Circumcision is one of the most commonly performed surgical procedures. A large variety of techni... more Circumcision is one of the most commonly performed surgical procedures. A large variety of techniques have been used, but unfortunately, complications such as pain, bleeding, swelling, stitch granuloma, scab formation, and removal of improper proportions of skin/mucous membrane occur in significant numbers. The authors present a technique using the carbon dioxide laser to excise the prepuce and weld the cut edges together, thus providing a completely bloodless operation. Suturing is optional as the laser can also be used to unite the cut edges. The technique allows exact proportions of skin and mucous membrane to be removed. This method has been used in a total of 1,154 patients ranging in age from infancy to 10 years. A detailed analysis of postoperative recovery and follow-up indicates that minor complications occurred in only 4 patients, none of whom required hospital admission.
Hematuria is not uncommonly seen among children. We describe the case of a 13-year-old boy who wa... more Hematuria is not uncommonly seen among children. We describe the case of a 13-year-old boy who was diagnosed with urothelial carcinoma after presenting with persistent gross hematuria for 2 weeks. We highlight the importance of adequate workup for gross hematuria as it is often associated with an underlying pathology that could lead to significant morbidity if left undiagnosed.
Journal of Laparoendoscopic & Advanced Surgical Techniques, Aug 1, 2007
In this paper, we report a case of bleeding solitary jejunal Dieulafoy pseudopolyp that was detec... more In this paper, we report a case of bleeding solitary jejunal Dieulafoy pseudopolyp that was detected on capsule endoscopy and treated with a laparoscopic-assisted transumbilical polypectomy procedure. This case illustrates an innovative, tailored application of minimal invasive techniques in the management of a relatively uncommon lesion. To our knowledge, this is the first case report of the combination of capsule endoscopy and laparoscopic-assisted transumbilical resection for a bleeding jejunal Dieulafoy pseudopolyp in children.
Introduction: Herlyn-Werner-Wunderlich syndrome (HWWS) is a rare variant of Mullerian ductal anom... more Introduction: Herlyn-Werner-Wunderlich syndrome (HWWS) is a rare variant of Mullerian ductal anomaly associated with ipsilateral renal agenesis. Most patients are diagnosed after menarche with complications of uterovaginal obstruction, genitourinary infection and pelvic adhesions. Patients often undergo additional operations for misdiagnosis or treatment of complications. Our institution manages several HWWS patients diagnosed before symptoms by screening for antenatally-diagnosed renal agenesis. This study aims to improve the presymptomatic management of HWWS patients. Methods: We carried out retrospective case review of patients diagnosed with HWWS from 2010 to 2017 on patient demographics, symptoms, clinical course and operative management and summarize the sparse literature published to date. Results: There were 8 patients with HWWS but only 2 symptomatic patients presented acutely with hematocolpos requiring urgent vaginal surgery. The other six patients had early diagnosis through postnatal ultrasound screening. No patient required further operation for diagnosis or complications related to obstructed hemivagina. Conclusion: Our case series and literature review show that the majority of prepubertal patients with HWWS do not require early gynecological surgery. We recommend that female babies with renal agenesis should be screened for HWWS syndrome with ultrasound. Early diagnosis and presymptomatic elective surgery may prevent urogynecological complications that cause fertility and renal impairment. Study design: Case series, level IV evidence.
Journal of Pediatric Gastroenterology and Nutrition, Dec 1, 2013
A nnular pancreas (AP) is a rare congenital anomaly consisting of a ring of pancreatic tissue par... more A nnular pancreas (AP) is a rare congenital anomaly consisting of a ring of pancreatic tissue partially or completely encircling the second part of the duodenum (1). Most cases are diagnosed in the neonatal period with symptoms of gastric outlet obstruction. We report an unusual case of AP presenting with acute upper gastrointestinal (GI) bleeding in a child. A 12-year-old boy of Malay origin presented with a 1-day history of sudden onset of hematemesis and passing malaenic stools. Before presentation, he had a 1-year history of intermittent postprandial abdominal bloatedness with mild epigastric pain and rare episode of nonbilious vomiting. He tolerated his meals well and showed normal growth along the 75th percentile for both height and weight. Physical examination revealed a pale boy with clinical evidence of hypovolemic shock. He had epigastric tenderness and per rectal examination revealed malaenic stools. The abdomen was not distended and the rest of the physical examination was normal. He required fluid resuscitation to stabilize his vital parameters and was commenced on intravenous omeprazole infusion. Empirical triple therapy for Helicobacter pylori infection comprising amoxicillin, metronidazole, and omeprazole was also started. Initial blood tests showed hemoglobin of 12.6 g/dL (normal 9–14), which dropped to 10.4 g/dL the following day, subsequent to that hemoglobin was stable. Coagulation profile, liver function test, C-reactive protein, and amylase were normal. His GI bleeding resolved within 48 hours with conservative management. Upper GI endoscopy performed on day 3 showed severe gastric erythema at the gastric antrum with a 3-mm irregularly shaped healing ulcer. The stomach antrum and the first part of duodenum (D1) were markedly dilated with stenosis at the junction of second and third part of duodenum (D2-D3). Duodenal mucosa was slightly erythematous with no ulceration (Fig. 1). Histology of the mucosa showed chronic gastritis and mild reflux esophagitis with no evidence of H pylori. The initial clinical impression was duodenal stenosis caused by extrinsic compression or a duodenal web. Magnetic resonance imaging of the abdomen was suggestive
Objective: To improve understanding of the implications of testicular microlithiasis (TM) in paed... more Objective: To improve understanding of the implications of testicular microlithiasis (TM) in paediatric patients diagnosed incidentally on scrotal ultrasonography (US). Patients and methods: 31 boys aged 4e14 years diagnosed with TM based on US between February 2000 and September 2007 were retrospectively reviewed. Demographic data, indications for US, associated inguino-scrotal pathologies and follow-up data were collated. Results: A total of 59 testes were evaluated. Fifty-four had TM at US. The most common indication for US was scrotal swelling (n Z 17). Twenty patients (65%) had at least one associated inguino-scrotal pathology related to patent processus vaginalis, with cryptorchidism being the most frequently observed (39%). On follow up (mean 39.6 months), 6 patients documented decrease or resolution of TM, while 2 showed increase in TM density. No testicular malignancy was observed during follow up. Conclusions: TM is commonly diagnosed incidentally on US in paediatric patients. A literature review revealed few case reports on its association with testicular malignancy and a prevalence of 4.2% among asymptomatic boys. The spontaneous resolution of TM supports degeneration of seminiferous tubules as the possible cause and further questions its malignant implication. An appropriate surveillance scheme would require involvement of a well-informed patient and parent with good compliance on testicular self-examination.
Background Improved survival of neonates with esophageal atresia with/without tracheoesophageal f... more Background Improved survival of neonates with esophageal atresia with/without tracheoesophageal fistula (EA/TEF) has resulted in increased prevalence of gastro-esophageal and respiratory-related morbidities. However, long-term outcome data on these patients remains limited, making it difficult to substantiate any guidelines on their chronic care. The purpose of our study is to report on their post-operative outcomes especially the long-term gastro-esophageal and respiratory morbidities. Methods This was a retrospective review of 65 patients (39 males, 26 females) who underwent EA/TEF repair from 1996 to 2019 at a single tertiary institution. Follow up data pertaining to clinical characteristics, operative management and long-term gastro-esophageal and respiratory morbidities was analyzed. Results Fifty-seven patients (87.7%) had Gross Type-C anatomy, followed by 5(7.7%) patients with Type-A, 1(1.5%) with Type-B and 1 with Type-D. One patient had a late diagnosis of H-type fistula (T...
Background Our study aimed to compare the clinical outcomes and cost-efficiency of antibiotic man... more Background Our study aimed to compare the clinical outcomes and cost-efficiency of antibiotic management versus laparoscopic appendectomy for acute uncomplicated appendicitis (AUA) in children during the COVID-19 pandemic when resources were limited and transmission risks uncertain. Method In this prospective comparative cohort study, we analyzed the data of 139 children diagnosed with AUA meeting the following inclusion criteria: 5-18 years of age, symptoms duration of ≤ 48 h, appendix diameter ≤ 11 mm and no appendicolith. Treatment outcomes between non-operative management group (78/139) and upfront laparoscopic appendectomy group (61/139) were compared. Antibiotic regimes were intravenous ceftriaxone/metronidazole or amoxicillin/clavulanic acid for 48 h, followed by oral antibiotics to complete total 10-days course. Results 8/78 (10.3%) children had early failure (within 48 h) requiring appendectomy. 17/70 (24.3%) patients experienced late recurrence within mean follow-up time of 16.2 ± 4.7 months. There were no statistical differences in peri-operative complications, negative appendicectomy rate, and incidence of perforation and hospitalization duration between antibiotic and surgical treatment groups. Cost per patient in upfront surgical group was significantly higher ($6208.5 ± 5284.0) than antibiotic group ($3588.6 ± 3829.8; p = 0.001). Conclusion Despite 24.3% risk of recurrence of appendicitis in 16.2 ± 4.7 months, antibiotic therapy for AUA appears to be a safe and cost-effective alternative to upfront appendectomy.
Background: During the Coronavirus disease 2019 (COVID-19) pandemic, a protocol was adopted by ou... more Background: During the Coronavirus disease 2019 (COVID-19) pandemic, a protocol was adopted by our department on antibiotics treatment for Acute Uncomplicated Appendicitis (AUA). Our study aimed to determine the feasibility and safety of non-operative treatment (NOT), compared to upfront laparoscopic appendectomy (LA), for AUA in children during the pandemic. Method: Our prospective comparative study was conducted from May 1, 2020 to January 31, 2021. Patient selection criteria included: age 5 years, abdominal pain duration 48 h, ultrasound (US)/Computered Tomography scan confirmation of AUA, US appendiceal diameter 6e11 mm with no features of perforation/abscess collection and no faecolith. For NOT patients, intravenous antibiotics were administered for 24e48 h followed by oral for 10-day course. Comparison was performed between patients whose parents preferred NOT to those who opted for up-front appendectomy. Primary outcomes were NOT success at index admission, early and late NOT failure rates till 27 months. Secondary outcomes were differences in complication rate, hospital length of stay (LOS) and cost between groups. Results: 77 patients were recruited: 43 (55.8%) underwent NOT while 34 (44.2%) patients opted for LA. Success of NOT at index admission was 90.7% (39/43). Overall, NOT failure rate at 27 months' follow-up was 37.2% (16/43). Of the NOT failures, 1 appendix was normal on histology while only 1 was perforated. There were no significant differences in secondary outcomes between both groups except for LOS of late NOT failure. Cost for upfront LA was nearly thrice that of NOT. Conclusion: Our stringent COVID protocol together with shared decision-making with parents is a safe and feasible treatment option during a crisis situation.
Introduction: The aim of this study was to analyse the feasibility, safety and benefits of laparo... more Introduction: The aim of this study was to analyse the feasibility, safety and benefits of laparoscopic appendicectomy (LA) in comparison with open appendicectomy (OA) for perforated appendicitis (PA) in children. Materials and Methods: A retrospective analysis of all consecutive cases of PA who underwent OA or LA between July 2001 and April 2004 was done. The patient demographics, duration of symptoms and operative findings were noted and the feasibility, safety and benefits of LA were analysed with respect to postoperative recovery and complications. Results: One hundred and thirty-seven consecutive patients with PA underwent either OA (n =46) or LA (n = 91). Both groups were comparable with respect to patient demographics, duration of symptoms and operative findings. The mean operative time was 106.5 min (95% CI, 100.2 - 112.8) in the LA group and 92.8 min (95% CI, 82.9-102.7) in the OA group (P = 0.02). The return to afebrile status after surgery was significantly faster in the ...
PurposeThis study aims to compare the outcomes of extravesical (EVUR) and intravesical (IVUR) ure... more PurposeThis study aims to compare the outcomes of extravesical (EVUR) and intravesical (IVUR) ureteric reimplantation for primary vesicoureteral reflux (VUR) via systematic review and meta-analysis.MethodsLiterature review from Medline, Embase, and Cochrane since inception to March 2022 was performed. Meta-analysis was conducted on eligible randomized controlled trials (RCT) and observational cohort studies (OCS) comparing outcomes between EVUR and IVUR.ResultsTwelve studies were included, comprising 577 patients (778 ureters) operated by EVUR and 395 patients (635 ureters) by IVUR. Pre-operative VUR grade, postoperative VUR persistence and hydronephrosis was not statistically significant. EVUR had shorter operative time [mean differences (MD) −22.91 min; 95% confidence interval (CI), −44.53 to −1.30, P = 0.04] and hospital stay (MD −2.09 days; 95% CI, −2.82 to −1.36, P < 0.00001) compared to IVUR. Bilateral EVUR had higher risk of postoperative acute urinary retention (ARU) (8.1...
Background Our study aimed to compare the clinical outcomes and cost-efficiency of antibiotic man... more Background Our study aimed to compare the clinical outcomes and cost-efficiency of antibiotic management versus laparoscopic appendectomy for acute uncomplicated appendicitis (AUA) in children during the COVID-19 pandemic when resources were limited and transmission risks uncertain. Method In this prospective case-control study between Apr 2020 to Jan 2022, we analyzed the data of 139 children diagnosed with AUA meeting the following inclusion criteria: symptoms duration of ≤48 hours, appendix diameter ≤11 mm and no appendicolith. 78/139 cases were treated with antibiotics while 61 matched controls underwent upfront laparoscopic appendectomy. Antibiotic regimes were intravenous Ceftriaxone/Metronidazole or Amoxicillin/Clavulanic acid for 48 hours, followed by oral antibiotics to complete total 10-days course. Results 8/78 (10.3%) children had early failure (within 48hours) requiring appendectomy. 17/78 patients (21.8%) experienced late recurrence within mean follow-up time of 16.2±4...
INTRODUCTION Posterior urethral valve (PUV) is the most common congenital cause of bladder outflo... more INTRODUCTION Posterior urethral valve (PUV) is the most common congenital cause of bladder outflow obstruction in male infants. Despite timely treatment, renal damage can still occur in the long-term leading to chronic kidney disease (CKD). METHODS A retrospective review of all PUV patients in a single tertiary institution between April 1998 and July 2019 was conducted to analyze their presentations, management and outcomes. Long-term renal function, radiologic scans and somatic growth were evaluated. RESULTS A total of 16 patients were included in this study. Two patients who defaulted all follow-ups were excluded. Seven patients (43.7%) presented in the antenatal period; four patients (25%) presented in the neonatal period and five patients (31.3%) presented in the post-neonatal period. Primary transurethral fulguration of valves was done in 13 patients, while three had vesicostomies as the primary procedure. Three patients had associated anterior urethral valves (AUV), which were treated endoscopically. Nine boys had additional procedures for diversion and undiversion, VUR, non-functioning kidney and clean intermittent catheterization. Ten patients had urodynamic studies performed, of which eight patients received anticholinergic therapy. Eleven patients had DMSA scans, of which three patients had a normal study and eight patients showed unilateral reduced function. Four patients were diagnosed with CKD on long-term follow-up duration over 5 years. All patients were shown to have good somatic growth. CONCLUSION Patients with PUV can suffer from complications despite primary treatment. In our small cohort, a quarter of our patients developed CKD on follow-up. Thus, patients need long-term follow-up to optimize bladder and renal function.
Introduction: Doppler scrotal ultrasonography (US) is the modality of choice in diagnosing testic... more Introduction: Doppler scrotal ultrasonography (US) is the modality of choice in diagnosing testicular torsion. We aimed to evaluate the performance of scrotal US in diagnosing testicular torsion over the past 18 years in our institution and determine the factors contributing to the length of wait times for it. Methods: A retrospective review was conducted of boys who presented with acute scrotal pain from 2014 to 2015. US reports, operative findings, final diagnosis and key time points of the patients' journey (time to emergency department consultation, time to admission, time to US and time to operating theatre [OT]) were collected. US performance results were compared with those observed in a historical cohort from 1998 to 2004. Wait times were compared between operated and non-operated patients. Results: Data from 519 boys with a mean age of 9.15 years was collected. Of these, 438 (84.4%) boys had undergone initial scrotal US; of these scrotal US cases, 28 were surgically exp...
Objective: The “Chinese Fan Spread ” (CFS) distraction technique for laparoscopic reduction of in... more Objective: The “Chinese Fan Spread ” (CFS) distraction technique for laparoscopic reduction of intussusception is herein described and its outcome and benefits are evaluated. Methods: A retrospective review was performed of all patients who underwent attempts at laparoscopic reduction of intussusception at our center. The CFS distraction technique was consistently applied in all cases. Results: Fourteen patients were identified. Median age was 2.4 years (range, 4 months to 10.3 years). Indications for surgery included (1) failed pneumatic reduction (n�11), (2) need to evaluate for lead point in a patient with 4 recurrences (n�1), (3) need to biopsy the lead point in a patient with suspected lymphoma (n�1), and (4) diagnostic laparoscopy for evaluation of hematochezia (n�1). Two patients who failed laparoscopic reduction by the CFS distraction technique also failed open manual reduction, requiring right hemicolectomy. Of the 12 (86%) who were successfully reduced laparoscopically, pa...
We report a case of junctional epidermolysis bullosa with pyloric atresia (JEB‐PA) with minimal s... more We report a case of junctional epidermolysis bullosa with pyloric atresia (JEB‐PA) with minimal skin involvement but severe protein‐losing enteropathy and airway involvement. Genetic analysis revealed heterozygous mutations in the ITGB4 gene encoding integrin β4 protein. Parental testing confirmed inheritance of frameshift variant (c.794dupC) as maternal and splice site variant (c.1608C>T/p.Cys536Cys) as paternal. Immunofluorescence mapping of her skin revealed a subepidermal blister with decreased and frayed integrin β4 at both the floor and the roof of the blister, while the intestinal mucosa showed complete absence of integrin β4. We review the literature and discuss the differential expression of integrins in the skin and gastrointestinal tract, as well as the role of chronic inflammation in the pathogenesis of EB.
To investigate the value of hidden incision applied to specimen extraction in children's robot-as... more To investigate the value of hidden incision applied to specimen extraction in children's robot-assisted laparoscopic radical nephrectomy.
Purpose Assays of salivary biomarkers for diagnosis are gaining popularity in pediatric diseases ... more Purpose Assays of salivary biomarkers for diagnosis are gaining popularity in pediatric diseases due to their non-invasive nature. Our pilot project aims to evaluate the utility of salivary leucine-rich-alpha-2-glycoprotein (LRG) in the diagnosis of pediatric acute appendicitis (AA). Methods We prospectively recruited 34 patients, aged between 4 and 16 years, admitted with acute abdominal pain suspicious of appendicitis. The patients' demography, clinical characteristics, laboratory investigations, imaging examination results, operative findings, and discharge diagnoses were recorded. We compared the diagnostic performance of the patients' total white counts, neutrophil percentages, C-reactive protein, and saliva LRG levels. Saliva samples were obtained using the SalivaBio Children's Swab and LRG levels were quantified using a commercially available LRG enzyme-linked immunosorbent assay (ELISA) kit. IRB approval was obtained. Results Seventeen patients had a confirmed diagnosis of appendicitis on histology. Another 17 were confirmed not to have appendicitis after a minimum of 24 h of hospitalization, with further verification via telephone interview 2 weeks later. The median levels of saliva LRG were elevated in patients with AA as compared to those without (P = 0.008). At a cutoff of LRG 0.33 ng/μg, we obtained a diagnostic specificity of 100% and sensitivity of 35.3%. Conclusion Our proof-of-concept study demonstrated the diagnostic potential of saliva LRG for appendicitis in children. The distinct advantage of saliva LRG assays is that the procedure is simple, pain-free, and requires no specialized skill. Further study with a larger cohort is needed to verify our results.
Circumcision is one of the most commonly performed surgical procedures. A large variety of techni... more Circumcision is one of the most commonly performed surgical procedures. A large variety of techniques have been used, but unfortunately, complications such as pain, bleeding, swelling, stitch granuloma, scab formation, and removal of improper proportions of skin/mucous membrane occur in significant numbers. The authors present a technique using the carbon dioxide laser to excise the prepuce and weld the cut edges together, thus providing a completely bloodless operation. Suturing is optional as the laser can also be used to unite the cut edges. The technique allows exact proportions of skin and mucous membrane to be removed. This method has been used in a total of 1,154 patients ranging in age from infancy to 10 years. A detailed analysis of postoperative recovery and follow-up indicates that minor complications occurred in only 4 patients, none of whom required hospital admission.
Hematuria is not uncommonly seen among children. We describe the case of a 13-year-old boy who wa... more Hematuria is not uncommonly seen among children. We describe the case of a 13-year-old boy who was diagnosed with urothelial carcinoma after presenting with persistent gross hematuria for 2 weeks. We highlight the importance of adequate workup for gross hematuria as it is often associated with an underlying pathology that could lead to significant morbidity if left undiagnosed.
Journal of Laparoendoscopic & Advanced Surgical Techniques, Aug 1, 2007
In this paper, we report a case of bleeding solitary jejunal Dieulafoy pseudopolyp that was detec... more In this paper, we report a case of bleeding solitary jejunal Dieulafoy pseudopolyp that was detected on capsule endoscopy and treated with a laparoscopic-assisted transumbilical polypectomy procedure. This case illustrates an innovative, tailored application of minimal invasive techniques in the management of a relatively uncommon lesion. To our knowledge, this is the first case report of the combination of capsule endoscopy and laparoscopic-assisted transumbilical resection for a bleeding jejunal Dieulafoy pseudopolyp in children.
Introduction: Herlyn-Werner-Wunderlich syndrome (HWWS) is a rare variant of Mullerian ductal anom... more Introduction: Herlyn-Werner-Wunderlich syndrome (HWWS) is a rare variant of Mullerian ductal anomaly associated with ipsilateral renal agenesis. Most patients are diagnosed after menarche with complications of uterovaginal obstruction, genitourinary infection and pelvic adhesions. Patients often undergo additional operations for misdiagnosis or treatment of complications. Our institution manages several HWWS patients diagnosed before symptoms by screening for antenatally-diagnosed renal agenesis. This study aims to improve the presymptomatic management of HWWS patients. Methods: We carried out retrospective case review of patients diagnosed with HWWS from 2010 to 2017 on patient demographics, symptoms, clinical course and operative management and summarize the sparse literature published to date. Results: There were 8 patients with HWWS but only 2 symptomatic patients presented acutely with hematocolpos requiring urgent vaginal surgery. The other six patients had early diagnosis through postnatal ultrasound screening. No patient required further operation for diagnosis or complications related to obstructed hemivagina. Conclusion: Our case series and literature review show that the majority of prepubertal patients with HWWS do not require early gynecological surgery. We recommend that female babies with renal agenesis should be screened for HWWS syndrome with ultrasound. Early diagnosis and presymptomatic elective surgery may prevent urogynecological complications that cause fertility and renal impairment. Study design: Case series, level IV evidence.
Journal of Pediatric Gastroenterology and Nutrition, Dec 1, 2013
A nnular pancreas (AP) is a rare congenital anomaly consisting of a ring of pancreatic tissue par... more A nnular pancreas (AP) is a rare congenital anomaly consisting of a ring of pancreatic tissue partially or completely encircling the second part of the duodenum (1). Most cases are diagnosed in the neonatal period with symptoms of gastric outlet obstruction. We report an unusual case of AP presenting with acute upper gastrointestinal (GI) bleeding in a child. A 12-year-old boy of Malay origin presented with a 1-day history of sudden onset of hematemesis and passing malaenic stools. Before presentation, he had a 1-year history of intermittent postprandial abdominal bloatedness with mild epigastric pain and rare episode of nonbilious vomiting. He tolerated his meals well and showed normal growth along the 75th percentile for both height and weight. Physical examination revealed a pale boy with clinical evidence of hypovolemic shock. He had epigastric tenderness and per rectal examination revealed malaenic stools. The abdomen was not distended and the rest of the physical examination was normal. He required fluid resuscitation to stabilize his vital parameters and was commenced on intravenous omeprazole infusion. Empirical triple therapy for Helicobacter pylori infection comprising amoxicillin, metronidazole, and omeprazole was also started. Initial blood tests showed hemoglobin of 12.6 g/dL (normal 9–14), which dropped to 10.4 g/dL the following day, subsequent to that hemoglobin was stable. Coagulation profile, liver function test, C-reactive protein, and amylase were normal. His GI bleeding resolved within 48 hours with conservative management. Upper GI endoscopy performed on day 3 showed severe gastric erythema at the gastric antrum with a 3-mm irregularly shaped healing ulcer. The stomach antrum and the first part of duodenum (D1) were markedly dilated with stenosis at the junction of second and third part of duodenum (D2-D3). Duodenal mucosa was slightly erythematous with no ulceration (Fig. 1). Histology of the mucosa showed chronic gastritis and mild reflux esophagitis with no evidence of H pylori. The initial clinical impression was duodenal stenosis caused by extrinsic compression or a duodenal web. Magnetic resonance imaging of the abdomen was suggestive
Objective: To improve understanding of the implications of testicular microlithiasis (TM) in paed... more Objective: To improve understanding of the implications of testicular microlithiasis (TM) in paediatric patients diagnosed incidentally on scrotal ultrasonography (US). Patients and methods: 31 boys aged 4e14 years diagnosed with TM based on US between February 2000 and September 2007 were retrospectively reviewed. Demographic data, indications for US, associated inguino-scrotal pathologies and follow-up data were collated. Results: A total of 59 testes were evaluated. Fifty-four had TM at US. The most common indication for US was scrotal swelling (n Z 17). Twenty patients (65%) had at least one associated inguino-scrotal pathology related to patent processus vaginalis, with cryptorchidism being the most frequently observed (39%). On follow up (mean 39.6 months), 6 patients documented decrease or resolution of TM, while 2 showed increase in TM density. No testicular malignancy was observed during follow up. Conclusions: TM is commonly diagnosed incidentally on US in paediatric patients. A literature review revealed few case reports on its association with testicular malignancy and a prevalence of 4.2% among asymptomatic boys. The spontaneous resolution of TM supports degeneration of seminiferous tubules as the possible cause and further questions its malignant implication. An appropriate surveillance scheme would require involvement of a well-informed patient and parent with good compliance on testicular self-examination.
Background Improved survival of neonates with esophageal atresia with/without tracheoesophageal f... more Background Improved survival of neonates with esophageal atresia with/without tracheoesophageal fistula (EA/TEF) has resulted in increased prevalence of gastro-esophageal and respiratory-related morbidities. However, long-term outcome data on these patients remains limited, making it difficult to substantiate any guidelines on their chronic care. The purpose of our study is to report on their post-operative outcomes especially the long-term gastro-esophageal and respiratory morbidities. Methods This was a retrospective review of 65 patients (39 males, 26 females) who underwent EA/TEF repair from 1996 to 2019 at a single tertiary institution. Follow up data pertaining to clinical characteristics, operative management and long-term gastro-esophageal and respiratory morbidities was analyzed. Results Fifty-seven patients (87.7%) had Gross Type-C anatomy, followed by 5(7.7%) patients with Type-A, 1(1.5%) with Type-B and 1 with Type-D. One patient had a late diagnosis of H-type fistula (T...
Background Our study aimed to compare the clinical outcomes and cost-efficiency of antibiotic man... more Background Our study aimed to compare the clinical outcomes and cost-efficiency of antibiotic management versus laparoscopic appendectomy for acute uncomplicated appendicitis (AUA) in children during the COVID-19 pandemic when resources were limited and transmission risks uncertain. Method In this prospective comparative cohort study, we analyzed the data of 139 children diagnosed with AUA meeting the following inclusion criteria: 5-18 years of age, symptoms duration of ≤ 48 h, appendix diameter ≤ 11 mm and no appendicolith. Treatment outcomes between non-operative management group (78/139) and upfront laparoscopic appendectomy group (61/139) were compared. Antibiotic regimes were intravenous ceftriaxone/metronidazole or amoxicillin/clavulanic acid for 48 h, followed by oral antibiotics to complete total 10-days course. Results 8/78 (10.3%) children had early failure (within 48 h) requiring appendectomy. 17/70 (24.3%) patients experienced late recurrence within mean follow-up time of 16.2 ± 4.7 months. There were no statistical differences in peri-operative complications, negative appendicectomy rate, and incidence of perforation and hospitalization duration between antibiotic and surgical treatment groups. Cost per patient in upfront surgical group was significantly higher ($6208.5 ± 5284.0) than antibiotic group ($3588.6 ± 3829.8; p = 0.001). Conclusion Despite 24.3% risk of recurrence of appendicitis in 16.2 ± 4.7 months, antibiotic therapy for AUA appears to be a safe and cost-effective alternative to upfront appendectomy.
Background: During the Coronavirus disease 2019 (COVID-19) pandemic, a protocol was adopted by ou... more Background: During the Coronavirus disease 2019 (COVID-19) pandemic, a protocol was adopted by our department on antibiotics treatment for Acute Uncomplicated Appendicitis (AUA). Our study aimed to determine the feasibility and safety of non-operative treatment (NOT), compared to upfront laparoscopic appendectomy (LA), for AUA in children during the pandemic. Method: Our prospective comparative study was conducted from May 1, 2020 to January 31, 2021. Patient selection criteria included: age 5 years, abdominal pain duration 48 h, ultrasound (US)/Computered Tomography scan confirmation of AUA, US appendiceal diameter 6e11 mm with no features of perforation/abscess collection and no faecolith. For NOT patients, intravenous antibiotics were administered for 24e48 h followed by oral for 10-day course. Comparison was performed between patients whose parents preferred NOT to those who opted for up-front appendectomy. Primary outcomes were NOT success at index admission, early and late NOT failure rates till 27 months. Secondary outcomes were differences in complication rate, hospital length of stay (LOS) and cost between groups. Results: 77 patients were recruited: 43 (55.8%) underwent NOT while 34 (44.2%) patients opted for LA. Success of NOT at index admission was 90.7% (39/43). Overall, NOT failure rate at 27 months' follow-up was 37.2% (16/43). Of the NOT failures, 1 appendix was normal on histology while only 1 was perforated. There were no significant differences in secondary outcomes between both groups except for LOS of late NOT failure. Cost for upfront LA was nearly thrice that of NOT. Conclusion: Our stringent COVID protocol together with shared decision-making with parents is a safe and feasible treatment option during a crisis situation.
Introduction: The aim of this study was to analyse the feasibility, safety and benefits of laparo... more Introduction: The aim of this study was to analyse the feasibility, safety and benefits of laparoscopic appendicectomy (LA) in comparison with open appendicectomy (OA) for perforated appendicitis (PA) in children. Materials and Methods: A retrospective analysis of all consecutive cases of PA who underwent OA or LA between July 2001 and April 2004 was done. The patient demographics, duration of symptoms and operative findings were noted and the feasibility, safety and benefits of LA were analysed with respect to postoperative recovery and complications. Results: One hundred and thirty-seven consecutive patients with PA underwent either OA (n =46) or LA (n = 91). Both groups were comparable with respect to patient demographics, duration of symptoms and operative findings. The mean operative time was 106.5 min (95% CI, 100.2 - 112.8) in the LA group and 92.8 min (95% CI, 82.9-102.7) in the OA group (P = 0.02). The return to afebrile status after surgery was significantly faster in the ...
PurposeThis study aims to compare the outcomes of extravesical (EVUR) and intravesical (IVUR) ure... more PurposeThis study aims to compare the outcomes of extravesical (EVUR) and intravesical (IVUR) ureteric reimplantation for primary vesicoureteral reflux (VUR) via systematic review and meta-analysis.MethodsLiterature review from Medline, Embase, and Cochrane since inception to March 2022 was performed. Meta-analysis was conducted on eligible randomized controlled trials (RCT) and observational cohort studies (OCS) comparing outcomes between EVUR and IVUR.ResultsTwelve studies were included, comprising 577 patients (778 ureters) operated by EVUR and 395 patients (635 ureters) by IVUR. Pre-operative VUR grade, postoperative VUR persistence and hydronephrosis was not statistically significant. EVUR had shorter operative time [mean differences (MD) −22.91 min; 95% confidence interval (CI), −44.53 to −1.30, P = 0.04] and hospital stay (MD −2.09 days; 95% CI, −2.82 to −1.36, P < 0.00001) compared to IVUR. Bilateral EVUR had higher risk of postoperative acute urinary retention (ARU) (8.1...
Background Our study aimed to compare the clinical outcomes and cost-efficiency of antibiotic man... more Background Our study aimed to compare the clinical outcomes and cost-efficiency of antibiotic management versus laparoscopic appendectomy for acute uncomplicated appendicitis (AUA) in children during the COVID-19 pandemic when resources were limited and transmission risks uncertain. Method In this prospective case-control study between Apr 2020 to Jan 2022, we analyzed the data of 139 children diagnosed with AUA meeting the following inclusion criteria: symptoms duration of ≤48 hours, appendix diameter ≤11 mm and no appendicolith. 78/139 cases were treated with antibiotics while 61 matched controls underwent upfront laparoscopic appendectomy. Antibiotic regimes were intravenous Ceftriaxone/Metronidazole or Amoxicillin/Clavulanic acid for 48 hours, followed by oral antibiotics to complete total 10-days course. Results 8/78 (10.3%) children had early failure (within 48hours) requiring appendectomy. 17/78 patients (21.8%) experienced late recurrence within mean follow-up time of 16.2±4...
INTRODUCTION Posterior urethral valve (PUV) is the most common congenital cause of bladder outflo... more INTRODUCTION Posterior urethral valve (PUV) is the most common congenital cause of bladder outflow obstruction in male infants. Despite timely treatment, renal damage can still occur in the long-term leading to chronic kidney disease (CKD). METHODS A retrospective review of all PUV patients in a single tertiary institution between April 1998 and July 2019 was conducted to analyze their presentations, management and outcomes. Long-term renal function, radiologic scans and somatic growth were evaluated. RESULTS A total of 16 patients were included in this study. Two patients who defaulted all follow-ups were excluded. Seven patients (43.7%) presented in the antenatal period; four patients (25%) presented in the neonatal period and five patients (31.3%) presented in the post-neonatal period. Primary transurethral fulguration of valves was done in 13 patients, while three had vesicostomies as the primary procedure. Three patients had associated anterior urethral valves (AUV), which were treated endoscopically. Nine boys had additional procedures for diversion and undiversion, VUR, non-functioning kidney and clean intermittent catheterization. Ten patients had urodynamic studies performed, of which eight patients received anticholinergic therapy. Eleven patients had DMSA scans, of which three patients had a normal study and eight patients showed unilateral reduced function. Four patients were diagnosed with CKD on long-term follow-up duration over 5 years. All patients were shown to have good somatic growth. CONCLUSION Patients with PUV can suffer from complications despite primary treatment. In our small cohort, a quarter of our patients developed CKD on follow-up. Thus, patients need long-term follow-up to optimize bladder and renal function.
Introduction: Doppler scrotal ultrasonography (US) is the modality of choice in diagnosing testic... more Introduction: Doppler scrotal ultrasonography (US) is the modality of choice in diagnosing testicular torsion. We aimed to evaluate the performance of scrotal US in diagnosing testicular torsion over the past 18 years in our institution and determine the factors contributing to the length of wait times for it. Methods: A retrospective review was conducted of boys who presented with acute scrotal pain from 2014 to 2015. US reports, operative findings, final diagnosis and key time points of the patients' journey (time to emergency department consultation, time to admission, time to US and time to operating theatre [OT]) were collected. US performance results were compared with those observed in a historical cohort from 1998 to 2004. Wait times were compared between operated and non-operated patients. Results: Data from 519 boys with a mean age of 9.15 years was collected. Of these, 438 (84.4%) boys had undergone initial scrotal US; of these scrotal US cases, 28 were surgically exp...
Objective: The “Chinese Fan Spread ” (CFS) distraction technique for laparoscopic reduction of in... more Objective: The “Chinese Fan Spread ” (CFS) distraction technique for laparoscopic reduction of intussusception is herein described and its outcome and benefits are evaluated. Methods: A retrospective review was performed of all patients who underwent attempts at laparoscopic reduction of intussusception at our center. The CFS distraction technique was consistently applied in all cases. Results: Fourteen patients were identified. Median age was 2.4 years (range, 4 months to 10.3 years). Indications for surgery included (1) failed pneumatic reduction (n�11), (2) need to evaluate for lead point in a patient with 4 recurrences (n�1), (3) need to biopsy the lead point in a patient with suspected lymphoma (n�1), and (4) diagnostic laparoscopy for evaluation of hematochezia (n�1). Two patients who failed laparoscopic reduction by the CFS distraction technique also failed open manual reduction, requiring right hemicolectomy. Of the 12 (86%) who were successfully reduced laparoscopically, pa...
We report a case of junctional epidermolysis bullosa with pyloric atresia (JEB‐PA) with minimal s... more We report a case of junctional epidermolysis bullosa with pyloric atresia (JEB‐PA) with minimal skin involvement but severe protein‐losing enteropathy and airway involvement. Genetic analysis revealed heterozygous mutations in the ITGB4 gene encoding integrin β4 protein. Parental testing confirmed inheritance of frameshift variant (c.794dupC) as maternal and splice site variant (c.1608C>T/p.Cys536Cys) as paternal. Immunofluorescence mapping of her skin revealed a subepidermal blister with decreased and frayed integrin β4 at both the floor and the roof of the blister, while the intestinal mucosa showed complete absence of integrin β4. We review the literature and discuss the differential expression of integrins in the skin and gastrointestinal tract, as well as the role of chronic inflammation in the pathogenesis of EB.
To investigate the value of hidden incision applied to specimen extraction in children's robot-as... more To investigate the value of hidden incision applied to specimen extraction in children's robot-assisted laparoscopic radical nephrectomy.
Purpose Assays of salivary biomarkers for diagnosis are gaining popularity in pediatric diseases ... more Purpose Assays of salivary biomarkers for diagnosis are gaining popularity in pediatric diseases due to their non-invasive nature. Our pilot project aims to evaluate the utility of salivary leucine-rich-alpha-2-glycoprotein (LRG) in the diagnosis of pediatric acute appendicitis (AA). Methods We prospectively recruited 34 patients, aged between 4 and 16 years, admitted with acute abdominal pain suspicious of appendicitis. The patients' demography, clinical characteristics, laboratory investigations, imaging examination results, operative findings, and discharge diagnoses were recorded. We compared the diagnostic performance of the patients' total white counts, neutrophil percentages, C-reactive protein, and saliva LRG levels. Saliva samples were obtained using the SalivaBio Children's Swab and LRG levels were quantified using a commercially available LRG enzyme-linked immunosorbent assay (ELISA) kit. IRB approval was obtained. Results Seventeen patients had a confirmed diagnosis of appendicitis on histology. Another 17 were confirmed not to have appendicitis after a minimum of 24 h of hospitalization, with further verification via telephone interview 2 weeks later. The median levels of saliva LRG were elevated in patients with AA as compared to those without (P = 0.008). At a cutoff of LRG 0.33 ng/μg, we obtained a diagnostic specificity of 100% and sensitivity of 35.3%. Conclusion Our proof-of-concept study demonstrated the diagnostic potential of saliva LRG for appendicitis in children. The distinct advantage of saliva LRG assays is that the procedure is simple, pain-free, and requires no specialized skill. Further study with a larger cohort is needed to verify our results.
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