Kin Wai Chan

Initial experience in children using conventional laparoscopic instruments in single-incision laparoscopic surgery

BACKGROUND Single-incision laparoscopic surgery (SILS) has been successfully performed in children using 5-mm reticulating instruments. There are, however, few reports investigating the use of conventional instruments in SILS in the pediatric population. METHODS We conducted a retrospective review of all consecutive children who underwent SILS from October 2009 to January 2010, with the procedure being solely performed by conventional 3- and 5-mm instruments through a standard access technique. RESULTS A total of 19 SILS procedures were successfully performed in children aged 3 to 15 years. They included appendectomy (n = 10), nephrectomy (n = 1), combined cholecystectomy and splenectomy (n = 2), cholecystectomy (n = 1), high ligation for varicocele (n = 2), excision of Meckel diverticulum (n = 1), and staged orchidopexy and exploration for impalpable testis (n = 2). There was one conversion to conventional laparoscopic surgery, and that occurred in our first case of splenectomy. All the patients had smooth recovery from surgery without complications. CONCLUSIONS Using conventional instruments in SILS is technically feasible in children from simple to complex procedures and may have the potential to popularize this approach by eliminating the mandatory demand for specially designed instruments.

Helicobacter pylori-positive versus Helicobacter pylori-negative idiopathic peptic ulcers in children with their long-term outcomes.

Objectives:The aim of this study is to investigate the differences in the characteristics between Helicobacter pylori–positive and H pylori–negative primary ulcers in Chinese children. Patients and Methods:We conducted a retrospective review of children with primary peptic ulcers. Demographic data, clinical presentations, endoscopic features, histological findings, H pylori prevalence, and ulcer recurrences were studied. Results:Forty-three Chinese children with primary peptic ulcers were diagnosed over 8 years and were reviewed. There were 31 boys and 12 girls (median age 12 years, range 3–16 years). Thirty children (70%) presented with acute gastrointestinal bleeding, whereas only 19 had a history of epigastric pain. Twenty-three patients (53.5%) were H pylori positive. H pylori–positive ulcers developed in older children (median age 12 vs 10 years, P < 0.05) and affected more males (91.3% vs 50%, P < 0.01) than the H pylori–negative group. The annual ulcer recurrence rates were estimated to be 5.2% (95% CI 4.2–6.3) and 11.4% (95% CI 9.1–13.6) for positive and negative groups, respectively (P < 0.05). Multivariate logistic regression suggested H pylori–negative status and ulcer size >1 cm were independent risk factors for recurrence. Conclusions:Our report suggests that H pylori–negative primary ulcers exist in children with their own distinct features. In contrast to H pylori–positive ulcers, H pylori–negative ulcers develop in younger children, affect both sexes equally, and carry a higher recurrence risk.

A population-based study of Helicobacter pylori infection in Chinese children resident in Hong Kong: prevalence and potential risk factors.

Background:  Data of Helicobacter pylori prevalence in children and its risk factors provide clues to the health authority to estimate burden of H. pylori‐associated diseases usually encountered in adulthood and facilitate healthcare planning.

Laparoscopic hernia repair in children by the hook method: a single-center series of 433 consecutive patients

BACKGROUND The relatively high recurrence rate reported in laparoscopic hernia repair in children using intracorporeal suturing technique remains a concern. We aimed to investigate the effectiveness of the hook method during hernia repair that allows extraperitoneal passage of suture to close the hernia sac without creating any tension or skip areas and does not require laparoscopic suturing skills. METHODS A retrospective review was conducted on 433 consecutive children who underwent laparoscopic hernia repair using the hook method by 1 of 4 surgeons from July 2004 to June 2007. RESULTS A total of 572 successful laparoscopic hernia repairs were performed among the 433 children with an age range of 1 week to 15 years (mean = 56 months). Conversion rate was 1.04%. Contralateral patent processus vaginalis was found in 26.8%. Mean operating time was 23.8 and 40.2 minutes for unilateral and bilateral repair, respectively. At a median follow-up of 20 months, there were 2 recurrences (0.35%), 2 hydroceles, 1 ascending testis, and 1 instance of testicular atrophy. No serious complications were associated with the procedure. CONCLUSIONS Medium-term results suggest that laparoscopic hernia repair with the hook method is a sound alternative to open herniotomy in children.

Socioenvironmental Factors Associated With Constipation in Hong Kong Children and Rome III Criteria

Objective: Data regarding the prevalence of constipation in the general population of Asian children using internationally standardized definitions are scarce. Environmental factors surrounding a childs day to day living may trigger or perpetuate constipation and encourage postponement of defecation. Methods: A territory-wide cross-sectional questionnaire survey was conducted in 2318 Hong Kong Chinese elementary school students. Constipation was defined by pediatric Rome III criteria. Results: The mean age of the children was 9 ± 1.9 years; 51% were boys. Two hundred eighty-two children (12.2%, 95% confidence interval [CI] 10.9%–13.5%) were found to have constipation. Children ages 6 to 7 years had the highest prevalence (16.8%, 95% CI 13.8%–19.8%). There was no difference in prevalence between boys and girls (11.6% vs 12.3%; P > 0.05) and between obese and nonobese children (11.5% vs 11.1%; P > 0.05). In univariate analysis, constipation was found to be significantly more prevalent among those children who lived with neither parent, had inadequate company of parents at home, refused to pass bowel movements in school, spent long hours doing homework, had inadequate sleep, and had decreased fiber intake and frequent consumption of fast food (P < 0.05). Multivariate analysis identified refusal to pass bowel movements in school toilets (odds ratio [OR] 1.97, 95% CI 1.42%–2.74%), having dinner with one/both parents <50% of time (OR 1.52, 95% CI 1.01%–2.31%), nighttime sleep <7 hours (OR 1.87, 95% CI 1.04%–3.33%), and frequent consumption of fast food (OR 1.14, 95% CI 1.03%–1.26%) to be independent factors associated with constipation. Conclusions: Socioenvironmental factors are associated with childhood constipation, and bringing them to the awareness of the public may help prevent or stop the progression of childhood constipation at its early stages.

Evidence-based adjustment of antibiotic in pediatric complicated appendicitis in the era of antibiotic resistance

IntroductionAntibiotic resistance is a global issue especially in developed areas. With the emergence of antibiotic resistant-bacteria, the traditional choice of broad spectrum antibiotics may not be effective in complicated appendicitis. We herein report the bacteriology and antibiotic susceptibility of intra-operative peritoneal culture in children with acute appendicitis in Hong Kong. This may guide us to adjust the choice of antibiotics with evidence.MethodsA retrospective review of all cases of children who underwent laparoscopic appendicectomy from 2003 to 2007 was performed. Data including histology of appendixes, the choice of antibiotics, bacteriology, and antibiotic susceptibility of the intra-operative peritoneal cultures were analyzed.ResultsOver a 5-year period, 250 children were included in this study. 41 children had gangrenous- and 77 had ruptured appendicitis, respectively. Peritoneal swab was taken in 158 children. Common bacteria isolated including E. coli, Streptococcus, and Bacteroides. Ampicillin, cefuroxime, and metronidazole were our choice of antibiotics. 26% of children with gangrenous- and 25% with ruptured appendicitis were insensitive to the current regime. Using 3 antibiotics regime by switching cefuroxime to ceftazidime, it covered 77% resistant bacteria. Using 4 antibiotics regime by adding gentamycin, it covered 96% resistant bacteria.ConclusionsOne-fourth of children with gangrenous or ruptured appendicitis were insensitive to the current regime. This study provides evidence-based information on the choice of antibiotics.

MINIMALLY INVASIVE APPROACH IN THE MANAGEMENT OF CHILDHOOD INTUSSUSCEPTION

Background:  Intussusception is one of the most common causes of intestinal obstruction in infancy. Non‐operative reduction using air enema or other hydrostatic reduction methods has been the standard treatment in most cases. However, if the non‐operative method is not indicated or fails, open surgery is still necessary. With the tremendous development of the minimally invasive approach in handling surgical conditions in children in the last decade, this has been applied recently for the reduction of intussusception in children. We herein reviewed our experience of using the combined approach, namely, pneumatic reduction and, if failed, laparoscopic reduction in the management of childhood intussusception.

Impact of pediatric Rome III criteria of functional dyspepsia on the diagnostic yield of upper endoscopy and predictors for a positive endoscopic finding.

Objective: Pediatric Rome III criteria of functional dyspepsia (FD) has eliminated the mandatory use of upper endoscopy and recommended a symptom-based approach. In the absence of alarm symptoms, FD can be positively diagnosed in children having normal physical findings without exclusionary investigations. We aimed to investigate the effectiveness of Rome III guidelines to discriminate organic diseases from FD and to identify the predictors for positive endoscopic findings. Patients and Methods: A prospective study was conducted on consecutive children fulfilling Rome III criteria of FD. Upper endoscopy was performed in all subjects, both with and without alarm features. Results: Eighty consecutive children ages 7 to 15 were recruited. Nine (11.3%) had experienced alarm features. Five (6.3%) had organic diseases confirmed in upper endoscopy: duodenal ulcer (n = 2), duodenitis with erosion (n = 2), and gastritis with erosion (n = 1), 33.3% of children having alarm features had organic pathology, compared with 2.8% of those without (P < 0.01). A male predominance (80% vs 25.3%, P < 0.01), higher prevalence of alarm features (60% vs 8%, P < 0.01), and higher prevalence of Helicobacter pylori infection (80% vs 5.3%, P < 0.01) were found in children with organic diseases, compared with FD. Multivariate analysis identified H pylori infection (odds ratio 23.2; 95% confidence interval 1.5–333) and nocturnal pain (odds ratio 26.3; 95% confidence interval 1.2–500) to be independent predictors for positive endoscopic findings. Conclusions: Rome III recommendations of screening dyspeptic children for alarm features and investigation for H pylori are effective to identify children who have a higher likelihood of organic diseases and require upper endoscopy before making a diagnosis of FD.

Early experience of robotic-assisted reconstructive operations in pediatric urology.

OBJECTIVES Laparoscopic pyeloplasty and ureteric reimplantation are complex urologic operations requiring delicate surgical skill. The use of a robot may provide benefits in performing these reconstructive operations. In this article, we report our early experience in the use of the robot in pediatric urologic operations. METHODS Children who underwent robotic-assisted reconstructive urologic operations were reviewed and analyzed. RESULTS From November 2005 to April 2008, 8 children underwent robotic-assisted reconstructive urologic operations. Three children had extravesical ureteral reimplantation performed for vesicoureteric reflux (VUR), and 5 children had pyeloplasty performed for pelvic-ureteric junction obstruction. There was no conversion to open procedure and no intraoperative complication. The operative time ranged from 105 to 420 minutes (mean, 219). Postoperatively, 1 patient had urinary retention and 1 patient had postoperative fever. Hospital stay ranged from 3 to 10 days (mean, 4.8). Mean follow-up time was 38 months (range, 17-46). VURs were resolved for the 2 children with simple VUR and was downgraded for the child with duplex kidney. All patients who underwent pyeloplasty showed satisfactory urinary drainage after the operation. CONCLUSIONS From this early experience, robotic-assisted urologic operations in children were safe and feasible. It was particularly useful in reconstructive operations that required precise suturing, such as ureteric reimplantation and pyeloplasty.

Laparoscopic excision of Meckel's diverticulum in children: What is the current evidence?

Complications aroused from Meckels diverticulum tend to developed in children. Children presented with abdominal pain, intestinal obstruction, intussusception or gastrointestinal bleeding may actually suffered from complicated Meckels diverticulum. With the advancement of minimally invasive surgery (MIS) in children, the use of laparoscopy in the diagnosis and subsequent laparoscopic excision of Meckels diverticulum has gained popularity. Recently, single incision laparoscopic surgery (SILS) has emerged as a new technique in minimally invasive surgery. This review offers the overview in the development of MIS in the management of children suffered from Meckels diverticulum. The current evidence in different laparoscopic techniques, including conventional laparoscopy, SILS, the use of special laparoscopic instruments, intracorporeal diverticulectomy and extracorporeal diverticulectomy in the management of Meckels diverticulum in children were revealed.