Publications (30)96.11 Total impact
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Article: Hypercapnia and Acidosis During Open and Thoracoscopic Repair of Congenital Diaphragmatic Hernia and Esophageal Atresia: Results of a Pilot Randomized Controlled Trial.
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ABSTRACT: OBJECTIVE:: We aimed to evaluate the effect of thoracoscopy in neonates on intraoperative arterial blood gases, compared with open surgery. BACKGROUND:: Congenital diaphragmatic hernia (CDH) and esophageal atresia with tracheoesophageal fistula (EA/TEF) can be repaired thoracoscopically, but this may cause hypercapnia and acidosis, which are potentially harmful. METHODS:: This was a pilot randomized controlled trial. The target number of 20 neonates (weight > 1.6 kg) were randomized to either open (5 CDH, 5 EA/TEF) or thoracoscopic (5 CDH, 5 EA/TEF) repair. Arterial blood gases were measured every 30 minutes intraoperatively, and compared by multilevel modeling, presented as mean and difference (95% confidence interval) from these predictions. RESULTS:: Overall, the intraoperative PaCO2 was 61 mm Hg in open and 83 mm Hg [difference 22 mm Hg (2 to 42); P = 0.036] in thoracoscopy and the pH was 7.24 in open and 7.13 [difference -0.11 (-0.20 to -0.01); P = 0.025] in thoracoscopy. The duration of hypercapnia and acidosis was longer in thoracoscopy compared with that in open. For patients with CDH, thoracoscopy was associated with a significant increase in intraoperative hypercapnia [open 68 mm Hg; thoracoscopy 96 mm Hg; difference 28 mm Hg (8 to 48); P = 0.008] and severe acidosis [open 7.21; thoracoscopy 7.08; difference -0.13 (-0.24 to -0.02); P = 0.018]. No significant difference in PaCO2, pH, or PaO2 was observed in patients undergoing thoracoscopic repair of EA/TEF. CONCLUSIONS:: This pilot randomized controlled trial shows that thoracoscopic repair of CDH is associated with prolonged and severe intraoperative hypercapnia and acidosis, compared with open surgery. These findings do not support the use of thoracoscopy with CO2 insufflation and conventional ventilation for the repair of CDH, calling into question the safety of this practice. The effect of thoracoscopy on blood gases during repair of EA/TEF in neonates requires further evaluation. (ClinicalTrials.gov Identifier: NCT01467245).Annals of surgery 04/2013; · 7.90 Impact Factor -
Article: Management of a Complication of Percutaneous Gastrostomy in Children.
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ABSTRACT: Aim "Buried bumper" is a complication of percutaneous gastrostomy related to the internal flange getting buried into the wall of the stomach. The aim of this study is to evaluate the management of this complication.Methods The surgical and interventional radiology database in our hospital from August 1999 to May 2011 was analyzed. There were 2,007 patients who underwent percutaneous gastrostomy insertion. Notes for patients with buried bumper were reviewed. A telephonic interview with the parents of these children was performed with focused assessment of the care of the gastrostomy tube before the episode of buried bumper. Continuous data are reported as median (range).Results Twenty children developed buried bumper after gastrostomy insertion. They had a primary diagnosis of neurological (n = 14), metabolic (n = 3), or endocrine (n = 3) disorders. The age at presentation was 5.7 years (2 to 18 years); 2.5 years (1 month to 5 years) after gastrostomy insertion. Ten children (50%) presented with symptoms related to buried bumper which included leakage around the gastrostomy (n = 4), pus, discharge or bleeding from the site (n = 5), stiffness on feeding (n = 3), and unable to push the flange (n = 1) (three children had more than one symptom). Ten children (50%) were asymptomatic and underwent routine change or removal of gastrostomy. In nine children, there was an attempt to remove the flange by interventional radiology but this was successful only in one. In the remaining 19 children, 4 had endoscopic removal while 15 children developed an inflammatory mass and required a laparotomy (n = 12) or laparoscopic-assisted excision (n = 3).Conclusion Buried bumper is a rare complication of percutaneous gastrostomy. Inadequate postoperative care without appropriate mobilization is a factor leading to this preventable complication. Endoscopic removal is possible, failing which laparoscopic surgery should be considered.European Journal of Pediatric Surgery 11/2012; · 0.81 Impact Factor -
Article: Recurrence rate of Morgagni diaphragmatic hernia following laparoscopic repair.
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ABSTRACT: PURPOSE: Morgagni diaphragmatic hernia can be repaired laparoscopically. The aim of this study is to evaluate the outcome of this minimally invasive approach. METHODS: A retrospective review was conducted on all consecutive children who underwent repair of Morgagni hernia from January 2002 to December 2011 in our hospital. Data are expressed as median (range). RESULTS: There were 12 children with Morgagni hernia. Age at surgery was 7.5 months (2-125). Associated malformations were present in 7 children (58 %). All children underwent initial laparoscopic approach. Two children (16 %) underwent conversion to open surgery. The hernia was closed primarily in 11 children (92 %), using a polyester patch in 1 (8 %). There were no intraoperative or immediate postoperative complications. Five children (42 %), all repaired initially without a patch, had a recurrence of the Morgagni hernia. The repair of the recurrent hernia was performed laparoscopically in four out of the five children, and a patch was used in two patients with no further recurrences or complications. CONCLUSIONS: There is a high rate of recurrence after laparoscopic Morgagni hernia repair. This is exclusively associated with laparoscopic repair without patch, and it is in contrast with the low recurrence rate reported previously. More frequent use of patch may be beneficial.Pediatric Surgery International 11/2012; · 1.25 Impact Factor -
Article: Outcomes following laparoscopic inguinal hernia repair in infants compared with older children.
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ABSTRACT: PURPOSE: Indications for laparoscopic inguinal hernia repair in infants and children remain controversial. The purpose of this study is to compare clinical features and outcome of laparoscopic inguinal hernia repair in infants with older children. METHODS: Retrospective single centre review of all patients <16 years of age (n = 380) undergoing laparoscopic inguinal hernia repair over a 5-year period (Jan 2005-Dec 2009). Outcomes were compared between infants (≤12 months of age) with older children (1-15 years). RESULTS: There was a trend towards higher recurrence rate in older children than in infants (4 % vs. 1 %; p = 0.17). Total complications and complications requiring surgery were similar in both age groups. There was one testicular atrophy in an infant who had an incarcerated inguinal hernia. The incidence of bilateral inguinal hernia and contralateral patent processus vaginalis (PPV) were both significantly higher in infants (total 61 % compared with 35 % in older children). CONCLUSIONS: Laparoscopic inguinal hernia repair in infants is safe and carries acceptable complication and recurrence rates. The laparoscopic approach may be particularly beneficial in infants since it allows simultaneous closure of a contralateral PPV and bilateral herniae. The outcome of laparoscopic inguinal hernia repair in older children requires further evaluation.Pediatric Surgery International 10/2012; · 1.25 Impact Factor -
Article: Clot dissolution: a novel treatment of midgut volvulus.
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ABSTRACT: Midgut volvulus due to malrotation may result in loss of the small bowel. Until now, after derotation of the volvulus, pediatric surgeons do not deal with the mesenteric thrombosis, which causes continuing ischemia of the intestine. On occasion, a "second look" laparotomy is performed in the hope that some improvement in blood supply to the intestine has occurred. We describe a new combined treatment to restore intestinal perfusion based on digital massage of the superior mesenteric vessels after derotation and systemic infusion of tissue-type plasminogen activator. This new therapy has been successful in 2 neonates with severe intestinal ischemia due to volvulus.PEDIATRICS 05/2012; 129(6):e1601-4. · 4.47 Impact Factor -
Article: Cost-effectiveness of laparoscopic versus open pyloromyotomy.
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ABSTRACT: 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. 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. Operation costs were similar between the two groups ($3,276 ± $244 LP versus $3,535 ± $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 ($2,650 ± $126 LP versus $3,398 ± $126 OP; P = .001) and a small difference in other costs. Overall, LP patients were $1,263 (95% confidence interval $395-$2,130; P = .005) less expensive to treat than OP patients. Sensitivity analyses of laparoscopic hardware usage and of incomplete pyloromyotomy indicated that LP was consistently less expensive than OP. LP is a cost-effective alternative to OP as it delivers improved clinical outcome at a lower price.Journal of Surgical Research 03/2012; 178(1):315-20. · 2.25 Impact Factor -
Article: Gastroschisis with intestinal atresia--predictive value of antenatal diagnosis and outcome of postnatal treatment.
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ABSTRACT: The purpose of this study is to evaluate (1) the predictive value of fetal bowel dilatation (FBD) for intestinal atresia in gastroschisis and (2) the postnatal management and outcome of this condition. A retrospective review of all gastroschisis cases diagnosed in our fetal medicine unit between 1992 and 2010 and treated postnatally in our center was performed. One hundred thirty cases had full postnatal data available. Intestinal atresia was found at surgery in 14 neonates (jejunum, n = 6; ileum, n = 3; ascending colon, n = 3; multiple, n = 2). Polyhydramnios and FBD were more likely in the atresia group compared with infants with no atresia (P = .0003 and P = .005, respectively). Fetal bowel dilatation had 99% negative predictive value (95% confidence interval, 0.9-0.99) and 17% positive predictive value (95% confidence interval, 0.1-0.3) for atresia. Treatment of intestinal atresia included primary anastomosis (n = 5), delayed anastomosis (n = 2), and stoma formation followed by anastomosis (n = 7). Infants with atresia had longer duration of parenteral nutrition, higher incidence of sepsis, and cholestasis compared with infants with no atresia (P = .0003). However, the presence of atresia did not increase mortality. Polyhydramnios and FBD are associated with atresia. Absence of FBD in gastroschisis excludes intestinal atresia. In our experience, atresia is associated with a longer duration of parenteral nutrition but does not influence mortality. These findings may be relevant for antenatal counseling.Journal of Pediatric Surgery 02/2012; 47(2):322-8. · 1.45 Impact Factor -
Article: Duhamel pull-through for Hirschsprung disease: a comparison of open and laparoscopic techniques.
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ABSTRACT: Various pull-through techniques, both open and laparoscopic, have been performed for Hirschsprung disease. Our study compares open and laparoscopic Duhamel pull-through. After ethical approval, we reviewed all children (n = 181) with Hirschsprung disease admitted to our institution between 1999 and 2009. We excluded total colonic aganglionosis (n = 14), previous pull-through done elsewhere (n = 33), or follow-up performed abroad (n = 58). Open and laparoscopic pull-through were done in the same period according to surgeon preference. Data were analyzed using χ(2) or Mann-Whitney U test. Seventy-six children had a Duhamel pull-through for rectosigmoid aganglionosis. Operative time, time to full feeds, and length of hospital stay were similar in each group. OPEN (N = 41): Fifteen children (37%) required 33 further procedures. Fourteen had procedures for persistent constipation, including redo Duhamel (n = 2), stoma formation (n = 2), spur division (n = 2), and dilatation/stretch/Botox/rectal biopsy/manual evacuation (n = 23). Three children had other procedures (adhesiolysis [n = 2] and incisional hernia repair [n = 1]). LAPAROSCOPIC (N = 35): Fourteen children (40%) required 30 further procedures. Eleven had procedures for persistent constipation, including redo Duhamel (n = 1), stoma formation (n = 4), spur division (n = 9), and dilatation/stretch/rectal biopsy (n = 8). Three children had other procedures (adhesiolysis [n = 1] and incisional hernia repair [n = 2]). There were 4 conversions. Open and laparoscopic Duhamel pull-through have similar outcomes. We show that the techniques have comparable operative times and hospital stay.Journal of Pediatric Surgery 02/2012; 47(2):308-12. · 1.45 Impact Factor -
Article: Clinical outcome of a randomized controlled blinded trial of open versus laparoscopic Nissen fundoplication in infants and children.
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ABSTRACT: To compare the clinical outcome and endocrine response in children who were randomized to open or laparoscopic Nissen fundoplication using minimization. It is assumed that laparoscopic surgery is associated with less pain, quicker recovery and dampened endocrine response. Few randomized studies have been performed in children. Parents gave informed consent, and this study was approved and registered (ClinicalTrials.gov Identifier: NCT00231543). Anesthesia, postoperative analgesia and feeding were standardized. Parents and staff were blinded to allocation. Blood was taken for markers of endocrine response. Twenty open and 19 laparoscopic patients were comparable with respect to age, weight, neurological status, and presence of congenital anomalies. Median time to full feeds was 2 days in both groups (P = 0.85); hospital stay was 4.5 days in the open group versus 5.0 days in the laparoscopic group (P = 0.57). Pain was adequately managed in both groups and there was no difference in morphine requirements. Median follow-up was 22 (range 12-34) months. Dysphagia, recurrence and need for redo fundoplication were not different between groups; retching was higher after open surgery (56% vs. 6%; P = 0.003). Insulin levels decreased at 24 hours, and was 54% lower (P = 0.02) after laparoscopy. Cortisol was elevated immediately postoperative, but was 42% lower (P = 0.02) after laparoscopy. There was no difference in the postoperative analgesia requirements and recovery. Laparoscopy decreased insulin levels to a greater extent, but caused less of a response in cortisol. Early postoperative outcome confirmed equal efficacy, but fewer children with retching after laparoscopy.Annals of surgery 06/2011; 254(2):209-16. · 7.90 Impact Factor -
Article: Outcomes of diverting jejunostomy for severe necrotizing enterocolitis.
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ABSTRACT: A diverting jejunostomy without bowel resection is an option for surgical management of extensive necrotizing enterocolitis (NEC). We aimed to determine outcomes of infants who underwent this operation. We collected clinical and outcome data on infants undergoing a diverting jejunostomy with no bowel resection as a primary procedure for extensive NEC. Data are median (range). Seventeen neonates underwent a diverting jejunostomy. Eleven (65%) had multifocal disease, whereas 6 (35%) had pan-intestinal involvement. Perforation was seen in 7 (41%), all with multifocal disease. The stoma was placed 12 cm (8-45) from the duodenojejunal flexure. Six infants (35%) died, 4 of these within a day of operation, owing to persisting instability. Intestinal continuity was achieved in all survivors after 52 (17-83) days, and only 1 infant (9%) had a colonic stricture. Seven infants recovered without the need for further intestinal resection distal to the jejunostomy. In those that survived, parenteral nutrition was needed for 2.2 months (1.3-18.0). A single patient had short bowel syndrome. A diverting jejunostomy is a useful surgical procedure that allows high survival and enteral autonomy in the treatment of extensive NEC. In most patients, the affected intestine recovers without further intestinal resection.Journal of Pediatric Surgery 06/2011; 46(6):1041-4. · 1.45 Impact Factor -
Article: Brain lipid-binding protein: a marker of differentiation in neuroblastic tumors.
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ABSTRACT: Neuroblastoma (NB), ganglioneuroblastoma (GNB), and ganglioneuroma (GN) are neuroblastic tumours (NT) of sympathetic nervous system origin. Brain lipid-binding protein (BLBP) has potential morphogenic activity during nervous system development but has not been studied in these tumours. We analyzed the expression of BLBP in NT according to histological subtypes and extent of differentiation. Thirty cases of NT (10 each of NB, intermixed GNB, and GN) were identified from the histopathology archive of a single center. Tissue sections were obtained from representative paraffin blocks and immunohistochemistry for BLBP performed. Brain lipid-binding protein was not expressed in any NB case. In all cases of GN, BLBP was strongly expressed in the cytoplasm of mature ganglion cells but negative in Schwannian stroma. In the intermixed GNB, there was similar strong BLBP immunoreactivity in the cytoplasm of fully differentiated and differentiating ganglion cells but no BLBP expression in immature neuroblasts. Brain lipid-binding protein is strongly expressed in mature and maturing ganglion cells in NT (GN and GNB), whereas it is absent in poorly differentiated neuroblasts of GNB and NB. Cytoplasmic expression of BLBP in NT increases as the cells undergo neural differentiation and is therefore associated with the extent of tumour differentiation and favorable histology.Journal of Pediatric Surgery 06/2011; 46(6):1197-200. · 1.45 Impact Factor -
Article: Decreased cerebral oxygen saturation during thoracoscopic repair of congenital diaphragmatic hernia and esophageal atresia in infants.
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ABSTRACT: Congenital diaphragmatic hernia (CDH) and esophageal atresia with tracheoesophageal fistula (EA/TOF) can be repaired thoracoscopically, but this may cause hypercapnia, acidosis, and reduced cerebral oxygenation. We evaluated the effect of thoracoscopy in infants on cerebral oxygen saturation (cSO(2)), arterial blood gases, and carbon dioxide (CO(2)) absorption. Eight infants underwent thoracoscopy (6 CDH and 2 EA/TOF). Serial arterial blood gases were taken. Regional cSO(2) was measured using near-infrared spectroscopy. Absorption of insufflated CO(2) was calculated from exhaled (13)CO(2)/(12)CO(2) ratio measured by mass spectrometry. CO(2) absorption increased during thoracoscopy with a maximum 29% ± 6% of exhaled CO(2) originating from the pneumothorax. Paco(2) increased from 9.4 ± 1.3 kPa at the start to 12.4 ± 1.0 intraoperatively and then decreased to 7.6 ± 1.2 kPa at end of operation. Arterial pH decreased from 7.19 ± 0.04 at the start to 7.05 ± 0.04 intraoperatively and then recovered to 7.28 ± 0.06 at end of operation. Cerebral hemoglobin oxygen saturation decreased from 87% ± 4% at the start to 75% ± 5% at end of operation. This had not recovered by 12 (74% ± 4%) or 24 hours (73% ± 3%) postoperatively. This preliminary study suggests that thoracoscopic repair of CDH and EA/TOF may be associated with acidosis and decreased cSO(2). The effects of these phenomena on future brain development are unknown.Journal of Pediatric Surgery 01/2011; 46(1):47-51. · 1.45 Impact Factor -
Article: Is there a benefit of peritoneal drainage for necrotizing enterocolitis in newborn infants?
Journal of Pediatric Surgery 11/2010; 45(11):2117-8. · 1.45 Impact Factor -
Article: Gastrostomy insertion in children: percutaneous endoscopic or percutaneous image-guided?
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ABSTRACT: Gastrostomy insertion in children can be performed in many ways, but which is the best technique remains uncertain. This study evaluates the outcome of percutaneous endoscopic gastrostomy (PEG) and image-guided gastrostomy (IG). We reviewed children who had either PEG (n = 136) inserted by pediatric surgeons or IG (n = 195) inserted by interventional radiologists in our hospital between May 2004 and July 2008. Gastrostomy-related complications were given scores ranging from 20 for major complications (eg, peritonitis, gastrointestinal bleed, and visceral injury) to 1 for minor (eg, site infection and tube migration), and total score per month of follow-up was calculated per patient. Conversion to laparoscopic or open gastrostomy was more frequent in PEG versus IG (P = .001). Fewer PEG patients (28%) had complications than did IG (47%) (P = .001). One PEG patient developed a gastrocolic fistula. In the IG group, 2 patients had transverse colon puncture, 1 had intraperitoneal tube detachment, and 1 had upper gastrointestinal bleeding. When scored and adjusted by length of follow-up, PEG had lower scores compared with IG, indicating a better outcome (P = .03). These findings were supported by zero-inflated Poisson regression analysis. Major complications were rare and observed more frequently after IG. Minor complications were observed in both procedures but were significantly less common in PEG.Journal of Pediatric Surgery 06/2010; 45(6):1153-8. · 1.45 Impact Factor -
Article: Peritoneal drainage does not stabilize extremely low birth weight infants with perforated bowel: data from the NET Trial.
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ABSTRACT: Proponents of peritoneal drainage (PD) hypothesize that it allows stabilization before laparotomy. We examined this hypothesis by comparing clinical status before and after either PD or primary laparotomy (LAP). In an ethically approved, international, prospective randomized controlled trial (2002-2006), extremely low birth weight (<1000 g) infants with pneumoperitoneum received primary PD (n = 35) or LAP (n = 34). Physiologic data were collected prospectively and organ failure scores calculated and compared between preprocedure and day 1 after procedure. Data, expressed as mean +/- SD or median (range), were analyzed using appropriate statistical tests. There was no postprocedure improvement in either PD or LAP group comparing heart rate (PD, P = 1.0; LAP, P = .6), blood pressure (PD, P = .6; LAP, P = .8), inotrope requirement (PD, P = .2; LAP, P = .3), or Arterial partial pressure of oxygen/fraction of inspired oxygen ratio (PD, P = .1; LAP, P = .5). Infants managed with PD had a worsening cardiovascular status (P = .05). There were no differences in total organ failure score in either group (PD, P = .5; LAP, P = 1). Only 4 infants survived with PD alone with no difference between preprocedure and postprocedure organ failure score (P = .4). Peritoneal drainage does not immediately improve clinical status in extremely low birth weight infants with bowel perforation. The use of PD as a stabilizing or temporizing measure is not supported by these results.Journal of Pediatric Surgery 02/2010; 45(2):324-8; discussion 328-9. · 1.45 Impact Factor -
Article: Thoracoscopic repair of congenital diaphragmatic hernia: intraoperative ventilation and recurrence.
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ABSTRACT: Thoracoscopic repair of congenital diaphragmatic hernia (CDH) has been described, but its efficacy and safety have not been validated. The aim was to compare our experience of thoracoscopy with laparotomy repair. After ethics approval, we reviewed the notes of neonates with CDH operated in our institution between 2003 and 2008. Two historical groups were compared: infants who underwent laparotomy (2003-2008) or thoracoscopy (2007-2008). Data were compared by t test or Mann-Whitney tests. Thirty-five children had open repair of CDH, and 13 had thoracoscopic repair. Groups were homogeneous for age and weight. Five (38%) neonates who had thoracoscopy were converted to open for surgical difficulties (n = 4) and O(2) desaturation (n = 1). Patch repair was used in 12 (34%) open and 6 (46%) thoracoscopic repairs. End-tidal CO(2) was significantly elevated during thoracoscopy, but this was not reflected in arterial CO(2) or pH. There were 3 (8%) recurrences after open repair and 2 (25%) after thoracoscopy (P = .19). Thoracoscopic repair of CDH is feasible. Arterial blood gases should be closely monitored. Despite higher EtCO(2), conversion to open was mainly because of difficult repair. A randomized trial is necessary to assess the effect of thoracoscopy on ventilation and recurrences.Journal of Pediatric Surgery 02/2010; 45(2):355-9. · 1.45 Impact Factor -
Article: Surgical outcomes of esophageal atresia without fistula for 24 years at a single institution.
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ABSTRACT: The aim of the study was to evaluate the surgical outcome of esophageal atresia (EA) without fistula for 24 years at a single tertiary center for pediatric surgery. The study used a retrospective chart review of infants diagnosed with EA without fistula between 1981 and 2005. Of 33 patients with EA without fistula, 31 charts were available. Mean birth weight was 2327 g (range, 905-3390 g), and 71% were male. Most common associated anomalies were cardiac (n = 6; 19%) and renal (n = 5; 16%), followed by vertebral (n = 4; 13%) and anorectal (n = 2; 7%). The median initial esophageal gap was 5 vertebral bodies. Six had a primary repair, and 25 patients had esophageal replacement at a median age of 7 months. This involved gastric transposition in 20 (1 followed failed jejunal interposition), colonic interposition in 5, jejunal interposition in 1 (after a failed colonic), and repair at another center in 1. With a median review of 9 years, 21 patients had long-term sequelae with the need for multiple further surgical procedures including an antireflux procedure in 5. One patient died. Management of EA without fistula remains challenging. Most patients required staged treatment that included esophageal replacement. The frequency of late complications indicates the need for programmed long-term review.Journal of Pediatric Surgery 10/2009; 44(10):1928-32. · 1.45 Impact Factor -
Article: Acute neonatal arterial occlusion: is thrombolysis safe and effective?
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ABSTRACT: We report our experience of the management of arterial occlusion in the newborn. A case note review was carried out after ethical approval. Doppler ultrasonography confirmed the occlusion. Thrombolysis was the primary intervention. Surgery was used selectively. A good outcome was one without tissue loss or functional impairment or minimal tissue loss without functional impairment. Data are presented as medians with ranges. Ten patients (9 male; median gestational age, 35.5 weeks [range, 28-39 weeks]) presented on day 1 (range, 1-8 days). Initial management included systemic tissue plasminogen activator (8 patients) and surgery (2 infants in whom thrombolysis was contraindicated). Improvement was noted in 7 of 8 infants treated medically and in both who underwent surgery. Three infants had significant tissue loss. Outcome at 29 months (range, 1.3-95.4 months) was good in the remaining 7. A multidisciplinary approach, thrombolysis and selective surgery achieved tissue preservation and function in the majority while minimizing complications. Early referral to centers with multidisciplinary teams is recommended.Journal of Pediatric Surgery 11/2008; 43(10):1827-32. · 1.45 Impact Factor -
Article: Upper abdominal teratomas in infants: radiological findings and importance of the vascular anatomy.
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ABSTRACT: Primary upper abdominal teratomas are extremely rare tumours, most commonly arising in infants. The radiological literature relating to them is sparse. Surgical resection is difficult due to distortion of the vascular anatomy. To reassess the value of preoperative imaging with specific reference to the presence/absence of typical features of teratoma, anatomical location and adjacent vascular anatomy. The histopathology database was used to identify infants with upper abdominal teratoma. Pathological, surgical and radiological data were reviewed. The search of the database identified 12 infants (10 girls, 2 boys) with an abdominal/retroperitoneal teratoma during the period 1993 to 2006. All teratomas were benign. In the majority of infants, typical radiological features of teratoma were demonstrated (fat, calcium). Identification of the major abdominal vessels on CT scan (most commonly the inferior vena cava) was not possible in all infants. Distortion (and commonly encasement) of the adjacent major abdominal vessels was usually evident. Upper abdominal teratomas in infants have typical radiological features. Preoperative delineation of the major vascular anatomy is often imprecise. Significant distortion of vascular anatomy was present in all infants and awareness of this feature impacts on surgical planning.Pediatric Radiology 08/2008; 38(7):750-5. · 1.67 Impact Factor -
Article: Peritoneal drainage or laparotomy for neonatal bowel perforation? A randomized controlled trial.
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ABSTRACT: To determine whether primary peritoneal drainage improves survival and outcome of extremely low birth weight (ELBW) infants with intestinal perforation. Optimal surgical management of ELBW infants with intestinal perforation is unknown. An international multicenter randomized controlled trial was performed between 2002 and 2006. Inclusion criteria were birthweight >or=1000 g and pneumoperitoneum on x-ray (necrotizing enterocolitis or isolated perforation). Patients were randomized to peritoneal drain or laparotomy, minimizing differences in weight, gestation, ventilation, inotropes, platelets, country, and on-site surgical facilities. Patients randomized to drain were allowed to have a delayed laparotomy after at least 12 hours of no clinical improvement. Sixty-nine patients were randomized (35 drain, 34 laparotomy); 1 subsequently withdrew consent. Six-month survival was 18/35 (51.4%) with a drain and 21/33 (63.6%) with laparotomy (P = 0.3; difference 12% 95% CI, -11, 34%). Cox regression analysis showed no significant difference between groups (hazard ratio for primary drain 1.6; P = 0.3; 95% CI, 0.7-3.4). Delayed laparotomy was performed in 26/35 (74%) patients after a median of 2.5 days (range, 0.4-21) and did not improve 6-month survival compared with primary laparotomy (relative risk of mortality 1.4; P = 0.4; 95% CI, 0.6-3.4). Drain was effective as a definitive treatment in only 4/35 (11%) surviving neonates, the rest either had a delayed laparotomy or died. Seventy-four percent of neonates treated with primary peritoneal drainage required delayed laparotomy. There were no significant differences in outcomes between the 2 randomization groups. Primary peritoneal drainage is ineffective as either a temporising measure or definitive treatment. If a drain is inserted, a timely "rescue" laparotomy should be considered. Trial registration number ISRCTN18282954; http://isrctn.org/Annals of surgery 07/2008; 248(1):44-51. · 7.90 Impact Factor
Top co-authors
Top Journals
Institutions
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2003–2013
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Great Ormond Street Hospital NHS
London, ENG, United Kingdom
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2011
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Royal Aberdeen Children's Hospital
Aberdeen, SCT, United Kingdom
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