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Papers by Joe Curry

Research paper thumbnail of Esophageal Atresia: Improved Outcome in High-Risk Groups Revisited

European journal of pediatric surgery : official journal of Austrian Association of Pediatric Surgery ... [et al] = Zeitschrift fur Kinderchirurgie, Jan 16, 2015

Objectives Improved survival in infants with esophageal atresia (EA) with a birth weight < 1,5... more Objectives Improved survival in infants with esophageal atresia (EA) with a birth weight < 1,500 g or a major cardiac anomaly has been reported when compared with the original Spitz classification proposed in 1994. Aim We reviewed outcome data for infants born over the last decade in our institution to update previously reported survival statistics. Materials and Methods The records of all neonates (n = 200) with a diagnosis of EA managed in a single institution between 2001 and 2011 were reviewed and compared with data from the original Spitz study and the subsequent reported cohort from the same institution. Data were obtained on birth weight, presence of a major cardiac anomaly, and survival. Differences in survival were compared using the Yates-corrected chi-square test. Local ethical study approval was obtained. Results Infants born over the last decade had a comparable overall survival rate of 93% (186/200) versus 92.6% (174/188) in the previously reported cohort (1993-2004...

Research paper thumbnail of Early Experience of Thoracoscopic Aortopexy for Severe Tracheomalacia in Infants After Esophageal Atresia and Tracheo-esophageal Fistula Repair

Journal of Laparoendoscopic & Advanced Surgical Techniques, 2014

Aortopexy is the most effective treatment for severe tracheomalacia associated with esophageal at... more Aortopexy is the most effective treatment for severe tracheomalacia associated with esophageal atresia with distal tracheo-esophageal fistula (EA/TOF). In the last few years, the thoracoscopic approach has been proposed, but the number of patients treated is limited. The purpose of this study is to review our initial experience with thoracoscopic aortopexy. A retrospective review of medical records was performed on EA/TOF patients undergoing thoracoscopic aortopexy at the Great Ormond Street Hospital for Sick Children (London, United Kingdom) from January 2009 to May 2012. Patient demographics, indication, perioperative course, and long-term results when available were noted. Four patients underwent a successful thoracoscopic aortopexy, with no operation being converted. No morbidity or mortality was associated with the procedure. Length of postoperative stay ranged from 2 to 4 days. All patients were relieved of their symptoms, and no recurrence was noted. Thoracoscopic aortopexy is a feasible and successful treatment for severe tracheomalacia in EA/TOF patients. The complication rate may be lower than after the open procedure and is more satisfactory in terms of cosmetic appearance. However, we need a larger and prospective study with a longer follow-up to confirm these preliminary results.

Research paper thumbnail of The role of parenteral nutrition following surgery for duodenal atresia or stenosis

Pediatric Surgery International, 2013

Purpose In our institution, some children routinely receive parenteral nutrition (PN) following s... more Purpose In our institution, some children routinely receive parenteral nutrition (PN) following surgery for duodenal atresia/stenosis, while others do not. Our aim was to compare growth and infection rate between these two treatment strategies. Methods This was a retrospective study of all children undergoing surgery for duodenal atresia/stenosis over 7 years. Results Of the 54 children, 19 commenced PN soon after surgery (the 'Initial PN' group). Of the remaining 35 children, 13 (37 %) subsequently required PN (the 'Delayed PN' group). The remaining 22 never received PN (the 'Never PN' group). The proportion of patients experiencing clinically suspected sepsis was higher in those receiving PN ('Initial' plus 'Delayed'; 41 %) compared with those who never received PN (14 %; p = 0.04). The 'Initial PN' and 'Never PN' groups did not show a significant change in weight Z score over time. However, the 'Delayed PN' group showed a significant decrease in weight Z scores from the time of operation to the time of achieving full enteral feeds, and failed to catch up by the time of last follow-up. Conclusion Children with duodenal atresia/stenosis can be managed without PN. However, a third of these children subsequently require PN, lose weight centiles, and have a high rate of sepsis.

Research paper thumbnail of High prevalence of gastroesophageal reflux in children after lung transplantation

Pediatric Pulmonology, 2005

Bronchiolitis obliterans and its clinical correlate bronchiolitis obliterans syndrome (BOS) are a... more Bronchiolitis obliterans and its clinical correlate bronchiolitis obliterans syndrome (BOS) are a major cause of morbidity and mortality following lung transplantation. Gastroesophageal reflux disease (GERD) may be a contributing factor for the development of BOS. Since 2002, all recipients of lung and heart-lung transplantation at our institution have been routinely investigated for GERD. In this observational study, we report on the prevalence of GERD in this population, including all pediatric patients undergoing single (SLTx) or double (DLTx) lung transplantation or heart-lung (HLTx) transplantation from January 2003-May 2004. GERD was assessed 3-6 months after transplantation by 24-hr pH testing. The fraction time (Ft) with a pH &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 4 within a 24-hr period was recorded. Spirometry data, episodes of confirmed acute rejection, and demographic data were also collected. Ten transplant operations were performed: 4 DLTx, 1 SLTx, and 5 HLTx. Nine patients had cystic fibrosis. One patient had end-stage pulmonary disease secondary to chronic aspiration pneumonia and postadenovirus lung damage. Of 10 patients tested, 2 had severe GERD (Ft &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; 20%), 5 had moderate GERD (Ft 10-20%), 2 had mild GERD (Ft 5-10%), and 1 had no GERD. The only patient in this group with no GERD had a Nissen fundoplication pretransplant. All study patients were asymptomatic for GERD. All patients with episodes of rejection had moderate to severe GERD posttransplant. There was no association between severity of GERD and peak spirometry results posttransplant. Moderate to severe GERD is common following lung transplantation in children.

Research paper thumbnail of Effect of Laparoscopy and Laparotomy on Energy and Protein Metabolism in Children: A Randomized Controlled Trial

The Journal of Pediatrics, 2010

To compare the effects of surgery on energy and protein metabolism in children randomized to unde... more To compare the effects of surgery on energy and protein metabolism in children randomized to undergo laparoscopic and open surgery. We randomized 41 patients to open or laparoscopic Nissen fundoplication. Anesthesia and postoperative management were standardized. We recorded core temperature, respiratory gas exchange preoperatively, intraoperatively, and 4 and 24 hours postoperatively and calculated resting energy expenditure (REE). Protein breakdown was measured by using stable isotopic leucine infusion preoperatively and 4 hours postoperatively. Intraoperative core temperature and oxygen consumption increased in the laparoscopic group compared with the open group. REE decreased in the early postoperative period in the open group, but did not decrease after laparoscopy. REE at 4 hours was higher after laparoscopy. Protein breakdown also decreased in the early postoperative period; the pattern of change between open and laparoscopic groups was of borderline significance. Laparoscopy in children may alter the changes in energy metabolism observed after open surgery. These differences may be partially caused by alterations in intraoperative thermoregulation and protein breakdown during laparoscopy in children.

Research paper thumbnail of Retroperitoneoscopic adrenalectomy: An early institutional experience

Journal of Pediatric Urology, 2007

To review our initial experience with the retroperitoneoscopic approach, which is rapidly becomin... more To review our initial experience with the retroperitoneoscopic approach, which is rapidly becoming the procedure of choice for paediatric adrenalectomy. Swift access to the vascular pedicle makes this approach ideal for adrenal surgery where haemodynamic instability is a common feature. Patients were placed in a fully prone position and the locations of the 12th rib, iliac crest and paravertebral muscles were marked. A 10-mm incision was made lateral to the para-vertebral muscle, halfway between the iliac crest and costal margin. A retroperitoneal working space was created around the kidney using a homemade balloon. A 10-mm Hasson port was then inserted. A 5-mm working port was placed lateral to the tip of the 12th rib and, if necessary, a second was inserted medial to the camera port. Dissection was performed with diathermy and/or Harmonic Scalpeltrade mark and the adrenal vessels were divided between clips. The specimen was retrieved in an endopouch through the 10-mm port. Over 16 months, six adrenalectomies were performed in five patients (three boys and two girls); two right, two left and one bilateral. Median age at surgery was 8 years. Presentation was with hypertension (n=2), Cushing&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s syndrome (n=2) and abdominal pain (n=1). Median operative time was 154 min. A single-instrument port adrenalectomy was performed in three patients. Histopathological diagnosis included adrenal cyst (n=1), cystic phaeochromocytoma (n=1), adrenal cortical tumour (n=2) and central Cushing&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s disease (n=1). All were completely resected. All patients remain symptom free with a median follow up of 17 months. These cases represent our initial institutional experience with retroperitoneoscopic adrenalectomy. The senior reporting surgeons have already surmounted the general learning curve for laparoscopy, and this experience has proved vital to expand our repertoire with encouraging early results. This is our technique of choice as it provides a superior view of the adrenal gland and vessels, with good intraoperative haemodynamic stability.

Research paper thumbnail of Testicular outcome following laparoscopic second stage Fowler–Stephens orchidopexy

Journal of Pediatric Urology, 2014

To assess outcome after laparoscopic second-stage Fowler-Stephens orchidopexy (L2(nd)FSO). Retros... more To assess outcome after laparoscopic second-stage Fowler-Stephens orchidopexy (L2(nd)FSO). Retrospective review of 94 children (aged 0.75-16 years, median 2.75 years), who underwent L2(nd)FSO for 113 intra-abdominal testes between January 2000 and May 2009: 75 unilateral, 19 bilateral (11 synchronous; 8 metachronous). Follow-up (range 3 months-10.9 years, median 2.1 years) was available for 88 children (102 testes: 71 unilateral, 31 bilateral). Testicular atrophy occurred in 9 out of 102 (8.8%), including 8 out of 71 (11.3%) unilateral and 1 out of 31 (3.2%) bilateral intra-abdominal testes (multivariate analysis: p = 0.59). Testicular ascent ensued in 9 out of 102 (8.8%), comprising four (5.6%) unilateral and five (16.1%) bilateral testicles (multivariate analysis: p = 0.11). Of the 18 bilateral testes brought to the scrotum synchronously none atrophied and four (22.2%) ascended, compared to one (7.7%) atrophy and one (7.7%) ascent among the 13 testes brought to the scrotum on separate occasions (Fisher exact test: p = 0.42 and p = 0.37, respectively). Mobilization of the testis through the conjoint tendon tended towards less ascent (multivariate analysis p = 0.08) but similar atrophy (p = 0.56) compared to mobilization through the deep-ring/inguinal canal. Logistical regression analysis identified no other patient or surgical factors influencing outcome. This is the largest series of L2(nd)FSO to date. A successful outcome is recorded in 85 out of 102 (83.3%) testicles. Atrophy occurred in 8.8% and ascent in 8.8%.

Research paper thumbnail of Laparoscopic inguinal herniotomy in bladder exstrophy: A new solution to an old problem?

Journal of Pediatric Urology, 2007

Laparoscopy is now the established management for infants with inguinal hernia at our institution... more Laparoscopy is now the established management for infants with inguinal hernia at our institution. Open inguinal herniotomy in children with bladder exstrophy can be a difficult operation and is associated with a high rate of recurrence (15%). Here, we report our initial experience with laparoscopic repair of inguinal hernia in three children with bladder exstrophy. Three boys with repaired bladder exstrophy presented with inguinal hernia during follow up. The clinical presentation was bilateral in one and findings at surgery were bilateral open internal rings in two. Under general anaesthesia, pneumoperitoneum of 10 mmHg was raised with a Hasson port at the umbilicus. Two further instruments were inserted in the right and left flanks without ports. Two 4/0 Prolenetrade mark purse string sutures were placed to securely close the internal ring. The umbilicus was closed with an absorbable suture, and the skin incisions were closed with Indermil Gluetrade mark. All infants made an uneventful recovery, being discharged within 24h. There were no complications. There has been no sign of recurrence during a mean follow up of 16 months. Laparoscopic inguinal herniotomy is a technically straightforward and effective way to treat inguinal hernias in children with bladder exstrophy.

Research paper thumbnail of Information on the World Wide Web—how useful is it for parents?

Journal of Pediatric Surgery, 2007

Aim: An enormous amount of information about pediatric surgical conditions is available on the Wo... more Aim: An enormous amount of information about pediatric surgical conditions is available on the World Wide Web (www). Our aim was to ascertain how many parents accessed the www and how useful they found the exercise. Method: Over a 2-month period, all parents attending the surgical outpatient clinics were asked to complete a questionnaire regarding Internet use in seeking more information about their child's condition. Parents were able to tick more than one option to the questions. Results: A total of 271 questionnaires were collected and analyzed. There were 53% of responders who had accessed the www. Of this group, 93% used a computer at home, with 60% using the Internet daily. The most popular search engine used was Google (75%). There were 90% who used their child's condition as keyword(s), with 21% using their child's symptoms. The most popular information sought is as follows:

Research paper thumbnail of Gastrostomy insertion in children: percutaneous endoscopic or percutaneous image-guided?

Journal of Pediatric Surgery, 2010

Background/Purpose: Gastrostomy insertion in children can be performed in many ways, but which is... more Background/Purpose: 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). Methods: 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. Results: 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. Conclusion: Major complications were rare and observed more frequently after IG. Minor complications were observed in both procedures but were significantly less common in PEG.

Research paper thumbnail of Attitudes to consent—a national survey

Journal of Pediatric Surgery, 2006

Purpose: The medicolegal case of Chester v Afshar (October 2004) raises important questions with ... more Purpose: The medicolegal case of Chester v Afshar (October 2004) raises important questions with regard to the consent process in medicine and surgery. If consent has to involve disclosure of all serious risks, regardless of frequency, how does a surgeon ensure the thoroughness of the consent procedure and minimise the risk of such litigation? Procedure-specific consent forms (PSCFs) -detailing all serious risks -are a possible solution. The aim of our study was to establish the frequency of the use of such consent forms throughout the UK. Methods: A postal questionnaire of UK consultant British Association of Pediatric Surgery (BAPS) members was conducted. Members were asked if they used PSCFs for 4 commonly performed procedures in paediatric surgery: central venous access, inguinal herniotomy, orchidopexy, and pyloromyotomy. Results: The response rate was 89% (108/122). We obtained at least one response from every centre involved in paediatric surgery (38/38) in the UK. Seventy-nine percent (85/108) of respondents do not use PSCFs, 19% (21/108) do use PSCFs, and 2% (2/108) forms were returned blank. Thirty-one percent (33/108) of respondents included comments regarding PSCFs. Conclusion: A medical negligence claim will succeed if the practitioner owes the patient a duty of care, there has been a breach of this duty, and that the breach caused a loss (causation). Our duty to the patient may now need to include disclosure of all risk regardless of frequency. PSCFs allow accurate and reproducible information for families about procedures. PSCFs currently have a low uptake amongst paediatric surgeons in the UK. The use of PSCFs for 4 procedures is currently under trial in our unit. It remains to be seen whether the success of further claims leads to an increase in their use nationally. D

Research paper thumbnail of Persistent ascites can be effectively treated by peritoneovenous shunts

Journal of Pediatric Surgery, 2011

Aim: The aim the study was to review our experience and determine the effectiveness of peritoneov... more Aim: The aim the study was to review our experience and determine the effectiveness of peritoneovenous shunts in the management of persistent ascites. Methods: A retrospective review of all patients who had a peritoneovenous shunt inserted for persistent ascites in our institution over 32 years was performed. Results: Thirty-one peritoneovenous shunts were inserted into 25 patients. Records from 22 were available. Median age was 34 months (range, 1 month-12 years), with median duration of ascites of 1.75 months (range, 3 weeks-2.5 years). Sixteen had previous abdominal surgery, whereas one had previous thoracic surgery. Other underlying pathologies included hepatitis (n = 2), lymphohistiocytosis, lymphatic hypoplasia, and carcinomatosis. One was regarded as idiopathic. Previous management consisted of paracentesis (n = 15), dietary modification (n = 11), diuretics (n = 9), and total parenteral nutrition (TPN) (n = 4). One underwent fetal drainage of ascites.

Research paper thumbnail of Outcomes of diverting jejunostomy for severe necrotizing enterocolitis

Journal of Pediatric Surgery, 2011

Background/Purpose: A diverting jejunostomy without bowel resection is an option for surgical man... more Background/Purpose: 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. Methods: 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). Results: 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. Conclusions: 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.

Research paper thumbnail of Decreased cerebral oxygen saturation during thoracoscopic repair of congenital diaphragmatic hernia and esophageal atresia in infants

Journal of Pediatric Surgery, 2011

Background/Purpose: Congenital diaphragmatic hernia (CDH) and esophageal atresia with tracheoesop... more Background/Purpose: 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. Methods: 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. Results: 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. Conclusions: 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.

Research paper thumbnail of Paediatric laparoscopic Heller’s cardiomyotomy: A single centre series

Journal of Pediatric Surgery, 2014

The optimal management of oesophageal achalasia remains unclear in the paediatric population due ... more The optimal management of oesophageal achalasia remains unclear in the paediatric population due to the rarity of the disease. This study reviews the institutional experience of the laparoscopic Heller&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s cardiomyotomy (HC) procedure and attempts to define the most appropriate treatment. A retrospective review of children undergoing HC at a single institution was performed. Demographics, pre-operative investigations, and interventions were reviewed. Post-operative outcomes and follow up were evaluated. Data is expressed as median (range). Twenty-eight children were included (13 male, 15 female) whose median age was 13 (3.2-17.4) years. Nine children underwent a pre-operative oesophageal balloon dilatation (OBD) a median of 1(1-6) times. Others included botulinum toxin injection (n=1) and Nifedipine (n=1). All had a pre-operative upper gastrointestinal contrast series, and twenty-five had upper gastrointestinal endoscopy and manometry. All had laparoscopic HC with no conversions, and ten had a concomitant fundoplication. Post-operative intervention occurred in eight (28%) incorporating OBD (n=7), of whom four required a redo HC. One patient underwent a redo without intervening OBD. Follow-up was for a median of 0.83 (0-5) years with fourteen children discharged from surgical follow-up. Twenty-seven have thus far had a good outcome. This study comprises the largest series of paediatric laparoscopic HC reported to date. It is effective with or without a fundoplication and is the best long term treatment modality available. OBD for persisting symptoms following HC may obviate the need for redo myotomy.

Research paper thumbnail of Successful Treatment of Extensive Infantile Hemangiomatosis of the Small Bowel in a 3-month-old With Thalidomide and Somatostatin Analog

Journal of Pediatric Gastroenterology and Nutrition, 2008

Research paper thumbnail of Pediatric Laparoscopic-Assisted Gastric Transposition: Early Experience and Outcomes

Journal of Laparoendoscopic & Advanced Surgical Techniques, 2010

astric transposition in children is a well-established treatment for long-gap esophageal atresia ... more astric transposition in children is a well-established treatment for long-gap esophageal atresia and long caustic strictures when preservation of the native esophagus is impossible, but does involve laparotomy and, often, thoracotomy incisions. The minimally invasive approach to this operation has been attempted in 7 patients to date in the UK, all at Great Ormond Street Hospital (London, UK). Four patients were male, 3 were female, with a mean age of 3 years and 7 months (range, 5 months to 13 years). Indications were long-gap esophageal atresia where primary anastomosis was impossible (5 patients) and caustic ingestion with long esophageal strictures (2 patients). The stomach was mobilized laparoscopically by using 5-mm instruments and a pneumoperitoneum of 10 mm Hg. Following pyloromyotomy or pyloroplasty, a tunnel in the posterior mediastinum was developed. The fundus of the stomach was drawn to the neck and sutured to the cervical esophagus. The patients were ventilated on our intensive care unit and then returned to the surgical ward before discharge. Gastric transposition was completed laparoscopically in 6 of 7 patients. The mean duration of surgery was 327 minutes (range, 240-455). All patients survived. Minor complications were pneumonia (2), pleural effusion (1), and hiatus hernia (2). The mean hospital stay was 16 days (range, 8-36). Our preliminary experience would suggest that laparoscopic gastric transposition is a safe alternative to open surgery with satisfactory results.

Research paper thumbnail of Laparoscopic Finding of Chylous Ascites and Intestinal Malrotation in an Infant Presenting with Left Inguinal Hernia

Journal of Laparoendoscopic & Advanced Surgical Techniques, 2008

This case report illustrates an unexpected advantage of using the laparoscopic approach for ingui... more This case report illustrates an unexpected advantage of using the laparoscopic approach for inguinal hernia repair in infants. In this paper, we report an infant referred to us with a diagnosis of an irreducible left inguinal hernia. He presented with a 1-day history of bilious vomiting and poor weight gain on breastfeeding. On arrival, a reducible left inguinal hernia was found and he was scheduled to have a laparoscopic inguinal hernia repair. During laparoscopy, chylous ascites was noted and the transverse colon and appendix could not be visualized. This raised the suspicion of malrotation with obstruction, which was confirmed on an upper gastrointestinal contrast study. He was taken back to the operating theater and a malrotation with volvulus was confirmed at laparotomy. A Ladd&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s procedure was performed, and he made an uneventful recovery.

Research paper thumbnail of Thoracoscopic Repair of Congenital Diaphragmatic Hernia in Neonates: Lessons Learned

Journal of Laparoendoscopic & Advanced Surgical Techniques, 2009

Introduction: Thoracoscopic repair of congenital diaphragmatic hernia (CDH) has been described, b... more Introduction: 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. Methods: 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)(2004)(2005)(2006)(2007)(2008) or thoracoscopy (2007)(2008). Data were compared by t test or Mann-Whitney tests. Results: 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). Conclusion: 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.

Research paper thumbnail of Regarding: Efficacy of Periportal Infiltration and Intraperitoneal Instillation of Ropivacaine After Laparoscopic Surgery in Children

Journal of Laparoendoscopic & Advanced Surgical Techniques, 2009

... KB) • PDF w/ links (44.2 KB). Erica Makin, MB ChB, MSc, FRCS (Paed Surg),. Kate Cross, BMed .... more ... KB) • PDF w/ links (44.2 KB). Erica Makin, MB ChB, MSc, FRCS (Paed Surg),. Kate Cross, BMed ... 3. Howard R, Carter B, Curry J, Morton N, Rivett K, Rose M, Tyrrell J, Walker ... Cutaneous Adenoid Cystic Carcinoma: A Case Report. Yumin Xia, Shizheng Xu, Xiaoming Liu, Aaron C.-H ...

Research paper thumbnail of Esophageal Atresia: Improved Outcome in High-Risk Groups Revisited

European journal of pediatric surgery : official journal of Austrian Association of Pediatric Surgery ... [et al] = Zeitschrift fur Kinderchirurgie, Jan 16, 2015

Objectives Improved survival in infants with esophageal atresia (EA) with a birth weight < 1,5... more Objectives Improved survival in infants with esophageal atresia (EA) with a birth weight < 1,500 g or a major cardiac anomaly has been reported when compared with the original Spitz classification proposed in 1994. Aim We reviewed outcome data for infants born over the last decade in our institution to update previously reported survival statistics. Materials and Methods The records of all neonates (n = 200) with a diagnosis of EA managed in a single institution between 2001 and 2011 were reviewed and compared with data from the original Spitz study and the subsequent reported cohort from the same institution. Data were obtained on birth weight, presence of a major cardiac anomaly, and survival. Differences in survival were compared using the Yates-corrected chi-square test. Local ethical study approval was obtained. Results Infants born over the last decade had a comparable overall survival rate of 93% (186/200) versus 92.6% (174/188) in the previously reported cohort (1993-2004...

Research paper thumbnail of Early Experience of Thoracoscopic Aortopexy for Severe Tracheomalacia in Infants After Esophageal Atresia and Tracheo-esophageal Fistula Repair

Journal of Laparoendoscopic & Advanced Surgical Techniques, 2014

Aortopexy is the most effective treatment for severe tracheomalacia associated with esophageal at... more Aortopexy is the most effective treatment for severe tracheomalacia associated with esophageal atresia with distal tracheo-esophageal fistula (EA/TOF). In the last few years, the thoracoscopic approach has been proposed, but the number of patients treated is limited. The purpose of this study is to review our initial experience with thoracoscopic aortopexy. A retrospective review of medical records was performed on EA/TOF patients undergoing thoracoscopic aortopexy at the Great Ormond Street Hospital for Sick Children (London, United Kingdom) from January 2009 to May 2012. Patient demographics, indication, perioperative course, and long-term results when available were noted. Four patients underwent a successful thoracoscopic aortopexy, with no operation being converted. No morbidity or mortality was associated with the procedure. Length of postoperative stay ranged from 2 to 4 days. All patients were relieved of their symptoms, and no recurrence was noted. Thoracoscopic aortopexy is a feasible and successful treatment for severe tracheomalacia in EA/TOF patients. The complication rate may be lower than after the open procedure and is more satisfactory in terms of cosmetic appearance. However, we need a larger and prospective study with a longer follow-up to confirm these preliminary results.

Research paper thumbnail of The role of parenteral nutrition following surgery for duodenal atresia or stenosis

Pediatric Surgery International, 2013

Purpose In our institution, some children routinely receive parenteral nutrition (PN) following s... more Purpose In our institution, some children routinely receive parenteral nutrition (PN) following surgery for duodenal atresia/stenosis, while others do not. Our aim was to compare growth and infection rate between these two treatment strategies. Methods This was a retrospective study of all children undergoing surgery for duodenal atresia/stenosis over 7 years. Results Of the 54 children, 19 commenced PN soon after surgery (the 'Initial PN' group). Of the remaining 35 children, 13 (37 %) subsequently required PN (the 'Delayed PN' group). The remaining 22 never received PN (the 'Never PN' group). The proportion of patients experiencing clinically suspected sepsis was higher in those receiving PN ('Initial' plus 'Delayed'; 41 %) compared with those who never received PN (14 %; p = 0.04). The 'Initial PN' and 'Never PN' groups did not show a significant change in weight Z score over time. However, the 'Delayed PN' group showed a significant decrease in weight Z scores from the time of operation to the time of achieving full enteral feeds, and failed to catch up by the time of last follow-up. Conclusion Children with duodenal atresia/stenosis can be managed without PN. However, a third of these children subsequently require PN, lose weight centiles, and have a high rate of sepsis.

Research paper thumbnail of High prevalence of gastroesophageal reflux in children after lung transplantation

Pediatric Pulmonology, 2005

Bronchiolitis obliterans and its clinical correlate bronchiolitis obliterans syndrome (BOS) are a... more Bronchiolitis obliterans and its clinical correlate bronchiolitis obliterans syndrome (BOS) are a major cause of morbidity and mortality following lung transplantation. Gastroesophageal reflux disease (GERD) may be a contributing factor for the development of BOS. Since 2002, all recipients of lung and heart-lung transplantation at our institution have been routinely investigated for GERD. In this observational study, we report on the prevalence of GERD in this population, including all pediatric patients undergoing single (SLTx) or double (DLTx) lung transplantation or heart-lung (HLTx) transplantation from January 2003-May 2004. GERD was assessed 3-6 months after transplantation by 24-hr pH testing. The fraction time (Ft) with a pH &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 4 within a 24-hr period was recorded. Spirometry data, episodes of confirmed acute rejection, and demographic data were also collected. Ten transplant operations were performed: 4 DLTx, 1 SLTx, and 5 HLTx. Nine patients had cystic fibrosis. One patient had end-stage pulmonary disease secondary to chronic aspiration pneumonia and postadenovirus lung damage. Of 10 patients tested, 2 had severe GERD (Ft &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt; 20%), 5 had moderate GERD (Ft 10-20%), 2 had mild GERD (Ft 5-10%), and 1 had no GERD. The only patient in this group with no GERD had a Nissen fundoplication pretransplant. All study patients were asymptomatic for GERD. All patients with episodes of rejection had moderate to severe GERD posttransplant. There was no association between severity of GERD and peak spirometry results posttransplant. Moderate to severe GERD is common following lung transplantation in children.

Research paper thumbnail of Effect of Laparoscopy and Laparotomy on Energy and Protein Metabolism in Children: A Randomized Controlled Trial

The Journal of Pediatrics, 2010

To compare the effects of surgery on energy and protein metabolism in children randomized to unde... more To compare the effects of surgery on energy and protein metabolism in children randomized to undergo laparoscopic and open surgery. We randomized 41 patients to open or laparoscopic Nissen fundoplication. Anesthesia and postoperative management were standardized. We recorded core temperature, respiratory gas exchange preoperatively, intraoperatively, and 4 and 24 hours postoperatively and calculated resting energy expenditure (REE). Protein breakdown was measured by using stable isotopic leucine infusion preoperatively and 4 hours postoperatively. Intraoperative core temperature and oxygen consumption increased in the laparoscopic group compared with the open group. REE decreased in the early postoperative period in the open group, but did not decrease after laparoscopy. REE at 4 hours was higher after laparoscopy. Protein breakdown also decreased in the early postoperative period; the pattern of change between open and laparoscopic groups was of borderline significance. Laparoscopy in children may alter the changes in energy metabolism observed after open surgery. These differences may be partially caused by alterations in intraoperative thermoregulation and protein breakdown during laparoscopy in children.

Research paper thumbnail of Retroperitoneoscopic adrenalectomy: An early institutional experience

Journal of Pediatric Urology, 2007

To review our initial experience with the retroperitoneoscopic approach, which is rapidly becomin... more To review our initial experience with the retroperitoneoscopic approach, which is rapidly becoming the procedure of choice for paediatric adrenalectomy. Swift access to the vascular pedicle makes this approach ideal for adrenal surgery where haemodynamic instability is a common feature. Patients were placed in a fully prone position and the locations of the 12th rib, iliac crest and paravertebral muscles were marked. A 10-mm incision was made lateral to the para-vertebral muscle, halfway between the iliac crest and costal margin. A retroperitoneal working space was created around the kidney using a homemade balloon. A 10-mm Hasson port was then inserted. A 5-mm working port was placed lateral to the tip of the 12th rib and, if necessary, a second was inserted medial to the camera port. Dissection was performed with diathermy and/or Harmonic Scalpeltrade mark and the adrenal vessels were divided between clips. The specimen was retrieved in an endopouch through the 10-mm port. Over 16 months, six adrenalectomies were performed in five patients (three boys and two girls); two right, two left and one bilateral. Median age at surgery was 8 years. Presentation was with hypertension (n=2), Cushing&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s syndrome (n=2) and abdominal pain (n=1). Median operative time was 154 min. A single-instrument port adrenalectomy was performed in three patients. Histopathological diagnosis included adrenal cyst (n=1), cystic phaeochromocytoma (n=1), adrenal cortical tumour (n=2) and central Cushing&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s disease (n=1). All were completely resected. All patients remain symptom free with a median follow up of 17 months. These cases represent our initial institutional experience with retroperitoneoscopic adrenalectomy. The senior reporting surgeons have already surmounted the general learning curve for laparoscopy, and this experience has proved vital to expand our repertoire with encouraging early results. This is our technique of choice as it provides a superior view of the adrenal gland and vessels, with good intraoperative haemodynamic stability.

Research paper thumbnail of Testicular outcome following laparoscopic second stage Fowler–Stephens orchidopexy

Journal of Pediatric Urology, 2014

To assess outcome after laparoscopic second-stage Fowler-Stephens orchidopexy (L2(nd)FSO). Retros... more To assess outcome after laparoscopic second-stage Fowler-Stephens orchidopexy (L2(nd)FSO). Retrospective review of 94 children (aged 0.75-16 years, median 2.75 years), who underwent L2(nd)FSO for 113 intra-abdominal testes between January 2000 and May 2009: 75 unilateral, 19 bilateral (11 synchronous; 8 metachronous). Follow-up (range 3 months-10.9 years, median 2.1 years) was available for 88 children (102 testes: 71 unilateral, 31 bilateral). Testicular atrophy occurred in 9 out of 102 (8.8%), including 8 out of 71 (11.3%) unilateral and 1 out of 31 (3.2%) bilateral intra-abdominal testes (multivariate analysis: p = 0.59). Testicular ascent ensued in 9 out of 102 (8.8%), comprising four (5.6%) unilateral and five (16.1%) bilateral testicles (multivariate analysis: p = 0.11). Of the 18 bilateral testes brought to the scrotum synchronously none atrophied and four (22.2%) ascended, compared to one (7.7%) atrophy and one (7.7%) ascent among the 13 testes brought to the scrotum on separate occasions (Fisher exact test: p = 0.42 and p = 0.37, respectively). Mobilization of the testis through the conjoint tendon tended towards less ascent (multivariate analysis p = 0.08) but similar atrophy (p = 0.56) compared to mobilization through the deep-ring/inguinal canal. Logistical regression analysis identified no other patient or surgical factors influencing outcome. This is the largest series of L2(nd)FSO to date. A successful outcome is recorded in 85 out of 102 (83.3%) testicles. Atrophy occurred in 8.8% and ascent in 8.8%.

Research paper thumbnail of Laparoscopic inguinal herniotomy in bladder exstrophy: A new solution to an old problem?

Journal of Pediatric Urology, 2007

Laparoscopy is now the established management for infants with inguinal hernia at our institution... more Laparoscopy is now the established management for infants with inguinal hernia at our institution. Open inguinal herniotomy in children with bladder exstrophy can be a difficult operation and is associated with a high rate of recurrence (15%). Here, we report our initial experience with laparoscopic repair of inguinal hernia in three children with bladder exstrophy. Three boys with repaired bladder exstrophy presented with inguinal hernia during follow up. The clinical presentation was bilateral in one and findings at surgery were bilateral open internal rings in two. Under general anaesthesia, pneumoperitoneum of 10 mmHg was raised with a Hasson port at the umbilicus. Two further instruments were inserted in the right and left flanks without ports. Two 4/0 Prolenetrade mark purse string sutures were placed to securely close the internal ring. The umbilicus was closed with an absorbable suture, and the skin incisions were closed with Indermil Gluetrade mark. All infants made an uneventful recovery, being discharged within 24h. There were no complications. There has been no sign of recurrence during a mean follow up of 16 months. Laparoscopic inguinal herniotomy is a technically straightforward and effective way to treat inguinal hernias in children with bladder exstrophy.

Research paper thumbnail of Information on the World Wide Web—how useful is it for parents?

Journal of Pediatric Surgery, 2007

Aim: An enormous amount of information about pediatric surgical conditions is available on the Wo... more Aim: An enormous amount of information about pediatric surgical conditions is available on the World Wide Web (www). Our aim was to ascertain how many parents accessed the www and how useful they found the exercise. Method: Over a 2-month period, all parents attending the surgical outpatient clinics were asked to complete a questionnaire regarding Internet use in seeking more information about their child's condition. Parents were able to tick more than one option to the questions. Results: A total of 271 questionnaires were collected and analyzed. There were 53% of responders who had accessed the www. Of this group, 93% used a computer at home, with 60% using the Internet daily. The most popular search engine used was Google (75%). There were 90% who used their child's condition as keyword(s), with 21% using their child's symptoms. The most popular information sought is as follows:

Research paper thumbnail of Gastrostomy insertion in children: percutaneous endoscopic or percutaneous image-guided?

Journal of Pediatric Surgery, 2010

Background/Purpose: Gastrostomy insertion in children can be performed in many ways, but which is... more Background/Purpose: 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). Methods: 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. Results: 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. Conclusion: Major complications were rare and observed more frequently after IG. Minor complications were observed in both procedures but were significantly less common in PEG.

Research paper thumbnail of Attitudes to consent—a national survey

Journal of Pediatric Surgery, 2006

Purpose: The medicolegal case of Chester v Afshar (October 2004) raises important questions with ... more Purpose: The medicolegal case of Chester v Afshar (October 2004) raises important questions with regard to the consent process in medicine and surgery. If consent has to involve disclosure of all serious risks, regardless of frequency, how does a surgeon ensure the thoroughness of the consent procedure and minimise the risk of such litigation? Procedure-specific consent forms (PSCFs) -detailing all serious risks -are a possible solution. The aim of our study was to establish the frequency of the use of such consent forms throughout the UK. Methods: A postal questionnaire of UK consultant British Association of Pediatric Surgery (BAPS) members was conducted. Members were asked if they used PSCFs for 4 commonly performed procedures in paediatric surgery: central venous access, inguinal herniotomy, orchidopexy, and pyloromyotomy. Results: The response rate was 89% (108/122). We obtained at least one response from every centre involved in paediatric surgery (38/38) in the UK. Seventy-nine percent (85/108) of respondents do not use PSCFs, 19% (21/108) do use PSCFs, and 2% (2/108) forms were returned blank. Thirty-one percent (33/108) of respondents included comments regarding PSCFs. Conclusion: A medical negligence claim will succeed if the practitioner owes the patient a duty of care, there has been a breach of this duty, and that the breach caused a loss (causation). Our duty to the patient may now need to include disclosure of all risk regardless of frequency. PSCFs allow accurate and reproducible information for families about procedures. PSCFs currently have a low uptake amongst paediatric surgeons in the UK. The use of PSCFs for 4 procedures is currently under trial in our unit. It remains to be seen whether the success of further claims leads to an increase in their use nationally. D

Research paper thumbnail of Persistent ascites can be effectively treated by peritoneovenous shunts

Journal of Pediatric Surgery, 2011

Aim: The aim the study was to review our experience and determine the effectiveness of peritoneov... more Aim: The aim the study was to review our experience and determine the effectiveness of peritoneovenous shunts in the management of persistent ascites. Methods: A retrospective review of all patients who had a peritoneovenous shunt inserted for persistent ascites in our institution over 32 years was performed. Results: Thirty-one peritoneovenous shunts were inserted into 25 patients. Records from 22 were available. Median age was 34 months (range, 1 month-12 years), with median duration of ascites of 1.75 months (range, 3 weeks-2.5 years). Sixteen had previous abdominal surgery, whereas one had previous thoracic surgery. Other underlying pathologies included hepatitis (n = 2), lymphohistiocytosis, lymphatic hypoplasia, and carcinomatosis. One was regarded as idiopathic. Previous management consisted of paracentesis (n = 15), dietary modification (n = 11), diuretics (n = 9), and total parenteral nutrition (TPN) (n = 4). One underwent fetal drainage of ascites.

Research paper thumbnail of Outcomes of diverting jejunostomy for severe necrotizing enterocolitis

Journal of Pediatric Surgery, 2011

Background/Purpose: A diverting jejunostomy without bowel resection is an option for surgical man... more Background/Purpose: 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. Methods: 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). Results: 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. Conclusions: 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.

Research paper thumbnail of Decreased cerebral oxygen saturation during thoracoscopic repair of congenital diaphragmatic hernia and esophageal atresia in infants

Journal of Pediatric Surgery, 2011

Background/Purpose: Congenital diaphragmatic hernia (CDH) and esophageal atresia with tracheoesop... more Background/Purpose: 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. Methods: 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. Results: 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. Conclusions: 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.

Research paper thumbnail of Paediatric laparoscopic Heller’s cardiomyotomy: A single centre series

Journal of Pediatric Surgery, 2014

The optimal management of oesophageal achalasia remains unclear in the paediatric population due ... more The optimal management of oesophageal achalasia remains unclear in the paediatric population due to the rarity of the disease. This study reviews the institutional experience of the laparoscopic Heller&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s cardiomyotomy (HC) procedure and attempts to define the most appropriate treatment. A retrospective review of children undergoing HC at a single institution was performed. Demographics, pre-operative investigations, and interventions were reviewed. Post-operative outcomes and follow up were evaluated. Data is expressed as median (range). Twenty-eight children were included (13 male, 15 female) whose median age was 13 (3.2-17.4) years. Nine children underwent a pre-operative oesophageal balloon dilatation (OBD) a median of 1(1-6) times. Others included botulinum toxin injection (n=1) and Nifedipine (n=1). All had a pre-operative upper gastrointestinal contrast series, and twenty-five had upper gastrointestinal endoscopy and manometry. All had laparoscopic HC with no conversions, and ten had a concomitant fundoplication. Post-operative intervention occurred in eight (28%) incorporating OBD (n=7), of whom four required a redo HC. One patient underwent a redo without intervening OBD. Follow-up was for a median of 0.83 (0-5) years with fourteen children discharged from surgical follow-up. Twenty-seven have thus far had a good outcome. This study comprises the largest series of paediatric laparoscopic HC reported to date. It is effective with or without a fundoplication and is the best long term treatment modality available. OBD for persisting symptoms following HC may obviate the need for redo myotomy.

Research paper thumbnail of Successful Treatment of Extensive Infantile Hemangiomatosis of the Small Bowel in a 3-month-old With Thalidomide and Somatostatin Analog

Journal of Pediatric Gastroenterology and Nutrition, 2008

Research paper thumbnail of Pediatric Laparoscopic-Assisted Gastric Transposition: Early Experience and Outcomes

Journal of Laparoendoscopic & Advanced Surgical Techniques, 2010

astric transposition in children is a well-established treatment for long-gap esophageal atresia ... more astric transposition in children is a well-established treatment for long-gap esophageal atresia and long caustic strictures when preservation of the native esophagus is impossible, but does involve laparotomy and, often, thoracotomy incisions. The minimally invasive approach to this operation has been attempted in 7 patients to date in the UK, all at Great Ormond Street Hospital (London, UK). Four patients were male, 3 were female, with a mean age of 3 years and 7 months (range, 5 months to 13 years). Indications were long-gap esophageal atresia where primary anastomosis was impossible (5 patients) and caustic ingestion with long esophageal strictures (2 patients). The stomach was mobilized laparoscopically by using 5-mm instruments and a pneumoperitoneum of 10 mm Hg. Following pyloromyotomy or pyloroplasty, a tunnel in the posterior mediastinum was developed. The fundus of the stomach was drawn to the neck and sutured to the cervical esophagus. The patients were ventilated on our intensive care unit and then returned to the surgical ward before discharge. Gastric transposition was completed laparoscopically in 6 of 7 patients. The mean duration of surgery was 327 minutes (range, 240-455). All patients survived. Minor complications were pneumonia (2), pleural effusion (1), and hiatus hernia (2). The mean hospital stay was 16 days (range, 8-36). Our preliminary experience would suggest that laparoscopic gastric transposition is a safe alternative to open surgery with satisfactory results.

Research paper thumbnail of Laparoscopic Finding of Chylous Ascites and Intestinal Malrotation in an Infant Presenting with Left Inguinal Hernia

Journal of Laparoendoscopic & Advanced Surgical Techniques, 2008

This case report illustrates an unexpected advantage of using the laparoscopic approach for ingui... more This case report illustrates an unexpected advantage of using the laparoscopic approach for inguinal hernia repair in infants. In this paper, we report an infant referred to us with a diagnosis of an irreducible left inguinal hernia. He presented with a 1-day history of bilious vomiting and poor weight gain on breastfeeding. On arrival, a reducible left inguinal hernia was found and he was scheduled to have a laparoscopic inguinal hernia repair. During laparoscopy, chylous ascites was noted and the transverse colon and appendix could not be visualized. This raised the suspicion of malrotation with obstruction, which was confirmed on an upper gastrointestinal contrast study. He was taken back to the operating theater and a malrotation with volvulus was confirmed at laparotomy. A Ladd&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s procedure was performed, and he made an uneventful recovery.

Research paper thumbnail of Thoracoscopic Repair of Congenital Diaphragmatic Hernia in Neonates: Lessons Learned

Journal of Laparoendoscopic & Advanced Surgical Techniques, 2009

Introduction: Thoracoscopic repair of congenital diaphragmatic hernia (CDH) has been described, b... more Introduction: 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. Methods: 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)(2004)(2005)(2006)(2007)(2008) or thoracoscopy (2007)(2008). Data were compared by t test or Mann-Whitney tests. Results: 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). Conclusion: 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.

Research paper thumbnail of Regarding: Efficacy of Periportal Infiltration and Intraperitoneal Instillation of Ropivacaine After Laparoscopic Surgery in Children

Journal of Laparoendoscopic & Advanced Surgical Techniques, 2009

... KB) • PDF w/ links (44.2 KB). Erica Makin, MB ChB, MSc, FRCS (Paed Surg),. Kate Cross, BMed .... more ... KB) • PDF w/ links (44.2 KB). Erica Makin, MB ChB, MSc, FRCS (Paed Surg),. Kate Cross, BMed ... 3. Howard R, Carter B, Curry J, Morton N, Rivett K, Rose M, Tyrrell J, Walker ... Cutaneous Adenoid Cystic Carcinoma: A Case Report. Yumin Xia, Shizheng Xu, Xiaoming Liu, Aaron C.-H ...