testes? a systematic review

There is controversy regarding the ideal surgical management of intra-abdominal testes (IAT) to preserve fertility; we conducted a systematic review to address this problem. We performed a comprehensive electronic search of CENTRAL, MEDLINE, EMBASE, and CINAHL from 2008 to September 2014 (the date range was limited due to an abundance of literature), as well as reference lists of included studies. Two researchers screened all studies for inclusion, and quality assessed each relevant study using AMSTAR for systematic reviews (SRs), Cochrane ‘Risk of bias’ tool for randomized controlled trials (RCTs), and MINORS for non-randomized studies. We identified two relevant SRs and 29 non-randomized studies. Due to the heterogeneity of the data, meta-analysis was not possible. Ultrasound and magnetic resonance imaging are insufficient for identification or localization of IAT; laparoscopic or surgical exploration is necessary. Primary orchiopexy is effective for low IAT, and Fowler-Stephens orchiopexy (FSO) is effective for high IAT. There is no clear benefit of one- vs. two-stage FSO, or of open vs. laparoscopic technique. Several alternative or modified techniques also show promise. RCTs are needed to confirm the validity of these findings, and to assess long-term outcomes.

Effect of delivery approach on outcomes in fetuses with gastroschisis.

BACKGROUND/PURPOSE There is considerable controversy regarding optimal mode and timing of delivery for fetuses with gastroschisis. Our objectives were to describe the variation in institutional approach regarding these factors, and to evaluate the effect of timing of delivery on outcomes in fetuses with gastroschesis. METHODS Members of the maternal-fetal medicine community across Canada were surveyed regarding their personal and institutional approach of delivery. Data from the Canadian Pediatric Surgery Network (CAPSnet) were analyzed. RESULTS The survey showed significant variability in delivery approach between institutions, although no center routinely performs cesarean section. Infants delivered vaginally (VD) were categorized into three groups: Group 1, VD <36 weeks (n=114); Group 2, VD 36-37 weeks (n=218); and Group 3, VD ≥38 weeks (n=75). Score of Neonatal Acute Physiology, complication rates, length of time on total parenteral nutrition (TPN), and length of hospital stay (LOS) were higher in Group 1; bowel matting was greater in Group 3. There were no differences between the groups regarding other complications. CONCLUSIONS Our data suggest that preterm delivery was associated with more complications, longer time on TPN, and longer LOS; delivery ≥38 weeks was associated with increased bowel matting. These outcomes should be considered when determining institutional protocol.

Feeding Post-Pyloromyotomy: A Meta-analysis.

CONTEXT: Postoperative emesis is common after pyloromyotomy. Although postoperative feeding is likely to be an influencing factor, there is no consensus on optimal feeding. OBJECTIVE: To compare the effect of feeding regimens on clinical outcomes of infants after pyloromyotomy. DATA SOURCES: Cumulative Index to Nursing and Allied Health Literature, The Cochrane Central Register of Controlled Trials, Embase, and Medline. STUDY SELECTION: Two reviewers independently assessed studies for inclusion based on a priori inclusion criteria. DATA EXTRACTION: Data were extracted on methodological quality, general study and intervention characteristics, and clinical outcomes. RESULTS: Fourteen studies were included. Ad libitum feeding was associated with significantly shorter length of stay (LOS) when compared with structured feeding (mean difference [MD] −4.66; 95% confidence interval [CI], −8.38 to −0.95; P = .01). Although gradual feeding significantly decreased emesis episodes (MD −1.70; 95% CI, −2.17 to −1.23; P < .00001), rapid feeding led to significantly shorter LOS (MD 22.05; 95% CI, 2.18 to 41.93; P = .03). Late feeding resulted in a significant decrease in number of patients with emesis (odds ratio 3.13; 95% CI, 2.26 to 4.35; P < .00001). LIMITATIONS: Exclusion of non-English studies, lack of randomized controlled trials, insufficient number of studies to perform publication bias or subgroup analysis for potential predictors of emesis. CONCLUSIONS: Ad libitum feeding is recommended for patients after pyloromyotomy as it leads to decreased LOS. If physicians still prefer structured feeding, early rapid feeds are recommended as they should lead to a reduced LOS.

Optimal age for elective surgery of asymptomatic congenital pulmonary airway malformation: a meta-analysis

Controversy exists on the optimal age for elective resection of asymptomatic congenital pulmonary airway malformation. Current recommendations vary widely, highlighting the overall lack of consensus. A systematic search of Embase, MEDLINE, CINAL, and CENTRAL was conducted in January 2016. Identified citations were screening independently in duplicate and consensus was required for inclusion. Results were pooled using inverse variance fixed effects meta-analysis. Meta-analysis results indicate no statistically significant differences for complications within the 3-month and 6-month age comparison groups [odds ratio (OR) 4.20, 95% confidence interval (CI) 0.78–22.77, I2 = 0%; OR 2.39, 95% CI 0.63–9.11, I2 = 0%, respectively]. Older patients were significantly favoured for 3-month and 6-month age comparison groups for length of hospital stay [mean difference (MD) 4.13, 95% CI 2.31–5.96, I2 = 0%; MD 3.38, 95% CI 0.44–6.31, I2 = 0%, respectively]. Borderline statistical significance was observed for chest tube duration in patients ≥6 months of age (MD 1.06, 95% CI 0.02–2.09, I2 = 0%). No mortalities were recorded. Surgical treatment appears to be safe at all ages, with no mortalities and similar rates of complications between age groups. The included evidence was not sufficient to make a conclusive recommendation on optimal age for elective resection.

Formula-feeding and hypertrophic pyloric stenosis: is there an association? A case–control study

BACKGROUND The etiology of infantile hypertrophic pyloric stenosis (HPS) is not fully understood. The objective of this study was to determine whether formula-feeding is associated with increased incidence. METHODS This case-control study included HPS cases and controls admitted between 1992 and 2012. Demographic data including feeding method were collected from patient charts and analyzed. RESULTS We identified 882 HPS cases and 955 controls. The highest incidence of HPS presentation was in summer (P=0.0028). Infants with HPS were more likely to have been exclusively formula-fed, have a family history of HPS, and be male compared to infants in the control group (P<0.001); they were also more likely to live in rural areas, although not significantly so. After adjusting for family history, sex, place of residence, and season of presentation, exclusively formula-fed infants were 1.36 times more likely to develop HPS compared with exclusively breastfed infants (RR 1.36, 95% CI 1.18-1.57, P<0.005). CONCLUSIONS Formula-feeding is associated with significantly increased risk of HPS. Further investigation may help to determine the components of formula that simulate hypertrophy of the pylorus muscle, or the components of breast milk that are protective, as well as other influencing factors. LEVEL OF EVIDENCE 3b.

A chest tube may not be needed after surgical repair of esophageal atresia and tracheoesophageal fistula

BackgroundAfter definitive repair of esophageal atresia (EA) and tracheoesophageal fistula (TEF), a chest tube (CT) may be left in place to diagnose and conservatively treat a postoperative anastomotic leak, although its necessity is controversial. The purpose of this study was to determine if the use of a CT decreases rates of early postoperative complications after EA and TEF repair.MethodsA retrospective chart review was performed to identify all patients with EA and TEF who underwent repair between 1985 and 2012. Univariate analysis was performed to compare patients who did or did not have a CT in terms of preoperative characteristics and postoperative outcomes.ResultsOne hundred twenty neonates were included; 69 had a CT inserted intraoperatively, while 51 did not. The two groups were similar in terms of patient characteristics. There was no statistically significant difference between the groups in terms of length of hospital stay (31 ± 12 vs. 36 ± 16 days, p = 0.5), or complication rates (13% vs. 12%, p = 0.9) for those with or without CT, respectively.ConclusionsThe use of a CT does not alter early postoperative complications after EA/TEF repair.

Use of ultrasound for the palpable undescended testis: a wasteful practice

Background Many primary care physicians order an ultrasound (US) before referral to specialist care for suspected undescended testis; however, the value of this practice is questionable. Objective To determine the proportion of boys referred for suspected undescended testis who had accompanying US, the cost of this practice and the accuracy of US for testis localization when compared with physical examination by a pediatric urologist. Methods This was a retrospective chart review at a pediatric urology service, including all patients referred for suspected undescended testis from 2008 to 2012. We determined the cost of US ordered, and calculated Cohens kappa, sensitivity and specificity, and positive and negative predictive value. Results We identified 894 eligible patients; 32% (289/894) were accompanied by US. In 77% (223/289), the urologist was able to palpate the testis: 51% (147/289) had a normal/retractile testis and 26% (76/289) had a palpable undescended testis. At a cost of 71.10 CAD per US, 20 547.90 CAD was expended on this practice. Of the 223 patients with palpable testes, we were able to gather detailed US and physical examination results for 214 patients. Cohens kappa was 0.06 (95% CI -0.005, 0.11; P = 0.10). US had 92.8% sensitivity (95% CI 84.1, 96.9%) and 15.2% specificity (95% CI 10.2, 21.9%) to detect an undescended testis. The positive predictive value was 34.2% (95% CI 27.8, 41.3%), while the negative predictive value was 81.5% (95% CI 63.3, 91.8%). Conclusions Referral of patients for suspected undescended testis should not be accompanied by an US study as US is not useful in these cases.

What is the optimal surgical strategy for complex perianal fistulous disease in pediatric Crohn’s disease? A systematic review

PurposePerianal fistulous disease is present in 10–15% of children with Crohn’s disease (CD) and is frequently complex and refractory to treatment, with one-third of patients having recurrent lesions. We conducted a systematic review of the literature to examine the best surgical strategy or strategies for pediatric complex perianal fistulous disease (CPFD) in CD.MethodsWe searched CENTRAL, MEDLINE, EMBASE, and CINAHL for studies discussing at least one surgical strategy for the treatment of pediatric CPFD in CD. Reference lists of included studies were hand-searched. Two researchers screened all studies for inclusion, quality assessed each relevant study, and extracted data.ResultsOne non-randomized prospective and two retrospective studies met our inclusion criteria. Combined use of setons and infliximab therapy shows promise as a first-line treatment. A specific form of fistulectomy, “cone-like resection,” also shows promise when combined with biologics. Endoscopic ultrasound to guide medical and surgical management is feasible in the pediatric population, though it is unclear if it improves outcomes.ConclusionThere is a paucity of evidence regarding the treatment of CPFD in the pediatric population, and further research is required before recommendations can be made as to what, if any, surgical management is optimal.