Maurizio Pacilli

Recovery after open versus laparoscopic pyloromyotomy for pyloric stenosis: a double-blind multicentre randomised controlled trial

BACKGROUND A laparoscopic approach to pyloromyotomy for infantile pyloric stenosis has gained popularity but its effectiveness remains unproven. We aimed to compare outcomes after open or laparoscopic pyloromyotomy for the treatment of pyloric stenosis. METHODS We did a multicentre international, double-blind, randomised, controlled trial between June, 2004, and May, 2007, across six tertiary paediatric surgical centres. 180 infants were randomly assigned to open (n=93) or laparoscopic pyloromyotomy (n=87) with minimisation for age, weight, gestational age at birth, bicarbonate at initial presentation, feeding type, preoperative duration of symptoms, and trial centre. Infants with a diagnosis of pyloric stenosis were eligible. Primary outcomes were time to achieve full enteral feed and duration of postoperative recovery. We aimed to recruit 200 infants (100 per group); however, the data monitoring and ethics committee recommended halting the trial before full recruitment because of significant treatment benefit in one group at interim analysis. Participants, parents, and nursing staff were unaware of treatment. Data were analysed on an intention-to-treat basis with regression analysis. The trial is registered with ClinicalTrials.gov, number NCT00144924. FINDINGS Time to achieve full enteral feeding in the open pyloromyotomy group was (median [IQR]) 23.9 h (16.0-41.0) versus 18.5 h (12.3-24.0; p=0.002) in the laparoscopic group; postoperative length of stay was 43.8 h (25.3-55.6) versus 33.6 h (22.9-48.1; p=0.027). Postoperative vomiting, and intra-operative and postoperative complications were similar between the two groups. INTERPRETATION Both open and laparoscopic pyloromyotomy are safe procedures for the management of pyloric stenosis. However, laparoscopy has advantages over open pyloromyotomy, and we recommend its use in centres with suitable laparoscopic experience.

Radial artery pseudoaneurysm successfully treated by compression bandage

In children, surgery for radial artery pseudoaneurysm (PA) may be followed by growth retardation of the hand because of inadequate blood flow. We believe this is the first report of a child with PA of the radial artery cured by compression bandage. Conservative management is a safe and valuable initial treatment option for uncomplicated radial PA.

Outcome of fetal exomphalos diagnosed at 11–14 weeks of gestation

To determine whether sonographic findings in cases of exomphalos detected at the 11–14‐week scan can be used to guide pregnancy management.

Gastric Emptying is Accelerated following Laparoscopic Nissen Fundoplication

AIM OF THE STUDY The effects on gastric motility following Nissen fundoplication in children are poorly documented. Some paediatric surgeons advocate additional procedures at the same time as fundoplication, such as a pyloroplasty, to enhance gastric emptying. The aim of this study was to determine whether laparoscopic Nissen fundoplication without pyloroplasty affects gastric emptying. METHODS Gastric emptying was measured before laparoscopic Nissen fundoplication in 8 children after ingestion of a standardised volume of milk for age mixed with 150 mg of (13)C-octanoic acid. None of the patients had a gastrostomy insertion at the time of fundoplication and 2 patients had neurological impairment. Breath samples were collected by breathing into a mask at baseline and every 15 minutes up to 3 hours, and were analysed for (13)CO (2)/ (12)CO (2) ratio by mass spectrometry. Gastric emptying time (t (1/2)) was derived from the curve of (13)CO (2)/ (12)CO (2) ratio against time. The test was repeated in 6 children following Nissen fundoplication at the time of full feeds. Data are reported as mean +/- SD and were analysed by the Mann-Whitney test. RESULTS AND CONCLUSIONS There were 4 males and 4 females; mean age at surgery was 3.3 +/- 3.0 years. Mean gastric emptying time was 59 +/- 17 min prior to laparoscopic Nissen fundoplication and 45 +/- 4 min following surgery (p = 0.03). Gastric emptying was accelerated in all except one patient. Gastric emptying for liquids is accelerated following Nissen fundoplication in children. Procedures aimed at improving gastric emptying time such as pyloroplasty or pyloromyotomy might not be justified at the time of laparoscopic Nissen fundoplication.

Surgery in Children With Crohn Disease Refractory to Medical Therapy

Objective: The aim of this study was to evaluate the results of surgery in children with Crohn disease (CD) not responding to medical therapy and establish whether surgery improves growth and nutrition. Patients and Methods: Children with CD diagnosed between 1998 and 2008 were reviewed. Relapse was defined by Harvey-Bradshaw index >5. Data, reported as median (range), were compared by Fisher exact test and repeated-measures ANOVA. Results: One hundred forty-one children, ages 12.7 years (3.5–16.8), were identified; 27 (19%) required surgery 14.5 months (1.1–61.8) after diagnosis. Twenty-one had elective surgery (19 isolated ileocaecal disease and stricture, 2 diffuse disease of ileum); 6 had emergency surgery (3 peritonitis, 2 haemorrhage, 1 perforation). Surgery included 18 ileocaecal resection and end-to-end anastomosis, 5 stoma formation, 2 left hemicolectomy and end-to-end anastomosis, and 2 stricturoplasty. Follow-up was 2.5 years (1–9.4). Growth and nutrition improved by 6 and 12 months after surgery, with a significant increase in weight z score (P < 0.0001), height z score (P < 0.0001), albumin (30 [13–36] vs 39 [30–46] vs 40 [33–45], P < 0.0001), and haemoglobin [10 (6.8–13.2) vs 11.7 (8.2–13.7) vs 12.0 (9.3–14.7), P < 0.0001]. All patients of the received azathioprine (2–2.5 mg · kg−1 · day−1) after surgery. Fifteen patients (55%) relapsed with a modified Harvey-Bradshaw index of 8 (6–11) within 11.5 months (4.2–33.4). Of these, 5 patients (18%) relapsed within 1 year. Five patients (18%) had further surgery (2 anastomotic strictures, 2 diseased stoma, and 1 enterocutaneous fistula). Conclusions: Growth and nutrition following surgery for CD improve, but there is a high relapse rate. Despite this, the improved growth and nutrition before relapse may be beneficial during puberty and justify surgery in children not responding to medications.

Cost-effectiveness of laparoscopic versus open pyloromyotomy

BACKGROUND Infantile hypertrophic pyloric stenosis can be corrected by either open (OP) or laparoscopic pyloromyotomy (LP). LP may provide clinical benefits of reduced time to postoperative full feeds and reduced postoperative inpatient stay, but the cost effectiveness is not known. Our aim was to compare the cost effectiveness of laparoscopic and open pyloromyotomy. METHODS OP and LP were compared in a multicenter randomized double-blind controlled trial, for which the primary outcomes were time to full feeds and time to discharge. In order to undertake a detailed cost analysis, we assigned costs, calculated on an individual patient basis, to laboratory costs, imaging, medical staff, medication, ward, operative, and outpatient appointments for 74 patients recruited from one of the participating centers. Data (mean ± SEM) were compared using linear regression analysis, adjusting for the minimization criteria used in the trial. RESULTS Operation costs were similar between the two groups (

Four year follow-up of a randomised controlled trial comparing open and laparoscopic Nissen fundoplication in children.

3,276 ±

Adenomyomatosis of the Gallbladder in Childhood: Report of a Case and Review of the Literature

244 LP versus

Use of Peristeen® transanal colonic irrigation for bowel management in children: A single-center experience☆

3,535 ±

Juvenile papillomatosis of the breast in a male infant with Noonan syndrome, café au lait spots, and family history of breast carcinoma.

152 OP). A shorter time to full feeds and shorter hospital stay in LP versus OP patients resulted in a highly significant difference in ward costs (