Warwick J. Teague

Comparison of intraabdominal abscess formation after laparoscopic and open appendicectomies in children

AIM Although laparoscopic appendicectomy (LA) is an accepted alternative to the open appendicectomy (OA) approach, it has been suggested that there is a higher incidence of intraabdominal abscesses (IAAs). Our aim was to determine the incidence of IAA in 3 pediatric surgical centers routinely practicing both techniques. METHODS Data were collected retrospectively for pediatric patients undergoing LA or OA over an 8-year period. Analysis included IAA formation, appendicitis complexity, radiologic/histologic investigations, grade of surgeon, and wound infection. MAIN RESULTS A total of 1267 appendicectomies were performed (514 LAs and 753 OAs). There was no difference between the incidences of IAA (LA, 3.9% [19/491] vs OA, 3.9% [28/714]; P = 1.0). The incidence of IAA was increased in those with complicated appendicitis (34/375 [9.1%] vs 13/830 [1.6%]; P ≤ .0001). There was an increased proportion of those with complicated appendicitis in the LA group (182/491 [37.1%] vs 193/714 [27.0%]; P = .0002). Surgical trainees were more likely to be the primary surgeon in the OA group (79% vs 63%; P = .0001), although the incidence of IAA did not correlate with grade of surgeon. There was no significant difference in incidence of wound infection between groups (LA, 4.6% [8/173] vs OA, 2.5% [18/377]; P = .93). CONCLUSION This large retrospective study shows that the technique of appendicectomy does not appear to affect the incidence of IAAs. Patients with complicated appendicitis are more likely to develop an IAA regardless of technique.

Long-term health status and trajectories of seriously injured patients: a population-based longitudinal study

Background Improved understanding of the quality of survival of patients is crucial in evaluating trauma care, understanding recovery patterns and timeframes, and informing healthcare, social, and disability service provision. We aimed to describe the longer-term health status of seriously injured patients, identify predictors of outcome, and establish recovery trajectories by population characteristics. Methods and findings A population-based, prospective cohort study using the Victorian State Trauma Registry (VSTR) was undertaken. We followed up 2,757 adult patients, injured between July 2011 and June 2012, through deaths registry linkage and telephone interview at 6-, 12-, 24-, and 36-months postinjury. The 3-level EuroQol 5 dimensions questionnaire (EQ-5D-3L) was collected, and mixed-effects regression modelling was used to identify predictors of outcome, and recovery trajectories, for the EQ-5D-3L items and summary score. Mean (SD) age of participants was 50.8 (21.6) years, and 72% were male. Twelve percent (n = 333) died during their hospital stay, 8.1% (n = 222) of patients died postdischarge, and 155 (7.0%) were known to have survived to 36-months postinjury but were lost to follow-up at all time points. The prevalence of reporting problems at 36-months postinjury was 37% for mobility, 21% for self-care, 47% for usual activities, 50% for pain/discomfort, and 41% for anxiety/depression. Continued improvement to 36-months postinjury was only present for the usual activities item; the adjusted relative risk (ARR) of reporting problems decreased from 6 to 12 (ARR 0.87, 95% CI: 0.83–0.90), 12 to 24 (ARR 0.94, 95% CI: 0.90–0.98), and 24 to 36 months (ARR 0.95, 95% CI: 0.95–0.99). The risk of reporting problems with pain or discomfort increased from 24- to 36-months postinjury (ARR 1.06, 95% CI: 1.01, 1.12). While loss to follow-up was low, there was responder bias with patients injured in intentional events, younger, and less seriously injured patients less likely to participate; therefore, these patient subgroups were underrepresented in the study findings. Conclusions The prevalence of ongoing problems at 3-years postinjury is high, confirming that serious injury is frequently a chronic disorder. These findings have implications for trauma system design. Investment in interventions to reduce the longer-term impact of injuries is needed, and greater investment in primary prevention is needed.

Position Paper of INoEA Working Group on Long-Gap Esophageal Atresia: For Better Care

INoEA is the International Network of Esophageal Atresia and consists of a broad spectrum of pediatric specialties and patient societies. The working group on long-gap esophageal atresia (LGEA) set out to develop guidelines regarding the definition of LGEA, the best diagnostic and treatment strategies, and highlight the necessity of experience and communication in the management of these challenging patients. Review of the literature and expert discussion concluded that LGEA should be defined as any esophageal atresia (EA) that has no intra-abdominal air, realizing that this defines EA with no distal tracheoesophageal fistula (TEF). LGEA is considerably more complex than EA with distal TEFs and should be referred to a center of expertise. The first choice is to preserve the native esophagus and pursue primary repair, delayed primary anastomosis, or traction/growth techniques to achieve anastomosis. A cervical esophagostomy should be avoided if possible. Only if primary anastomosis is not possible, replacement techniques should be used. Jejunal interposition is proposed as the best option among the major EA centers. In light of the infrequent occurrence of LGEA and the technically demanding techniques involved to achieve esophageal continuity, it is strongly advised to develop regional or national centers of expertise for the management and follow-up of these very complex patients.

An audit of patient-controlled analgesia after appendicectomy in children.

Patient‐controlled analgesia (PCA) is commonly used after appendicectomy in children.

Surgical management of oesophageal atresia.

There have been major advances in the surgery for oesophageal atresia (OA) and tracheo-oesophageal fistula(TOF) with survival now exceeding 90%. The standard open approach to OA and distal TOF has been well described and essentially unchanged for the last 60 years. Improved survival in recent decades is most attributable to advances in neonatal anaesthesia and perioperative care. Recent surgical advances include the use of thoracoscopic surgery for the repair of OA/TOF and in some centres isolated OA, thereby minimising the long term musculo-skeletal morbidity associated with open surgery. The introduction of growth induction by external traction (Foker procedure) for the treatment of long-gap OA has provided an important tool enabling increased preservation of the native oesophagus. Despite this, long-gap OA still poses a number of challenges, and oesophageal replacement still may be required in some cases.

Fetoscopic endoluminal tracheal occlusion (FETO) for congenital diaphragmatic hernia in Australia and New Zealand: Are we willing, able, both or neither?

An estimated 140 pregnancies are diagnosed with congenital diaphragmatic hernia (CDH) in Australia and New Zealand each year, with these fetuses having a less than even chance of 1‐year survival. Fetoscopic endoluminal tracheal occlusion (FETO) is a relatively new technique that offers a prenatal interventional strategy for selective cases of CDH. This is not routinely offered in Australia or New Zealand. The aim of this systematic review is to critically appraise controlled clinical trials investigating the role of FETO in moderate and severe isolated CDH and explore whether this treatment is justified within our region.

Road safety: serious injuries remain a major unsolved problem

Objective: To investigate temporal trends in the incidence, mortality, disability‐adjusted life‐years (DALYs), and costs of health loss caused by serious road traffic injury.

Quality of life outcomes in children with Hirschsprung disease

BACKGROUND Morbidity following repair of Hirschsprung disease (HD) is common. However, quality of life (QoL) results focused on HD children are contradictory. We aimed to measure QoL outcomes in HD children using validated questionnaires. METHODS Patients with HD, managed at a large tertiary pediatric institution between 2004 and 2013, were identified. Parents completed validated questionnaires. Results were compared with published healthy population controls. QoL outcomes were measured using Pediatric Quality of Life (PedsQL) and Fecal Incontinence and Constipation Quality of Life (FIC QOL). Functional outcomes were assessed using Baylor Continence Scale, Cleveland Clinic Constipation Scoring System, and Vancouver Dysfunctional Elimination Syndrome Survey. RESULTS Parents of 60 HD patients [M:F 49:11; median age 6.4years (2.3-10.9)] were interviewed (59% participation). The majority (47/60, 78%) had rectosigmoid disease. There was significant reduction in psychosocial (social and emotional) QoL compared with healthy children (p=0.03). Psychosocial functioning was affected by increasing age (r=-2.72, p<0.001), fecal incontinence (r=-0.475, p=0.007), constipation (r=-1.58, p=0.006), and dysfunctional elimination (r=-2.94, p=0.004). Fecal incontinence also reduced physical functioning QoL (r=-0.306, p=0.007). Children with HD had significantly higher levels of fecal incontinence (p<0.01). CONCLUSIONS We have demonstrated that HD children have significant reductions in psychosocial QoL and functional outcomes. LEVEL OF EVIDENCE Prognosis Study - Level II (Prospective cohort study).

Impact of Esophageal Atresia on the Success of Fundoplication for Gastroesophageal Reflux

Objectives Fundoplication is commonly performed in patients with a history of esophageal atresia (EA), however, the success of this surgery is reduced, as reflected by an increased rate of redo fundoplication. We aimed to determine whether EA impacts the prevalence of fundoplication, its timing, and performance of a redo operation. Study design A single‐center, retrospective review of all patients undergoing fundoplication over a 20‐year period (1994‐2013) was performed. Redo fundoplication was used as a surrogate for surgical failure. Results A total of 767 patients (patients with EA 85, those who did not have EA 682) underwent fundoplication during the study period. Median age (months) at primary fundoplication was lower in patients with EA (7.2 vs those who did not have EA 23.3; P < .001). Redo fundoplication rates between groups were not significantly different (EA 11/85 vs 53/682; P = .14). Median time (months) between primary and redo fundoplication was greater in patients with EA (36.2 vs 11.7; P = .03). Conclusions Contrary to popular belief, the incidence of redo fundoplication was not significantly increased in patients with a history of EA. However, patients with EA underwent fundoplication at younger ages, which may be related to early life‐threatening events in these patients. These results inform perioperative counseling, and highlight the importance of sustained surgical follow‐up in patients with EA.

Oesophageal atresia: Are “long gap” patients at greater anesthetic risk?

Long gap oesophageal atresia occurs in approximately 10% of all oesophageal atresia infants and surgical repair is often difficult with significant postoperative complications. Our aim was to describe the perioperative course, morbidity, and early results following repair of long gap oesophageal atresia and to identify factors which may be associated with complications.