How often is a surgical process the cause of bilious emesis in a newborn?

Pediatric surgeons are trained to recognize bilious (green) emesis as a "red flag" that necessitates immediate attention to evaluate for surgical causes, specifically malrotation with midgut volvulus.

Godbole et al evaluated the outcome of 63 neonates with bilious emesis over a two-year period and noted that 38% had a surgical cause. Nine had Hirschsprung's disease, 5 had small bowel atresia, 4 had intestinal malrotation, 3 had meconium ileus, and one each had meconium plug, colonic atresia, and milk inspissation.

Importantly, one of the four neonates with malrotation had no abdominal signs or symptoms, as well as a normal abdominal radiograph at time of diagnosis. On the other hand, the majority of neonates with non-surgical causes had a normal exam and abdominal radiographs. .

Non surgical causes for bilious emesis were thought to mostly represent gastro-esophageal reflux and gastric dysmotility, metabolic disturbances, and/or sepsis.

All patients with bilious emesis need a thorough abdominal exam and an abdominal radiograph. Although a relatively small number of these patients (4/63) will have malrotation with potential midgut volvulus, a prompt evaluation with an UGI should always be considered given the potential catastrophic consequences of a missed midgut volvulus.

Godbole P, Stringer MD. Bilious vomiting in the newborn: how often is it pathologic? J Pediatr Surg 2002;37:909-911

Are bowel preps really necessary before abdominal operations in children?

It’s 11pm, and a 12 YO girl is sitting teary-eyed with a tube hanging form her nose. She tried her best to drink that “stuff” but finally gave up and asked for the naso-gastric tube so she can get her bowel prep. Why is she getting her bowel prep? well, apparently, someone in the 1970’s thought it was a good idea!

The current data on the need for bowel preparations before elective colorectal surgery in the adult literature overwhelmingly contradicts the dogma that a bowel preparation is necessary for a safe operation, with a decreased risk of anastomotic leak and wound infection.

Recently, a pilot study by Leys et al, from Vanderbilt University Medical Center, showed findings in the pediatric population consistent with those in the adult literature. The study, which was retrospective in nature, compared the outcomes between 33 patients who did not undergo a bowel prep (No Prep) and 110 who did (Prep).

The study results showed that, despite the Prep group receiving postoperative antibiotics for a longer duration than the No Prep group, as well as greater incidence of delayed wound closure, the two groups did not have any significant difference in anastomotic leaks or wound infection rates.

The rationale behind bowel preps is that they decrease the fecal and bacterial load inside the lumen of the bowel, and thus decrease the risk of infectious complications. Some studies, which have found an increased risk of infectious complications with patients undergoing bowel preps, theorize that the liquid bowel content that results from the bowel prep is more difficult to manage, spills more easily and thus may explain the increased risk of infectious complications.

Despite the retrospective nature of this study by Leys et al, one cannot help but suspect that the results of the research in the adult literature should apply to this younger and generally healthier patient population. Obviously, and before any recommendations can be made about the need to omit bowel preps, a multi-center randomized prospective study with sufficient patients is needed.

Leys C M, Austin M T, Pietsch J B, Lovvorn H N, Pietsch J B. Elective intestinal operations in infants and children without mechanical bowel preparations; A pilot study. J Pediatr Surg 2001;40:978-82

Avoiding placement of implanted central venous catheters in neutropenic patients decreases complication rates

The authors of this study evaluated the outcome of the implementation of a protocol that restricts the placement of implanted central venous catheters to patients with an ANC greater or equal to 500. This was based on previous findings that suggested that placement of implantable central venous devices in neutropenic patients is associated with higher rate of complications.

The authors found a higher rate of complications (infectious and technical) in neutropenic patients. Additionally, the rate of these complications was substantially decreased after implementation of a protocol that excludes neutropenic from device placement.

Gollin G, Gutierrez I. Exclusion of neutropenic children form implanted central venous catheter placement: impact on early catheter removal. J Pediatr Surg 2010;45:1115-1119

Cryptorchidism and testicular cancer

Prevalence of undescended testicles (UDT) is 3-4% at birth. The rate of UDT drops to 1% at 12 months, given that 2/3 of UDT demonstrate descent by age 3 months. The rate of UDT is higher in preterm infants, with no increased risk of malignancy in testes that descend spontaneously in the first 3-12 months. Infants (term or preterm) should be allowed to reach an adjusted gestational age of 12 months before orchidopexy is performed.

Using a meta analysis of current literature, the authors set out to answer 5 questions regarding cryptorchidism:

1. What is the RR of testicular cancer in a cryptorchid or formerly cryptorchid testis?

The historically quoted increased risk for testicular cancer (RR = 48) considered a substantial overestimate. The true RR for testicular cancer was found to be 4-6 in the undescended testes.

2. What is the relative risk for malignancy in the contralateral, normally descended testis?

Historically, it was believed that the contralateral, normal testis has a 5-10% chance of malignancy. Based on current literature, the authors identified no increased risk for malignancy in the contralateral testis.

3. Does relocating the testis affect the type of testicular cancer

Uncorrected cryptorchidism carries a higher risk for seminoma, while a corrected conditions carries a higher risk for non-seminomatous malignancies.

4. Does orchidopexy decrease the risk of malignancy

Relative risk of testicular cancer in the undescended testicle after operative correction depends on patient age at time of orchidopexy. When performed before the age of 10-12 years, the RR of testicular cancer is between 2 and 3. When orchidopexy is performed after age of 12, the RR is 2-6 times that of patients who undergo surgery before age 10-12 (this is comparable to the risk in uncorrected UDT).

5. Is there a risk of malignant degeneration in testicular remnants?

The risk of malignant degeneration from atrophic testes, resulting from perinatal spermatic cord torsion, is minimal.



Reference: Cryptorchidism and testicular cancer: Separating fact from fiction. Wood MW, Elder JS. Journal of Urology (2009);181:452-61

Stoma Complications in Infants with NEC

Up to 50% of infants with NEC require surgical intervention, which generally consists of exploration of the abdomen, bowel resection, and stoma formation. The bowel used for formation of the stoma is frequently of marginal viability, and the infants are usually systemically ill during this emergent procedure.

Aguayo et al [Journal of Surgical Research (2009) 157(2):275-8] performed a retrospective study to assess the factors associated with an increased risk of stomal complications in infants undergoing operative intervention for NEC. The authors noted a 43% rate of stomal complications (5% retraction, 5% Skin excoriation, 8% prolapse, 7% necrosis, 15% stricture, 3% parastomal hernias). They also noted a significant increase in risk of complications with lower gestational age and lower preoperative weight.

Intestinal stomas, although potentially life saving, have a surprisingly high rate of complications. They should be created with meticulous technique in order to help decrease the risk of morbid complications and need for revision.

When is prophylaxis against infectious endocarditis indicated?

Infectious endocarditis (IE) occurs when nonbacterial thrombotic endocarditis (NBTE) becomes infected after an episode of transient bacteremia. NBTE results from platelet/fibrin deposition at areas of abnormal and turbulent blood flow. Any event that can cause transient bacteremia (eg. violation of the GI tract) can transform NBTE to IE.

The AHA recommendations for endocarditis prophylaxis were modified in 2007 [Circulation (2007);116:1736-54) in light of the understanding that most IE results from random episodes of bacteremia not related to specific procedures and the concern for the potential harmful effects of unwarranted antibiotic administration

Only patients with specific cardiac IE risk factors [table] should be considered for prophylactic antibiotic administration.

Recommendations for respiratory tract procedures:
Single pre-procedure antibiotic dose (Cefazolin/clindamycin/ceftriaxone or Vanco if MRSA suspected) for any procedure expected to violate (incision/biopsy) the mucosa or for procedures intended to treat an existing infection (drainage of empyema/abscess).

Recommendations for GI or GU tract procedures:
Single pre-procedure antibiotic dose effective against enterococci should be used, when indicated, since these are the only organisms likely to cause IE.
Prophylaxis is NOT indicated for diagnostic GI/GU procedures (endoscopy, cycstoscopy etc..).

When patients are receiving antibiotics for a GI/GU infection or to prevent wound infection, it is suggested that the antibiotics used include an agent effective against enterococci (PCN, ampicillin, piperacillin, or Vanco).

Recommendations for infected skin/skin structure/musculoskeletal tissue
Only staph and B-hemolytic strep are likely causes of IE in this situation. Prudent to use antistaphylococcal agents.

Laparoscopic contralateral groin exploration: is it cost effective

The authors addressed the cost effectiveness of laparoscopic exploration of the contralateral groin in children undergoing inguinal hernia repairs. lap exploration identified a 10% (8/78) rate of contralateral patent processus vaginalis. Assuming all substantial PPV's (defined by the authors as those that could admit a scope, those whose distal aspect could not be visualized, and those that result in gas reaching the scrotum) eventually became hernias, the authors estimated the total cost of contralateral exploration/repair vs. repair when clinical hernias developed in the 8 patients with PPV to be $13,080 and $20,440, respectively. Thus they concluded that contralateral exploration and repair is a cost effective approach to inguinal hernias in children. This did not take into account the expense of the use of laparoscopic instruments.

Lee et al. Journal of Pediatric Surgery (2010);45:793-795