Nigel J. Hall

Established indications for surgery in necrotizing enterocolitis (NEC) are pneumoperitoneum and failure to improve or clinical deterioration with medical treatment alone. It has been proposed that infants with intestinal necrosis may benefit from surgery in the absence of one of these indications yet the diagnosis of definitive intestinal necrosis is challenging. Recent data suggest that abdominal ultrasound (US) examination focused on the gastrointestinal tract and the peritoneal cavity may be of utility in this regard. The aim of this study was to evaluate the ability of abdominal US to detect intestinal necrosis in infants with radiographically confirmed NEC. Twenty-six consecutive infants with Bell stage II or III NEC were prospectively included in the study between September 2013 and July 2014. Infants with a pre-existing indication for surgery were excluded. At least one abdominal US examination was performed in each patient using a standardized previously described method. Surgery was performed at the discretion of the attending surgeon based on clinical and imaging findings. Clinical, radiographic, US, and intra-operative data were recorded to allow comparison between US findings, surgical findings and outcome. US demonstrated signs of intestinal necrosis in 5 of the 26 patients. All of these five had laparotomy. Intestinal necrosis requiring resection was confirmed in four and the other was found to have NEC but no necrosis was identified. In 21 patients US did not suggest intestinal necrosis. Of these, only one had surgery in whom NEC but no necrosis was identified. The remaining 20 responded to medical treatment for NEC and were assumed not to have had intestinal necrosis based on improvement without surgical intervention. The sensitivity, specificity, positive predictive value and negative predictive values of US for the detection of bowel necrosis were calculated as 100, 95.4, 80.0, and 100 %, respectively. Our prospective findings suggest that abdominal US can identify those infants with NEC who may need surgery by detecting bowel necrosis (prior to the development of perforation or medical deterioration) with high sensitivity and specificity. Early surgical intervention in the clinical pathway of NEC may lead to improved outcomes.

Background Appendicectomy for acute appendicitis in children may be performed in specialist centres by paediatric surgeons or in general surgery units. Service provision and outcome of appendicectomy in children may differ between such units. Methods This multicentre observational study included all children (aged less than 16 years) who had an appendicectomy at either a paediatric surgery unit or general surgery unit. The primary outcome was normal appendicectomy rate (NAR). Secondary outcomes included 30‐day adverse events, use of ultrasound imaging and laparoscopy, and consultant involvement in procedures. Results Appendicectomies performed in 19 paediatric surgery units (242 children) and 54 general surgery units (461 children) were included. Children treated in paediatric surgery units were younger and more likely to have a preoperative ultrasound examination, a laparoscopic procedure, a consultant present at the procedure, and histologically advanced appendicitis than children treated in general surgery units. The unadjusted NAR was significantly lower in paediatric surgery units (odds ratio (OR) 0·37, 95 per cent confidence interval 0·23 to 0·59; P < 0·001), and the difference persisted after adjusting for age, sex and use of preoperative ultrasound imaging (OR 0·34, 0·21 to 0·57; P < 0·001). Female sex and preoperative ultrasonography, but not age, were significantly associated with normal appendicectomy in general surgery units but not in paediatric surgery units in this adjusted model. The unadjusted 30‐day adverse event rate was higher in paediatric surgery units than in general surgery units (OR 1·90, 1·18 to 3·06; P = 0·011). When adjusted for case mix and consultant presence at surgery, no statistically significant relationship between centre type and 30‐day adverse event rate existed (OR 1·59, 0·93 to 2·73; P = 0·091). Conclusion The NAR in general surgery units was over twice that in paediatric surgery units. Despite a more severe case mix, paediatric surgery units had a similar 30‐day adverse event rate to general surgery units. Service provision differs between paediatric and general surgery units.

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.

Purpose Contralateral groin exploration with closure of a patent processus vaginalis (PPV) in children with a unilateral inguinal hernia remains controversial. We aimed to generate precise, age-related probabilities of patency of the contralateral processus vaginalis (PV) in infants with a unilateral inguinal hernia to guide practice. Methods Retrospective review of all unilateral laparoscopic inguinal hernia repairs in 5 years to determine patency of contralateral PV. Using logistic binomial regression, age-adjusted odds ratio (OR), probability of contralateral PPV and number needed to explore (NNE) in order to close all PPVs were estimated. Results Data from 331 children [262 male, median 3.8 months corrected gestational age (CGA)] were analysed; 160 (48 %) had a contralateral PPV. In the regression model, CGA is linearly related to log[OR] such that for each month increase in CGA, the log[OR] of having a contralateral PPV decreased by 0.017 ± 0.006 (mean ± SEM; p = 0.005). Gender and side of hernia had no significant effect. The probability of contralateral PPV is 50 % (NNE = 2) at 8 m CGA, 33 % (NNE = 3) at 49 m and 25 % (NNE = 4) at 72 m. Conclusions These data contribute to our knowledge of the natural history of the PV and may help guide the need for contralateral groin exploration in infants with inguinal hernia.