Marion C.W. Henry

Neonatal necrotizing enterocolits

Necrotizing enterocolitis (NEC) remains a major cause of morbidity and death in neonates. The 30% to 50% mortality rate for NEC with perforation has not changed appreciably in the past 30 years. The critical relevant outcomes following NEC include survival, gastrointestinal function, and neurodevelopmental status. In each of these areas, initial anecdotal and case-series analysis has been followed by studies using more sophisticated methods of analysis. The single most important predictor of outcome, besides gestational age, is whether or not the disease has progressed to the point requiring surgical intervention. Patients with NEC requiring operation have a high mortality. Moreover, the vast majority of morbidity following NEC occurs in the patients who survive following operation. The purpose of this review is to examine the evolution of evidence regarding outcomes for patients with NEC and to provide an update on our current state of knowledge.

Small evidence for small incisions: pediatric laparoscopy and the need for more rigorous evaluation of novel surgical therapies

BACKGROUND/PURPOSE Laparoscopic surgery has been widely adopted for many pediatric surgical diseases for its potential to reduce morbidity and hospital stay. To date, no study has examined the qualitative state of evidence supporting the use of these techniques in children. The authors present a systematic and objective review of this evidence. METHODS The authors identified all clinical reports during the last 10 years for the 3 most common pediatric surgical diseases managed laparoscopically (appendicitis, gastroesophageal reflux, and conditions requiring splenectomy). Standardized and previously validated quality assessment instruments were used to examine individual studies in 4 areas: (1) clinical relevance, (2) generalizability to clinical practice, (3) reporting methodology, and (4) strength of conclusions. RESULTS The authors evaluated a total of 131 clinical reports (39 to 48 per disease). Ninety-three percent of all studies were retrospective, with single institution case reports accounting for the majority of evidence. Only 23% of studies used a control group of any kind. Randomized trials comprised 3% of all evidence (4 studies). Forty-five percent of nonrandomized studies were found to be of poor quality, and 55% were of fair quality by epidemiologic standards. The distribution of quality scores was not significantly different between the 3 operative indications examined (analysis of variance P =0.10). Randomized studies also were found to be of poor methodologic quality by standardized assessment criteria. CONCLUSIONS The current body of evidence is of insufficient quality to justify the widespread adoption of laparoscopic techniques into accepted standards of care. Wider use of prospective studies such as multicenter databases and randomized trials are needed to clarify the indications and outcomes for these innovative techniques. Significant improvement in the quality of published observational studies is also warranted, and this may be facilitated by the adoption of standardized reporting guidelines specific to nonrandomized data.

Primary versus delayed wound closure in complicated appendicitis: an international systematic review and meta-analysis

The purpose of this study was to determine, by means of a systematic review, whether the method of wound closure in complicated appendicitis affects the incidence of wound infection. A comprehensive literature search of multiple databases including MEDLINE (1980–2003), was performed, using the Cochrane search strategy, for articles on wound closure and complicated appendicitis. Clinical trials examining the method of wound closure were selected for systematic review and all quasi-randomized and randomized trials underwent meta-analysis. Failure to close the wound as planned in delayed closure (DC) was considered indicative of a wound infection. Purulent drainage requiring wound opening indicated an infection in the wounds closed primarily. Six randomized trials were considered adequate for meta-analysis. None independently showed a statistically significant difference in the risk of developing a wound infection with primary closure (PC). When pooled data were subjected to meta-analysis, PC achieved a statistically significant reduction in the relative risk of treatment failure and did not lead to an increase in wound infections. Primary closure does not increase the risk of developing a wound infection after operation for perforated appendicitis. Given the lack of benefit of DC, and the less traumatic, less painful, and less costly nature of PC; primary closure is a safe and practical treatment option.