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Introduction: Antibiotic 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.Methods: A 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.Results: Over 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.Conclusions: One-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. [ABSTRACT FROM AUTHOR]

Introduction:  Age of patient and experience of biliary atresia (BA) center are well-known factors associated with early jaundice clearance (EJC) after Kasai portoenterostomy (KPE) in infants with BA. This study focused on the impact of age and surgeon factor on the short-term outcome after KPE within a single center.Materials and Methods:  Fifty-four consecutive infants (18 boys and 36 girls) who underwent KPE from January 2010 to January 2020 were reviewed. KPE was performed in the earliest available operative session once the initial work-up was completed. In group A (n = 41), KPE was performed by surgeon A. In group B (n = 13), KPE was performed by specialists under the supervision of surgeon B (who is the mentor of surgeon A) when surgeon A was not available for operation. The demographics of patients, the EJC (total bilirubin <20 μmol/L within 6 months of KPE), and 2-year native liver survival (NLS) between the two groups were studied.Results:  The median age at operation was 52 days (range 26-135 days). The overall EJC rate and 2-year NLS were 85.2 and 89.4%, respectively. Group A (p = 0.015) and male gender (p = 0.029) were statistically associated with EJC but not the age at operation (p = 0.101). Group A was also statistically associated with superior 2-year NLS (p = 0.047).Conclusion:  Balancing between the impact of age at operation and the experience of surgeon on the outcome after KPE, our result suggested that KPE may be deferred until a more experienced surgeon to operate. [ABSTRACT FROM AUTHOR]

We present a 37 years' experience in the management of biliary atresia (BA) and discuss long-term complications after Kasai portoenterostomy (KPE). A retrospective territory-wide study from 1980 to 2017 on 231 patients with open KPE from three tertiary paediatric surgical centres was performed. Outcome parameters were clearance of jaundice (COJ), native liver survival (NLS) and long-term complications. Factors affecting the operative outcomes were analyzed. The median duration of follow up was 17.5 (IQR: 13.5–22) years. Over 66% of patients became jaundice-freed at 1 year after KPE. Seventy patients (30.3%) received liver transplant (LT) at a median age of 6.2 (IQR: 4.3–8.4) years. The NLS rates at 10 and 20 years were 70.7% and 61.5% respectively with no significant change over the study period. The median age at KPE was 59 (IQR: 49–67) days. KPE performed before 70 days was associated with higher odd ratios for successful drainage but the age of KPE did not have an impact on the long-term NLS. Among all native liver survivors (n = 153), the median bilirubin level was 24 (IQR: 16–36) µmol/L. Portal hypertension (PHT) and recurrent cholangitis were found in 51.6% and 27.5% of them respectively. With a vigilant follow up program, more than 60% of BA patients could remain stable with the disease and achieve long-term survival without LT. Although cholestasis, portal hypertension and recurrent cholangitis are common in long-term NLS, with a comprehensive follow management strategy, they do not always necessitate LT. Our study serves as an example for countries where deceased donor organs are scarce due to very low donation rate. [ABSTRACT FROM AUTHOR]

Purpose: Despite the fact that the laparoscopic-assisted endorectal pull-through (LAEPT) for Hirschsprung's disease (HD) was introduced over 20 years ago, published outcomes in older children and adolescent are lacking. To address this, we studied the long-term results of LATEP for rectosigmoid HD in patients above 5 years of age. Materials and Methods: A retrospective review was conducted on all nonsyndromic patients above 5 years of age and who underwent one-stage LAEPT for rectosigmoid HD between January 2002 and December 2017. Late Hirschsprung-associated enterocolitis (HAEC) was defined as HAEC occurring 1 year after the pull-through operation. Postoperative bowel function was assessed using the Krickenbeck classification. Results: Forty-one patients (37 males and 4 females) were included in this study with a median follow-up of 9.0 years. The median age at surgery was 55 days. Two patients had anastomotic leakage. No patient had late HAEC, rectal prolapse, anastomotic stricture, or intestinal obstruction. According to the Krickenbeck classification, all patients had voluntary bowel movements without constipation. Overall, 65.8% of patients had no soiling. However, on subgroup analysis, only 45.4% of patients younger than 11 years of age had no soiling compared with 89.5% in patients at or older than 11 years of age (P = .003). Conclusions: Our results showed that LAEPT for rectosigmoid HD was a safe procedure. Nearly 90% of patients had normal bowel function by puberty. Further studies are needed to address the problem of soiling in patients younger than 11 years of age. [ABSTRACT FROM AUTHOR]

Purpose: The aim of this study was to compare the characteristics and the outcome between infants and young children with antenatally (AN) and postnatally (PN) detected choledochal cyst (CC) in a laparoscopic surgery center. Methods: A retrospective review was conducted for all children who underwent excision of CC and hepaticojejunostomy (HJ) before 36 months of age between October 2004 and October 2019. Results: Thirty-nine children (28 girls and 11 boys) were included in this study. Twenty-one children had AN detected CC and 18 had PN detected CC. The median age at operation (AN vs. PN; 3 months vs. 15.5 months, P < .001) and body weight (AN vs. PN; 5.6 kg vs. 10.5 kg, P < .001) were significantly different between the two groups. Children in PN group has an increased risk of being symptomatic (AN vs. PN; 6 vs. 18, P < .001) and having intervention before operation (AN vs. PN; 0 vs. 4, P = .037). Laparoscopic excision was performed in all children in AN group and in 12 children (66.7%) in PN group (P = .006). Conversion to open HJ was performed in 4 children in AN group but none in PN group (P = .146). There was no statistical differences in success in laparoscopic operation (P = .257), median operative time (P = .094), postoperative complication (P = .576), and median length of hospital stay (P = .749). Conclusions: Despite younger age at operation, the outcome of laparoscopic excision of AN detected CC was comparable with PN detected CC. Earlier detection and operation decreased the risk of preoperative intervention. [ABSTRACT FROM AUTHOR]

Purpose: Children may require the long‐term use of a central venous catheter (CVC) for treatment. Multiple revisions may be required when these catheters malfunction. We herein reported our experience of utilizing the fibrous sheath in tunnelled CVCs for the revision. Methods: A retrospective review was conducted from July 2008 to June 2018 on all children with the revision of tunnelled CVCs using the fibrous sheath. Results: Sixteen children underwent 31 revisions of a tunnelled CVC (16 Broviac/Hickman catheters, 15 Permcath for haemodialysis). The age ranged from 6 months to 16 years old (mean 3.8 years old). The indications for CVC revision included blockage (n = 14), breakage (n = 9) and dislodgement (n = 6). The mean time interval between CVC insertion and revision was 10.1 months (range: 20 days to 39 months). The fibrous sheath could be used for re‐insertion in 27 revisions (success rate: 87%). The failure was associated with the upsizing of the CVC (P =.003). In three of the four failed cases, a new CVC could be inserted by the cut‐down technique through the same venous access site. The overall success rate of CVC revision using the same venous access was 97%. There was no 30‐day postoperative infective complication. Conclusions: The fibrous sheath of tunnelled CVCs is a reliable access for CVC re‐insertion. This helps to preserve the same venous access site for repeated revision of CVCs. This is extremely important in those children who depend on long‐term CVC usage. [ABSTRACT FROM AUTHOR]

Purpose: Laparoscopic Kasai portoenterostomy (LKP) remains controversial in the management of infants with biliary atresia (BA). There are no data reporting the 10-year native liver survival rate after LKP. The study aims to present the 10-year native liver survival rate after LKP and complications in native liver survivors after Kasai portoenterostomy (KP).Methods: A retrospective review was conducted for 31 consecutive infants with BA who underwent KP by day 75 of life in our institute from January 1993 to December 2007. The demographics and outcomes of patients after LKP and open KP (OKP) were compared.Results: Eleven patients underwent LKP and 20 patients underwent OKP. No statistical difference was observed in the age at operation and the preoperative bilirubin level. The operative time for LKP was significantly longer than that for OKP (mean 314.5 minutes versus 271.5 minutes, P = .03). The 10-year native liver survival rate was 45% (5/11) after LKP and was 85% (17/20) after OKP (P = .03). Forty percent (2/5) of the native liver survivors in the LKP and 71% (12/17) in the OKP developed complications within 10 years after KP (P = .23).Conclusions: The 10-year native liver survival rate in patients who underwent LKP by 75 days of life was 45%. With superior 10-year liver survival rate and comparable complication rate after OKP, OKP is still the treatment of choice for BA in our institute. [ABSTRACT FROM AUTHOR]

Aim: Choledochal cyst is characterized by congenital dilatation of the biliary system. Patients with choledochal cyst tend to be symptomatic in their childhood. The aim of this study was to review the current practice in laparoscopic management of choledochal cyst in infants and children. Patients and Methods: A PubMed database search was performed for all the studies on children who underwent laparoscopic excision of choledochal cyst. Additional literature was cited second hand from the first‐tier literatures. Results: Studies on i) laparoscopic excision of choledochal cyst and hepaticojejunostomy in children; ii) laparoscopic management of choledochal cyst in antenatally detected choledochal cyst; iii) single incision laparoscopic surgery (SILS) in children with choledochal cyst; iv) robotic assisted laparoscopic surgery in children with choledochal cyst and v) hepaticoduodenostomy in children with choledochal cyst were reviewed. Conclusions: Laparoscopic excision of choledochal cyst and hepaticojejunostomy remains safe and feasible in children and infants. In centers experienced in MIS, SILS and robotic–assisted laparoscopy in the management of children with choledochal cyst were reported to be an alternative approach. The debate on hepaticoduodenostomy versus hepaticojejunostomy in biliary reconstruction will continue until a longterm outcome is available in the future. [ABSTRACT FROM AUTHOR]

Background/Purpose Evaluating the long-term outcome of spontaneous intestinal perforation (SIP). Methods We studied all patients treated for SIP at our institution between January 1, 2005 and December 31, 2014. Results Twenty-three infants (13 males) with a median gestational age of 26 (range: 23-32) weeks and a median weight of 825 (range: 560-1,965) g composed this cohort. Seventeen (74%) infants had an extremely low birth weight (ELBW); nine (39%) infants were the result of multiple pregnancies.Patent ductus arteriosus (PDA) was present in 16 (70%) infants. Cyclooxygenase inhibitors were administered in 12 (52%) infants.Ten infants (seven males, 44%) were diagnosed with intraventricular hemorrhage (IVH), which was identified in the majority (8/10) at a median of 9 (range: 1-11) days prior to the perforation.All patients presented with pneumoperitoneum and underwent a laparotomy at a median age of 9 (range: 2-16) days. Twenty-one patients had an ileal perforation. A temporary stoma was placed in 21 patients, whereas two got primary anastomosis. Two (8.7%) male infants died. During the long-term follow-up period (median 6 years), six (five males) (26%) infants developed moderate to severe disabilities in combination with cerebral palsy. No surgical complications were observed. Conclusion The most important risk factor for SIP is ELBW (75%). The distal ileum is the most frequent site of perforation (88%). Approximately 40% develop IVH most often prior to the SIP. Moderate to severe neurologic disabilities are seen in more than a quarter of the children. Disability and mortality affect mostly the male sex. Long-term risks of surgical complications are very low. [ABSTRACT FROM AUTHOR]

Background: The aim of this review was to study the characteristics and the outcome of children who underwent laparoscopic management of the antenatally detected choledochal cyst.Methods: A retrospective review was conducted for all children who underwent excision of antenatally detected choledochal cyst and hepaticojejunostomy from 2005 to 2015.Results: Fourteen patients (11 females and 3 males) were included in this study. The mean diameter of the cyst was 5.0 cm (range 2-12 cm). The mean age at operation was 3.5 months (range 11 days to 9 months). The mean body weight was 6.0 kg (range 3.9-10.0 kg). Five patients were symptomatic before operation. Laparoscopic excision of choledochal cyst was successful in all cases. The distal end of common bile duct (CBD) was cauterized in all but two cases. Conversion to open hepaticojejunostomy was required in two children. There was no intraoperative complication. Two patients had postoperative fever. One patient had minor bile leak that resolved on conservative management. The mean operative time was 286 min (range 200-390 min). The median hospital stay was 8 days (range 6-25 days). At a median follow-up of 46 months (range 6-118 months), all patients were freed from cholangitis or intestinal obstruction. Symptomatic patients had earlier operation (mean, 1.7 vs. 4.5 months p = 0.012) and were associated with postnatal increase in cyst size (p = 0.023) but were not associated with increased risk of complication or conversion (p = 1.000).Conclusions: Laparoscopic excision of choledochal cyst and hepaticojejunostomy could be safety performed in patients with the cyst detected antenatally. The distal CBD was usually small and stenotic. Symptomatic patients had earlier operation with no increase in morbidity. [ABSTRACT FROM AUTHOR]

Purpose: To investigate and compare the outcomes after tubularized incised plate (TIP) urethroplasty in mid-shaft and proximal hypospadias using a standard and a modified technique.Methods: We conducted a retrospective study in 104 consecutive children who underwent mid-shaft or proximal TIP repairs from Jan 2007 to Sept 2015. Patients in Cohort One had dorsal dartos (DD) neourethral coverage while patients in Cohort Two had either de-epithelialized split preputial (DESP) or tunica vaginalis (TV) flap coverage. TV flap was used only when DESP flap was not sufficient to cover the neourethra.Results: There were 52 patients each in Cohort One (DD, n = 52) and Cohort Two (DESP, n = 38; TV, n = 14) with no difference in ratio of mid-shaft/proximal between the two cohorts. At a median follow-up of 28 months, 36 patients (34.6 %) developed 47 complications including fistula (n = 19; 18.3 %) and neourethral dehiscence (n = 4; 3.8 %). Cohort One patients had significantly more fistula (28.8 vs 7.7 %; p = 0.005) and neourethral dehiscence (7.7 vs 0 %; p = 0.04) than Cohort Two. There was no difference between the two cohorts in the complication rates of meatal stenosis, recurrent ventral curvature and neourethral stricture.Conclusions: Both DESP and TV flap appear to be superior to DD in preventing fistula and neourethral dehiscence in non-distal TIP repairs. [ABSTRACT FROM AUTHOR]

Aim Length of stay ( LOS) is an important outcome measure of the Surgical Outcomes Monitoring and Improvement Program ( SOMIP). After analyzing the outcomes of the first two SOMIP reports, we introduced the Palatoplasty Enhanced Recovery ( PER) pathway for primary cleft palate repair in 2012. We aim to study if the implementation of PER pathway can decrease the LOS without increasing the complication rate. Methods All children who underwent primary cleft palate repair from January 2008 to April 2015 were studied. PER pathway was introduced in January 2012. Demographics data, postoperative outcomes including the LOS, readmission, morbidity and oro-nasal fistula ( ONF) were compared between patients operated before (pre- PER) and after ( PER) the implementation of the pathway. Results Eighty five children were recruited in the study (29 PER and 56 pre- PER). There were no statistical differences in the age, sex, type of cleft palate and associated syndrome between the two groups. Incidence of ONF ( PER 13.8% vs pre- PER 8.9%, p = 0.490), morbidity (0% vs 5.4%, p = 0.204) and readmission (6.9% vs 3.6%, p = 0.493) were not statistically different. Median LOS (3 days vs 6 days, p < 0.0001) was significantly shorter in the PER group. Conclusions The implementation of the PER pathway for primary cleft palate repair significantly decreased the length of stay without an increase in morbidity and readmission. The SOMIP initiated the establishment of the PER pathway and the positive outcome can be reflected in subsequent SOMIP reports. [ABSTRACT FROM AUTHOR]

Aim In the past, von Langenbeck palatoplasty was the technique adopted for cleft palate repair at our institution. Since 2002, Furlow palatoplasty has become the technique of choice. The present study aims to compare the outcome of cleft palate repair in children using the two different techniques. Patients and Methods All children who underwent primary cleft palate repair at our institution from January 1996 to December 2011 were studied. The sex, type of cleft palate, age at operation and the presence of associated syndromes were recorded. Postoperative outcome, including the incidence of oronasal fistula (ONF) and pharyngoplasty, were studied. Results A total of 230 children were included in this study. There were 120 boys and 110 girls. Ninety-five children had cleft palate associated with cleft lip; 135 children had cleft palate only. Twenty-eight children were syndromic. The mean age at operation was 19 ± 20 months (range: 10-150 months). A total of 112 children underwent von Langenbeck repair, and 118 children underwent Furlow repair. There was no statistical different in the sex, age at operation and associated syndromes between the two groups. More children had isolated cleft palate in the Furlow group ( P < 0.05). Nineteen children developed ONF after surgery ( Langenbeck : Furlow, 13:6; P = 0.072). Twenty one of 112 (19 per cent) children required pharyngoplasty to correct velopharyngeal insufficiency after von Langenbeck repair. No child in the Furlow group required pharyngoplasty ( P < 0.05). Conclusions The frequency of ONF after palatoplasty was 11.6 per cent after von Langenbeck repair, and 5.1 per cent after Furlow's palatoplasty. Compared with von Langenbeck repair, Furlow palatoplasty appeared to have a superior outcome, with no child requiring pharyngoplasty. [ABSTRACT FROM AUTHOR]

Objective: To investigate the safety and effectiveness of laparoendoscopic single-site surgery (LESS) using standard laparoscopic setup in pediatric nephrectomy/heminephroureterectomy (HN) by comparing with conventional laparoscopy (CL). Methods: Twelve consecutive children who underwent LESS (nephrectomy = 8, HN = 4) from 2009 to 2012 were compared with a matched cohort of 18 children who underwent CL (nephrectomy = 12, HN = 6) at the same institution. Data were reviewed retrospectively. Results: There was no difference between the 2 groups in the age of patients, body weight, gender distribution, laterality of pathology, postoperative analgesic requirement, and hospital stay. Eleven of the 12 children in the LESS group underwent the procedure successfully without additional trocar placement. The only open conversion happened in the case of LESS of the lower moiety HN. LESS nephrectomy took longer operative time than CL (mean 156 +/- 45 vs 99 +/- 35 minutes, median 155 vs 90 minutes, P <.01). Wound infection occurred in 1 patient after CL nephrectomy. No postoperative complication or access site hernia was noted in the children in the LESS group at follow-up. Conclusion: LESS nephrectomy and HN in the pediatric population is safe and effective with a minimally invasive nature comparable to CL. Learning curve factors may contribute to the reported longer operative time in LESS. Further studies are required to investigate the implication of patient selection and the cosmetic benefits of LESS, which may potentially require longer operative time. [Copyright &y& Elsevier]

Background: Metachronous hernia has been reported to develop unexpectedly in children after negative evaluation for contralateral patent processus vaginalis (CPPV) by transinguinal laparoscopy. Scarce data exist regarding such phenomena following laparoscopic unilateral hernia repair and negative findings for CPPV in transumbilical laparoscopy. Patients and Methods: A retrospective study was performed to investigate metachronous hernia development in a cohort of consecutive children who had undergone laparoscopic unilateral hernia repair with negative findings of CPPV by transumbilical laparoscopy 5 or more years ago. Results: Study subjects included 293 children 1 month to 15 years old at the time of laparoscopic unilateral hernia repair (left, n=116; right, n=177). There were 246 boys and 47 girls. Nine children (3.1%), all boys, developed metachronous hernia at a median of 24 months (range, 6-42 months) from the time of negative laparoscopic evaluation for CPPV. There was no statistical difference between the genders and laterality of the initial hernia in the development of metachronous hernia. Conclusions: False-negative CPPV evaluation by transumbilical laparoscopy during laparoscopic unilateral hernia repair can occur and result in unexpected metachronous hernia development. Further prospective studies are warranted to develop effective maneuvers in addition to inspection alone to reduce false-negative laparoscopic assessment. [ABSTRACT FROM AUTHOR]

Aim: Oophorectomy performed in children is extremely uncommon. We aimed to investigate the disease pattern and the association between the underlying pathology and the clinical presentation among those patients who had their ovaries removed in their childhood. Methods: A retrospective study was performed on 41 consecutive children who underwent oophorectomy in a tertiary referral centre in the period between June 1995 and May 2008. Results: The median age was 11 years, ranged from 11 weeks to 15 years at the time of surgery. The primary presentations were acute lower abdominal pain ( n= 20), progressive abdominal distension or abdominal mass ( n= 13), chronic abdominal pain ( n= 3), irregular menses ( n= 1), antenatal diagnosis ( n= 3) and incidental finding ( n= 1). Ultrasound examination was performed in 31 patients and positive findings of ovarian pathology were found in all but one examination. Twenty cases of ovarian torsion were confirmed intra-operatively. Patients presenting with acute abdominal pain were more likely to have torsion than other presentations ( P < 0.01). Non-neoplastic conditions and ovarian neoplasms were found in 11 and 30 patients, respectively. The most common neoplasm was mature teratoma (52%). Malignant neoplasms included immature teratoma ( n= 3), dysgerminoma ( n= 1), mixed dysgerminoma + yolk sac tumour ( n= 2), yolk sac tumour ( n= 2) and juvenile granulose cell tumour ( n= 1). Malignant neoplasms were found to have more chronic presentation and less torsion than benign pathologies ( P < 0.05). Conclusion: Although ovarian pathology is uncommon in children, a girl presenting with acute lower abdominal pain or progressive abdominal distension should raise the suspicion and prompt immediate investigation to rule out ovarian torsion or ovarian neoplasms. [ABSTRACT FROM AUTHOR]

Aim: There were only a few reports on laparoscopic portoenterostomy for biliary atresia in children. We report our experience on laparoscopic Kasai operation for biliary atresia.Material and Methods: A retrospective review of all children who had biliary atresia underwent laparoscopic portoenterostomy from January 2002 to September 2006 were included and analyzed.Results: Sixteen children (five boys and eleven girls) with a mean age of 66 days (range 47-106 days) at operation were included in this study. All patients had type III biliary atresia. There was no conversion to open procedure. The operative time ranged from 193 to 435 min (mean 292 min). At a median follow-up of 72 months (range 33-89 months), eight patients were free of jaundice with bilirubin level <20 μmol/L and did not require liver transplantation. Seven patients underwent liver transplantation. One patient who had persistent elevated bilirubin defaulted follow-up. One patient complicated with volvulus of intestine post-operatively. All patients survived except one patient who had combined liver and intestine transplantation.Conclusion: Laparoscopic portoenterostomy in children with biliary atresia is technically feasible. 50% of children who had type III biliary atresia were free of jaundice and did not require liver transplantation. A longer follow-up is required to assess the long-term outcome. [ABSTRACT FROM AUTHOR]