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Background: Acute appendicitis is classified into simple (SA) and complicated (CA). Ultrasound scans (USS) can be useful in clinically equivocal cases, by visualising primary and secondary signs. This study explores the utility of sonographic signs to diagnose and differentiate appendicitis in children. Methods: Single-centre retrospective cohort study over a 2-year period. Consecutive USS for suspected appendicitis were included; sonographic signs were extracted from standardised institutional worksheets. USS results were compared with pre-defined intraoperative criteria for SA and CA, confirmed with histological analysis. Data are reported as median [interquartile range], percentages (number), area under the curve (AUC), conventional diagnostic formulae and adjusted odds ratios following multiple logistic regression (p < 0.05 considered significant). Results: A total of 934 USS were included, with median age 10.7 [8.0–13.4] years, majority were female (54%). One quarter (n = 226) had SA, 12% (n = 113) had CA, 61% (n = 571) had no appendectomy and 3% (n = 24) had negative appendicectomy. Appendix visualisation rate on USS was 61% (n = 569), with 62% (n = 580) having a conclusive report. Sonographic signs suggesting appendicitis included an appendiceal diameter > 7 mm (AUC 0.92, [95% CI: 0.90–0.94]), an appendicolith (p = 0.003), hyperaemia (p = 0.001), non-compressibility (p = 0.029) and no luminal gas (p = 0.004). Secondary sonographic signs included probe tenderness (p < 0.001) and peri-appendiceal echogenic fat (p < 0.001). Sonographic signs suggesting CA over SA comprised a diameter > 10.1 mm (AUC 0.63, [95% CI: 0.57–0.69]), an appendicolith (p = 0.003) and peri-appendiceal fluid (p = 0.004). Conclusion: Presence of specific sonographic signs can aid diagnosis and differentiation of simple and complicated appendicitis in children. [ABSTRACT FROM AUTHOR]

Purpose: Factors leading to mechanical complications following insertion of central venous access devices (CVADs) in children are poorly understood. We aimed to quantify the rates and elucidate the mechanisms of these complications. Methods: Retrospective (2016–2021) review of children (< 18 years old) receiving a CVAD. Data, reported as number of cases (%) and median (IQR), were analysed by Fisher's exact test, chi-squared test and logistic regression analysis. Results: In total, 317 CVADs (245 children) were inserted. Median age was 5.0 (8.9) years, with 116 (47%) females. There were 226 (71%) implantable port devices and 91 (29%) Hickman lines. Overall, 54 (17%) lines had a mechanical complication after 0.4 (0.83) years from insertion: fracture 19 (6%), CVAD migration 14 (4.4%), occlusion 14 (4.4%), port displacement 6 (1.9%), and skin tethering to port device 1 (0.3%). Younger age and lower weight were associated with higher risk of complications (p < 0.0001). Hickman lines had a higher incidence of complications compared to implantable port devices [24/91 (26.3%) vs 30/226 (13.3%); p = 0.008]. Conclusion: Mechanical complications occur in 17% of CVADs at a median of < 6 months after insertion. Risk factors include younger age and lower weight. Implantable port devices have a lower complications rate. Level of evidence: Level 4: case-series with no comparison group. [ABSTRACT FROM AUTHOR]

Background: Simulation‐based medical education (SBME) is an integral part of undergraduate and postgraduate training in high‐income countries (HICs). Despite potential benefits to low‐ and middle‐income countries (LMICs), it has not been widely applied. Our aim was to use SBME to address some essential paediatric surgery learning needs in a LMIC. Methods: Eleven SBME courses were designed, implemented and evaluated over a 4‐year period in partnership with local paediatric surgeons and the University of Medicine 1 in Yangon, Myanmar. All courses were simulation‐based and different major SBME modalities were utilized. Evaluation included pre‐ and post‐course questionnaires, other evaluation assessments including Likert scale self‐rated confidence in different domains, as well as, mixed method evaluation and Kirkpatrick's hierarchy of evaluation. Results: Over 4 years, a multidisciplinary team consisting of surgical consultants, fellows, and educational specialists delivered 11 courses at a tertiary LMIC paediatric surgical centre. Attendance varied between 23 and 50 healthcare professionals, with some participants attending all of the educational activities. SBME modalities were utilized to meet each courses' learning objectives. All educational courses scored highly and showed statistically significant differences in all the self‐rated pre and post‐course confidence Likert scale domains. SBME was accepted and embraced by local participants and faculty, and transition to local delivery of educational content has begun. Level 4 of Kirkpatrick's hierarchy of evaluation was demonstrated. Conclusion: SBME can be used to meet essential learning objectives of local staff in a LMIC. Through various modalities, it offers a reliable, proven and affordable means of teaching multiple aspects of paediatric surgical clinical practice. By employing innovative simulation‐based solutions, it can be adapted by local faculty to continue meeting ongoing learning needs. [ABSTRACT FROM AUTHOR]

Background: Intussusception is a common, potentially life‐threatening paediatric condition. Non‐operative treatment with an air enema has been established as the clinical gold standard. There is no validated model for the training of this procedure. Our aim was to produce a novel air enema reduction simulator and validate its use as a training tool. Methods: A low‐cost paediatric intussusception air enema simulator was created. It was designed to include essential key clinical procedural steps. Participants included both procedural experts and novices from the Departments of Paediatric Radiology and Surgery. The simulator was assessed for face and content validity and its physical, conceptual and experiential fidelity by a structured questionnaire using a 5‐point Likert's scale. Statistical analysis included a t‐test, and a P‐value of <0.05 was considered significant. Results: Twenty‐four clinicians completed the simulation activity (expert: 13 and novices: 11). All experts had performed a minimum of 40 clinical procedures, and 46% had performed >50 procedures. All scores were favourable in all domains for face and content validity: 3.5 (physical appearance), 3.3 (insertion of the tube and taping), 3.1 (holding of the buttocks) and 3.5 (performing the air enema). The simulator also scored highly with fidelity assessment; visual 3.5, conceptual 3.4. There was no difference in procedural confidence with experts (3.8 versus 3.6, P = 0.28), but there was for novices (1.0 versus 2.9, P = 0.0002). Conclusions: This low‐cost air enema reduction simulator for intussusception has an excellent educational potential for use in a training program in a tertiary centre, as well as, resource‐constrained environments. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the efficacy of tissue glue in pediatric circumcision.Materials and Methods: A systematic review and meta-analysis of the English literature (1997-2017) was conducted according to the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) statement on children who underwent circumcision with tissue glue. Meta-analysis was conducted using RevMan 5.3, Comprehensive Meta-Analysis 2, and MedCalc 18. P values <.05 were considered significant.Results: The search returned 15 studies for a total of 4567 circumcisions, of which 3045 (66%) were performed with tissue glue. The systematic review indicated that overall complication rates were 4.3% (tissue glue) and 5.9% (sutures). The use of tissue glue was associated with reduced postoperative pain, better cosmetic results, and reduced cost. Meta-analysis showed that there was no difference between the incidence of total postoperative complications (relative risk [RR] 0.86 [95% confidence interval {CI}: 0.62-1.19], P = .36) and wound infection and dehiscence between the 2 groups (RR 0.95 [95% CI: 0.59-1.56], P = .85). Postoperative bleeding and hematoma formation were reduced with the use of tissue glue (RR 0.55 [95% CI: 0.32-0.95], P = .03). Tissue glue also significantly shorten the operative time (mean difference -0.22 [95% CI: -0.39 to -0.05], P = .01).Conclusion: The incidence of postoperative bleeding and hematoma formation in pediatric circumcision is reduced with the use of tissue glue. Tissue glue has reduced operative time; furthermore, it might be associated with reduced postoperative pain, less overall cost, and superior cosmetic results. [ABSTRACT FROM AUTHOR]

Aims: Recent systematic reviews have suggested an increased incidence of intraabdominal abscess (IAA) formation following laparoscopic appendicectomy (LA) compared with the open approach (OA). As the majority of these analyses have focused on appendicectomy in adults, our aim was to review the evidence base for pediatric patients. Subjects and Methods: We performed a comprehensive review of relevant studies published between 1990 and 2012. Specific inclusion and exclusion criteria were used to identify studies that investigated the incidence of IAA following LA and OA in pediatric patients. The primary outcome measure in the present meta-analysis was IAA formation, and secondary outcomes included wound infection (WI) and incidence of postoperative small bowel obstruction (SBO). Results: Sixty-six studies with a total of 22,060 pediatric patients were included: 56.5% OA and 43.5% LA. There was no overall difference in the incidence of IAA formation: 2.7% for OA (333/12,460) versus 2.9% for LA (282/9600) ( P=.25). However, OA patients had a higher incidence of wound infection: 3.7% for OA (337/9228) versus 2.2% for LA (183/8154) ( P<.001). Moreover, the incidence of SBO was lower in patients undergoing LA: 0.4% LA (86/5767) versus 1.5% (29/6840) ( P<.001). Conclusions: The IAA incidence is comparable in LA versus OA in pediatric patients. LA confers a significantly lower risk of other postoperative complications, including WI and SBO. [ABSTRACT FROM AUTHOR]

Aim: The development of effective multiple drug regimens for treating human immunodeficiency virus (HIV) are associated with nonadherence in children. HIV-positive children also have a higher incidence of malnutrition. Placement of a percutaneous endoscopic gastrostomy (PEG) is a potential solution. Primary outcome was to determine the complications of PEG placement in a pediatric HIV-positive population. Materials and Methods: A 10 year retrospective data analysis was carried out on all HIV-positive children undergoing insertion of a PEG at two institutions. Parameters examined included infections, leakage, displacement, reasons for removal, total time in situ, HIV stage, CD4 count, and serological investigation. Data were compared against published data for PEG insertion in pediatric oncology patients and other comparable pediatric series using Fisher's exact test. Results: Eighteen children were identified, with a median age 35 months and follow-up of 62 months. The majority of patients had advanced disease (Stage C; 65%). Fifty percent of PEGs were inserted for feeding supplementation and all were used for the administration of medications. Sixty-one percent experienced a minor complication; 5/18 (27.7%) experienced peristomal infection; 2/18 (11.1%) experienced either bleeding, leakage, or excessive granulation; and 1/18 (5.6%) experienced dislodgement. Stage of HIV did not affect the incidence of bleeding or infection: 5/11(Stage C) versus 2/7(Stage B) ( P = .3). There was no significant difference for major complications when compared with any series though comparison with a large pediatric series revealed a significant difference for minor complications 11/18 versus 27/120 ( P = .0003). Conclusions: There is a low rate of serious complications with PEG insertion in our patients, and the rate is comparable to that seen in pediatric oncology patients. The minor complication rate is, however, higher than a nonimmune compromised population; and careful follow-up for these patients is recommended so that the appropriate therapy can be promptly initiated. [ABSTRACT FROM AUTHOR]

Background: Controversy exists over the association between laparoscopic (LA) and open appendicectomy (OA) and the formation of postoperative intra-abdominal abscesses (IAAs). Our aim was to compare the outcome following these two techniques in a pediatric population. Subjects and Methods: A retrospective data collection was carried out on all patients undergoing either an LA or OA at a single center over a 26-month period. Patients were identified from a hospital database and theater records. An intra-abdominal abscess was defined as recorded pyrexia, a raised inflammatory marker, and radiologic confirmation of an intra-abdominal collection. Other parameters studied included wound infection, appendiceal perforation, hospital stay, conversion rate, microbiology, histology, radiologic investigation, and serologic analysis. Data were analyzed from using Fisher's exact and Mann-Whitney tests, as appropriate. A P-value of <0.05 was considered significant. Results: Two hundred children were identified, with a median follow-up of 18 months. Forty patients underwent an LA and 151 an OA. Nine patients underwent interval appendicectomy and were not included in the final data. There was no difference between the two groups in terms of baseline demographics, duration of stay ( P = 0.5), or wound infection ( P = 1.0). The incidence of an intra-abdominal abscess was 0 of 40 (0%) in the laparoscopic group and 5 of 151 (3.3%) in the open group, although this was not statistically significant ( P = 0.8). The median time to postoperative diagnosis of abscess was 9 days (range, 8–11). A consultant was present in more laparoscopic procedures than open (88 versus 24%; P = 0.0001). Conclusions: The rate of intra-abdominal abscess formation was not significantly different following either an LA or OA, although there were no intra-abdominal abscesses observed in the laparoscopic group. Further investigation could address this finding more accurately in a randomized, controlled trial. [ABSTRACT FROM AUTHOR]

Evaluation is a vital part of any learning activity and is essential to optimize and improve educational programmes. It should be considered and prioritized prior to the implementation of any learning activity. However, comprehensive programme evaluation is rarely conducted, and there are numerous barriers to high‐quality evaluation. This review provides a framework for conducting outcome evaluation of simulation‐based education programmes in low and middle‐income countries (LMICs). The basis of evaluation, including core ideas of theory, purpose and structure are outlined, followed by an examination of the levels and healthcare applications of the Kirkpatrick model of evaluation. Then, methods of conducting evaluation of simulation‐based education in LMICs are discussed through the lens of a successful surgical simulation programme in Myanmar, a lower‐middle‐income country. The programme involved the evaluation of 11 courses over 4 years in Myanmar and demonstrated evaluation at the highest level of the Kirkpatrick model. Reviewing this programme provides a bridge between evaluation theory and practical implementation. A range of evaluation methods are outlined, including surveys, interviews, and clinical outcome measurement. The importance of a mixed‐methods approach, enabling triangulation of quantitative and qualitative analysis, is highlighted, as are methods of analysing data, including statistical and thematic analysis. Finally, issues and challenges of conducting evaluation are considered, as well as strategies to overcome these barriers. Ultimately, this review informs readers about evaluation theory and methods, grounded in a practical application, to enable other educators in low‐resource settings to evaluate their own activities. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic simulation is integral to surgical education but requires significant resources. We aimed to compare the effectiveness of dyadic practice (DP), involving two individuals working together, to individual practice (IP) for novices acquiring laparoscopic skills and assess their learning experience. Methods: We conducted a Randomized Controlled Trial comparing DP and IP for novice medical students who completed a laparoscopic simulation workshop. Participants were assessed individually pre‐course (test 1), post‐course (test 2), and 8‐week retention (test 3) using a validated quantitative method. A post‐course questionnaire and interview, analyzed with thematic analysis, assessed the learning experience. Results: In total, 31 DP and 35 IP participants completed the study. There was no difference in mean scores between DP and IP groups in all three tests: test 1 (p = 0.55), test 2 (p = 0.26), test 3 (p = 0.35). In trend analysis, the DP group improved post‐course (test 1 vs. 2: p = 0.02) and maintained this level at the retention test (2 vs. 3: p = 0.80, 1 vs. 3: p = 0.02). Whilst the IP group also improved post‐course (test 1 vs. 2: p < 0.001), this improvement was not retained (2 vs. 3: p = 0.003, 1 vs. 3: p = 0.32). Thematic analysis revealed that DP participants valued peer support, peer feedback and observation time, but also acknowledged the limitations of reduced practical time and issues with teamwork. Conclusion: DP is non‐inferior to IP for novices learning laparoscopic skills, is well received and may lead to superior long‐term skill retention. [ABSTRACT FROM AUTHOR]

Backgrounds: The effect of foetal position on the degree of antenatal hydronephrosis (ANH) is unknown. We hypothesized that foetal position is an important contextual factor in ANH, with consequences on prenatal counselling and postnatal management. The current study aimed to investigate the effect of foetal position on the degree of ANH. Methods: A retrospective study was carried out on consecutive pregnancies with isolated ANH over a 10‐year period. Gestational age, foetal presentation (cephalic vs. breech), and degree of ANH (as measured by the AP diameter) were retrieved. Foetuses with other ultrasound findings of the renal tract (renal parenchymal abnormality, ureteric dilatation, or bladder abnormalities) were excluded. Logistic regression analysis was conducted to examine the relationship between the anterior–posterior diameter (APD) and the mode of presentation (cephalic or breech). A P‐value of <0.05 was considered significant. Results: Initially 745 scans were identified, with 436 included in the final analysis. Overall, there was an association between foetal presentation and APD regardless of trimester, with cephalic presentations having a greater APD (OR 1.07, 95% CI 1.02–1.11, P = 0.04). Conclusion: Cephalic presentations are associated with a significantly greater APD indicating that foetal position should be considered when stratifying ANH. Furthermore, foetal position may be a contributing factor in the mechanism of 'physiological' hydronephrosis. [ABSTRACT FROM AUTHOR]

Background: The optimal management of perianal abscess in neonates and infants remains unclear, including the need for laying open of the fistula and the role of microscopy and culture studies (MCS). We aimed to report the recurrence rate following incision and drainage alone (I&D) compared to incision and drainage with laying open of the fistula (I&DF) and to determine the value of MCS in perianal abscess management. Methods: Following ethical approval (16326Q), a 10‐year (2007–2017) review of children younger than 1 year presenting with a perianal abscess was performed. Presence of a fistula was sought in all patients. Data are presented as number of cases (%), median (range) and analysed using Fisher's exact test and Mann–Whitney U‐test. P‐values of <0.05 were considered significant. Results: We identified 108 patients (107 (99.1%) males) with 111 abscesses (three bilateral); 26 in I&D group and 85 in I&DF group. Initial abscess occurred to the right of midline in 64 cases (58%) and to the left of midline in 47 cases (42%). Twenty‐two (20%) recurred after 30 (6–372) days. Sixty‐five (59%) had MCS performed. Recurrence was higher in I&D group (9/26) versus I&DF group (13/85) (P = 0.04 (relative risk 2.2, 95% confidence interval 1.0–4.5)). There was no difference in recurrence within each group between patients with or without MCS (I&D group, P = 0.1; I&DF group, P = 0.3). Conclusion: The recurrence of surgically managed perianal abscess is lower when a fistula is identified and laid open at the initial operation. There is little value of MCS in the management of paediatric perianal abscess. [ABSTRACT FROM AUTHOR]

Introduction: Surgical skill assessment utilises direct observation and feedback by an expert which is potentially subjective, therefore obtaining objective data for hand and eye tracking is essential. Our aim was to evaluate a wearable mixed reality (MR) headset in these domains. Methods: Participants with differing levels of surgical expertise [novice (N), intermediate (I) & expert (E)] performed 4 simulated surgical tasks; 2 general dexterity (tasks 1&2) and 2 surgical skills (tasks 3&4) wearing the MR headset capturing their hand and eye movements (median & range). Metrics included hand path length and the speed of each index or thumb tip. Gaze data were also captured. Participant demographics, prior expertise and current experience were captured with an electronic survey. Data were analysed with a Shapiro-Wilk test or ANOVA as appropriate. A p-value of < 0.05 was significant. Results: Thirty-six participants were analysed (N = 18, I = 8, E = 8). Tasks 1&2 revealed 2 speed outcomes (left index and left-hand speed) which were significant. For tasks 3&4, various outcomes were significant: path length for left hand (N:45 cm vs. I:31 cm vs. E:27 cm, p = 0.03) and right hand (N:48 cm vs. I:29 cm vs. E:28 cm, p = 0.01) and total time (N:456s vs. I:292 vs. E: 245, p = 0.0002). With left-hand-tying, average path length (N:61 cm vs. I:39 vs. E:36, p = 0.04), average speed (N:11 cm/s vs. I:23 vs. E:24, p = 0.03), and total time (N:156s vs. I:43 vs. E:37, p = 0.003) were significant. The gaze-tracking was not statistically significant. Conclusion: The MR headset can be utilised as a valid tool for surgical performance assessment. Outcomes including path length and speed can be valuable metrics captured by the MR Headset during the task completion for detecting surgical proficiency. [ABSTRACT FROM AUTHOR]

Background: Tissue adhesive, adhesive tape, and sutures are used to close surgical incisions. However, it is unclear which produces the best results in children, and whether combination wound closure is better than sutures alone. Methods: In this parallel randomised controlled trial (ANZCTR: ACTRN12617000158369), children (aged 18 years or less) undergoing elective general surgical or urological procedures were randomized to skin closure with sutures alone, sutures and adhesive tape, or sutures and tissue adhesive. Participants were assessed 2 weeks, 6 weeks, and more than 6 months after operation. Outcomes included wound cosmesis (clinician- and parent-rated) assessed using four validated scales, parental satisfaction, and wound complication rates. Results: 295 patients (333 wounds) were recruited and 277 patients (314 wounds) were included in the analysis. Tissue adhesive wounds had poorer cosmesis at 6 weeks: median 10-point VAS score 7.7 with sutures alone, 7.5 with adhesive tape, and 7.0 with tissue adhesive (P=0.014). Respective median scores on a 100-point VAS were 80.0, 77.2, and 73.8 (P=0.010). This difference was not sustained at over 6 months. There was no difference in parent-rated wound cosmesis at 6 weeks (P=0.690) and more than 6 months (P=0.167): median score 9.0 with sutures alone, 10.0 with adhesive tape, and 10.0 with tissue adhesive at both stages. Parental satisfaction was similar at all points, with a median score of 5 (very satisfied) for all groups. There was one instance of wound dehiscence in the tissue adhesive group and no wound infections. Conclusion: Short-term wound cosmesis was poorer with tissue adhesive although it is unclear whether this difference is sustained in the long-term. There were no differences between techniques for the study outcomes. [ABSTRACT FROM AUTHOR]

The article discusses the management of paediatric paraphimosis. Topics covered include the fundamental definition of paraphimosis, the common occurrence of paraphimosis in young children and infants, and the non-manipulative methods for reducing paraphimosis. It also discusses how to manually reduce paraphimosis, and other options for reducing paraphimosis if surgical review is not available.

Aim: Criteria‐led discharge (CLD) protocols have been suggested to increase efficiency of discharge from hospital following surgical interventions. Our aim was to assess the feasibility, clinical outcomes and parental satisfaction following the introduction of a pilot CLD for simple appendicitis (SA) in children. Methods: A prospective pilot cohort study was conducted including paediatric patients with SA who were managed with CLD and a control group who were managed with standard discharge procedures. A CLD pro forma was developed, standardising care guidelines and clinical criteria indicators to be met for children to be discharged post‐operatively. A post‐discharge parent survey was also utilised. The primary outcome measure was post‐operative length of stay (pLOS), with secondary outcomes of post‐operative complication rates and parental satisfaction. Results: The control group consisted of 31 patients and CLD group 35 patients. There was no difference in the median pLOS (24 [16.7–44.6] vs. 25.3 [19.1–50.1] h, P = 0.3). Furthermore, there were no significant differences on any of the secondary outcomes. Parental confidence with time of discharge was very high in both control (85.7%) and CLD (88.2%) groups (P = 1.0). Conclusion: The introduction of CLD is safe and feasible. Whilst this pilot has not demonstrated a reduction in pLOS, our data suggest that it is well accepted by the parents. [ABSTRACT FROM AUTHOR]

Aim: Magnet ingestion has become more frequent in children as magnetic toys and jewellery have been popularised, with the potential to cause significant morbidity. Our aim was to describe our experience at a tertiary paediatric surgical centre.Methods: Retrospective review of patients admitted with multiple magnet ingestion (January 2011-December 2020). Division into an intervention group and conservative group. Comparisons included demographics, number of magnets and clinical outcomes. Data analysis with a Student's t-test and ROC Curve, P value of <0.05 was significant.Results: A total of 23 patients were identified with a total of 150 magnets ingested. The majority required an intervention for magnets retrieval (15/23, 65.2%), 11/15 (73.3%) surgical and 4/15 (26.7%) endoscopic. In the surgery group, 6/11 (54%) presented with an initial perforation and 1/11 (9.1%) an entero-enteric fistula. One patient (9.1%) had a multi-site anastomotic leak post-operatively. The conservative group had a significantly lower median number of ingested magnets (2 (2-6) vs. 7 (2-40), P = 0.03) and median length of stay (1 (1-4) vs. 7 (1-24), P = 0.03). ROC curve analysis revealed ingestion of >3 magnets had a sensitivity of 86.7% (95% CI: 62.1-97.6%) and specificity of 87.5% (95% CI: 53.0-99.4%) for requiring an intervention.Conclusion: This series highlights a significant morbidity in children with a higher incidence of intervention following ingestion of more than three magnets. There is a strong requirement for the creation and adherence to new legislature involving industry standards. [ABSTRACT FROM AUTHOR]

Purpose: Controversy still surrounds the treatment of the asymptomatic inguinal region in paediatric patients with a unilateral inguinal hernia. The concern is the development of a future metachronous contralateral inguinal hernia (MCIH) and therefore the need for a second operation. Our aim was to provide a current systematic review of the evidence for routine contralateral exploration, and identify potential at-risk groups.Methods: Comprehensive review of the literature utilising broad search terms to identify all relevant publications. Precise inclusion and exclusion criteria to identify studies that included paediatric unilateral inguinal hernia repair without routine contralateral exploration.Data Analysis: Chi-square with Yates' correction or a Fisher's exact test as appropriate. Numbers needed to treat (NNT) calculated with 95% confidence intervals.Results: A total of 7,130 titles and abstracts were screened and 61 studies included with data on 49,568 paediatric patients with a unilateral inguinal hernia fulfilling the inclusion criteria. 2,857 of these patients later developed a MCIH, revealing an overall risk is 5.76% (95% CI: 5.55-5.97%). The NNT for a MCIH is 18 (95% CI: 16.8-18) with 18 contralateral exploration required for the prevention of one MCIH. Patients <6 months at the time of the initial intervention were more likely to develop a MCIH; 183/1,470 (<6/12) versus 144/2,044 (≥6/12), P < 0.0001. As were patients with an original left-sided hernia; 815/6,739 versus 865/12,615, P < 0.0001. The NNTs for both of these groups were 9. There was no association with the gender of the patient; 888/14,480 (♂) versus 268/4,206 (♀), P = 0.37.Conclusions: There is insufficient evidence to support the routine contralateral inguinal exploration in all paediatric patients presenting with a unilateral inguinal hernia. However, with patients presenting with an originally left-sided hernia or who are less than 6 months old, a parental discussion should occur about the possible benefits and risks of contralateral exploration. [ABSTRACT FROM AUTHOR]

Esophageal atresia (EA) is the most common congenital esophageal disorder. Radiological imaging facilitates diagnosis, surgical interventions, and follow-up. Despite this, standardized monitoring guidelines are lacking. We aimed to: (1) review the literature regarding radiation burden in children with EA; (2) establish the presence of guidelines for diagnosis and follow-up in children with EA. The systematic review was performed according to PRISMA protocol. Two investigators conducted independent searches (PubMed, Ovid, Cochrane Review) and data extraction. Analysis focused on pre- and post-operative imaging type and frequency to determine the radiation burden. Seven studies met the inclusion criteria (337 patients). All authors agreed upon the need to minimize radiation burden, recommending symptoms-guided management, use of dosimeters, and non-radiating imaging. One study identified a median 130-fold increase in cumulative lifetime cancer risk in children with EA compared with other babies in the special care unit. The most common investigations were X-ray and CT (pre-operatively), and X-ray and contrast swallow (post-operatively). Standardized guidelines focused upon the frequency and type of radiological imaging for children with EA are lacking. Children with EA are subjected to more radiation exposure than the general population. Implementation of non-radiating imaging (ultrasonography, manometry) is recommended. [ABSTRACT FROM AUTHOR]

Background: COVID‐19 has resulted in a massive increase in telehealth utilisation. Aims: To determine the user and clinician satisfaction during this period and compare to a pre‐COVID‐19 cohort. Methods: A prospectively collected voluntary questionnaire following the telehealth appointment at a tertiary‐level hospital with all adult and paediatric‐based specialities was conducted over two time periods: COVID‐19 (16 March 2020 to 15 April 2020) and pre‐COVID‐19 (1 January 2019 to 31 December 2019). There were four groups of participants: patients; parents; adult‐based clinicians; and paediatric‐based clinicians. The outcomes assessed included perceived standard of care, willingness for repeat telehealth consultations, and patient and parental perceptions of safety. Results: Five thousand and thirty‐three telehealth consultations occurred in the COVID‐19 period with 1757 questionnaires completed, compared to 1917 consultations with 271 questionnaires completed in the pre‐COVID‐19 period. Clinicians were more likely to have previously used telehealth in both time periods than end‐users. In COVID‐19, 1240 actual onsite hospital outpatients' visits were prevented. All groups reported a good overall impression of the telehealth quality; patients/parents scored higher compared to clinicians: 3.6/4 versus 3.3/4, P = 0.02 (pre‐COVID‐19) and 3.3/4 versus 2.8/4, P = 0.001 (COVID‐19). The majority of patients and parents (90%, 1379/1528) felt safer by having a telehealth appointment compared to a face‐to‐face appointment in the COVID‐19 pandemic. All participant groups reported an overall good standard of care, good levels of engagement and were strongly willing to use telehealth again in both of the study time periods. Patients and parents consistently rated higher than clinicians. Conclusions: During a rapid increase in its utilisation and scope due to the COVID‐19 pandemic, telehealth was generally well accepted by patients, parents and clinicians, which was consistent with pre‐COVID‐19 experiences. [ABSTRACT FROM AUTHOR]

OBJECTIVES: In children, intravenous therapy (IVT) is generally administered via peripheral intravenous catheters (PIVCs) (2-6 cm in length). There is evidence that PIVCs are unreliable after 2 days. Long peripheral catheters (LPCs) (6-15 cm in length) could improve the delivery of IVT. The aim of this trial was to determine if LPCs could decrease catheter failure and the number of catheters in children receiving multiday IVT. METHODS: This was an open-label randomized controlled trial conducted at Monash Children's Hospital in Melbourne, Australia. Participants were from the ages of 1 to 17 years, undergoing surgery and requiring >48 hours of postoperative IVT. Participants were randomly assigned to a 2.5-cm 22G PIVC or an 8-cm 22G LPC. RESULTS: Seventy-two children were randomly assigned, 36 received PIVCs, and 36 received LPCs. The median duration of IVT was 5.1 days and was similar between groups (P = .9). Catheter failure was higher for PIVCs than LPCs (66.7% vs 19.4%; relative risk [RR]: 3.4; P = .0001 or 187.9 vs 41.0 failures per 1000 catheter-days). Infiltration was the most common reason for PIVC failure (33.3% vs 2.8%; RR: 12.0; P = .001). LPCs exhibited superior life span (4.7 vs 3.5 days [median]; P = .01). Children with LPCs were twice as likely to complete therapy with a single catheter (80.6% vs 38.9%; RR: 2.1; P = .0006). CONCLUSIONS: LPCs reduce catheter failure and total catheters in children. They should be considered as the first-line device for peripheral access in any child receiving prolonged IVT. [ABSTRACT FROM AUTHOR]

Background: Acute scrotal pain is a common paediatric surgical presentation. Delays in treatment can result in testicular loss from torsion. It is unclear where delays occur. We aimed to investigate presentations with an acute scrotum to identify any potential areas of delay. Methods: We conducted a prospective study (April 2017–November 2018) of paediatric patients (<18 years) presenting with acute scrotal pain. Data collected included: patient demographics, history/examination findings, mode of presentation, clinical timeline details and outcomes. Results: A total of 107 acute scrotum presentations were identified: 58 (54.2%) testicular appendage torsion, 23 (21.5%) testicular torsion, 6 (5.6%) epididymo‐orchidits and 20 (18.7%) other diagnoses. Median age at presentation was 11 years (4 months–16 years). Fifty‐seven (53.3%) underwent emergency surgery, of whom 23 (40.4%) had testicular torsion, with 2 requiring orchidectomy. Median time from onset of symptoms to seeking medical opinion was 5.5 (0–135) h. Once assessed by a medical professional, the route to paediatric surgical review via general practitioner (GP) and local emergency department (ED) to paediatric ED was 4.84 (1.67–24.5) h; via GP to paediatric ED was 2.58 (0.75–25.5) h; via local ED to paediatric ED was 2.25 (1–7.75) h; and directly to paediatric ED was 0.45 (0–1.42) h. Conclusion: Delays in assessment and treatment of acute scrotal pain occur from the time parents are aware of symptoms to seeking medical opinion. Education to increase awareness may reduce time delays. GPs should refer patients directly to a paediatric ED. Local EDs should manage paediatric cases as per the local surgeons' skill base. [ABSTRACT FROM AUTHOR]

Aim: To evaluate the trend in presentation and postoperative outcomes of infants with hypertrophic pyloric stenosis (HPS) over the last decade.Methods: This was a multicentre retrospective study in two tertiary paediatric centres between 2005 and 2015 inclusive. Participants included 626 infants who underwent a pyloromyotomy for HPS. We collected data on presentation features (age, weight, clinical signs, blood gas results, ultrasound findings) and postoperative outcomes (length of stay (LOS), complications, time to first postoperative feed).Results: No trend was identified during the study period with regards to age, weight, biochemical findings (pH, chloride, base excess) or pre-operative ultrasound measurements. There was a downtrend in the number of palpated tumours over time, with a mean of 36% of tumours clinically palpated. Pyloric wall thickness had a moderate association with LOS in patients admitted for >8 days (correlation = 0.4752) but had a weak negative association with shorter lengths of stay (≤8 day, correlation = -0.094). Overall, median time to first feed was 7.80 h and improved yearly during the study period (hazard ratio = 1.07).Conclusions: Patients presenting with HPS are not being identified at an earlier age or with fewer biochemical derangements, in contrast to our initial perceptions. Subsequently, biochemical derangements can still play an important role in the diagnosis of HPS, and attention needs to be given to fluid management and electrolyte correction in all patients with HPS. [ABSTRACT FROM AUTHOR]

Circumcision is one of the most commonly performed surgical procedures in the world. Despite this, the practice of paediatric circumcision remains highly controversial, and continues to generate ongoing debate. This debate has become more relevant recently with the provisional guidelines from the Centers for Disease Control and Prevention recommending a change of practice. In this review article, we provide an overview of the history and incidence of circumcision, normal preputial development, types of phimosis, the absolute and relative indications for circumcision as well as the evidence base for its use as a preventative measure. Our aim is to provide paediatricians with a greater understanding of this common surgical procedure and the conditions it treats, to guide their clinical practice and parent counselling. [ABSTRACT FROM AUTHOR]

Purpose: As appendicitis in children can be managed differently according to the severity of the disease, we investigated whether commonly used serum biomarkers on admission could distinguish between simple and complicated appendicitis.Methods: Admission white blood cell (WBC), neutrophil (NEU), and C-reactive protein (CRP) levels were analysed by ROC curve, and Kruskal-Wallis and contingency tests. Patients were divided according to age and histology [normal appendix (NA), simple appendicitis (SA), complicated appendicitis (CA)].Results: Of 1197 children (NA = 186, SA = 685, CA = 326), 7% were <5 years, 55% 5-12, 38% 13-17. CA patients had higher CRP and WBC levels than NA and SA (p < 0.0001). NEU levels were lower in NA compared to SA or CA (p < 0.0001), but were similar between SA and CA (p = 0.6). CA patients had higher CRP and WBC levels than SA patients in 5-12- (p < 0.0001) and 13-17-year groups (p = 0.0075, p = 0.005), but not in <5-year group (p = 0.72, p = 0.81). We found CRP >40 mg/L in 58% CA and 37% SA (p < 0.0001), and WBC >15 × 109/L in 58% CA and 43% SA (p < 0.0001).Conclusions: Admission CRP and WBC levels may help the clinician predict complicated appendicitis in children older than 5 years of age. Early distinction of appendicitis severity using these tests may guide caregivers in the preoperative decision-making process. [ABSTRACT FROM AUTHOR]

The article explains ways of reducing inguinal hernia in pediatric male patients. Topics covered include description of inguinoscrotal lump clinical features, hydrocele and encysted hydrocele of the cord, palpation of testis position, ultrasound and reduction procedure including creating a funnel for entering herniated bowel into inguinal canal while the scrotum is moved to the contralateral part. Also mentioned are testicular swelling, strangulated inguinal hernia and testicular atrophy.

The article discusses the use of additive manufacturing techniques for paediatric choledochal malformations. It mentions that such replicas of real clinical pathology may aid teaching of undergraduate medical students and surgical trainers as well as patient education. The article also talks about a case study of a 3-year-old girl with recurrent pancreatitis was investigated magnetic resonance cholangiopancreatography (MRCP).