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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).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.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.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.

Anorectal malformations (ARMs) are one of the more common congenital anomalies encountered in pediatric surgery where the majority are diagnosed in the early neonatal period. The etiology of ARM remains uncertain and is likely to be multifactorial. A majority of ARMs result from abnormal development of the urorectal septum in early fetal life. There can be a broad range of presentation features varying from low anomalies with perineal fistula to high anomalies mandating intricate management. To develop a standardized system for comparison in follow-up studies, the Krickenbeck classification was introduced according to the type of fistula. According to the Krickenbeck classification of ARM, those with a rectoperineal fistula are classified as low-type ARM and are usually managed with a perineal anoplasty without colostomy. In this case series, we describe two rare cases of distinct high and intermediate ARM with rectoperineal fistulas, which were thought to be low-type ARM but were subsequently found to have urethral involvement. Our cases consisted of high and intermediate ARMs, which were successfully treated with posterior sagittal anorectoplasty as described. These cases exemplified rare variants of ARM where rectoperineal fistulas can be associated with high-type anomalies. Rare-variant ARM with rectopenile or rectoscrotal fistula can be associated with high-type anomalies in contrast to classical rectoperineal fistulas. A high index of suspicion should remain in cases with previous urinary tract infection despite normal imaging. Careful planning is also needed with consideration of possible need for urethral repair during anoplasty, which was needed in both our cases.

OBJECTIVE To design and examine the feasibility of a sustainable training program to build local capacity and improve obstetric outcomes in Kampong Chhnang, Cambodia. METHODS A "train-the-trainers" model was used to conduct an obstetrics course between 2012 and 2015, its aim to reduce maternal mortality and morbidity. All Cambodian healthcare providers trained by the program were included in the study. The obstetric outcomes of all patients under the care of the trained healthcare providers were analyzed retrospectively to assess the feasibility of the program. Data from all three hospitals and 42 health centers in the province that the trainees worked at were collected from case logs. RESULTS There was a significant increased trend in recognition of cases of postpartum hemorrhage and pre-eclampsia, and occurrence of difficult deliveries and cesarean deliveries (P

PURPOSEPediatric solid tumors require coordinated multidisciplinary specialist care. However, expertise and resources to conduct multidisciplinary tumor boards (MDTBs) are lacking in low- and middle-income countries (LMICs). We aimed to profile the landscape of pediatric solid tumor care and practices and perceptions on MDTBs among pediatric solid tumor units (PSTUs) in Southeast Asian LMICs.METHODSUsing online surveys, availability of specialty manpower and MDTBs among PSTUs was first determined. From the subset of PSTUs with MDTBs, one pediatric surgeon and one pediatric oncologist from each center were queried using 5-point Likert scale questions adapted from published questionnaires.RESULTSIn 37 (80.4%) of 46 identified PSTUs, availability of pediatric-trained specialists was as follows: oncologists, 94.6%; surgeons, 91.9%; radiologists, 54.1%; pathologists, 40.5%; radiation oncologists, 29.7%; nuclear medicine physicians, 13.5%; and nurses, 81.1%. Availability of pediatric-trained surgeons, radiologists, and pathologists was significantly associated with the existence of MDTBs ( P = .037, .005, and .022, respectively). Among 43 (89.6%) of 48 respondents from 24 PSTUs with MDTBs, 90.5% of oncologists reported > 50% oncology-dedicated workload versus 22.7% of surgeons. Views on benefits and barriers did not significantly differ between oncologists and surgeons. The majority agreed that MDTBs helped to improve accuracy of treatment recommendations and team competence. Complex cases, insufficient radiology and pathology preparation, and need for supplementary investigations were the top barriers.CONCLUSIONThis first known profile of pediatric solid tumor care in Southeast Asia found that availability of pediatric-trained subspecialists was a significant prerequisite for pediatric MDTBs in this region. Most PSTUs lacked pediatric-trained pathologists and radiologists. Correspondingly, gaps in radiographic and pathologic diagnoses were the most common limitations for MDTBs. Greater emphasis on holistic multidisciplinary subspecialty development is needed to advance pediatric solid tumor care in Southeast Asia.

Background Pediatric solid tumors require coordinated multidisciplinary specialist care. However, expertise and resources to conduct multidisciplinary tumor board (MDTB) meetings are lacking in low- and middle-income countries (LMICs). We aimed to profile practices and perceptions on MDTBs among pediatric solid tumor units (PSTUs) in Southeast Asian LMIC countries. Methods Using online survey forms, availability of specialty manpower and MDTBs among PSTUs was first determined. From the subset of PSTUs with MDTBs, 1 pediatric surgeon and 1 pediatric oncologist from each center were queried using 5-point Likert scale questions adapted from published questionnaires. Results In 37/46 (80.4%) identified PSTUs, pediatric-trained oncologists, surgeons, radiologists, pathologists, radiation oncologists, nuclear medicine physicians and nurses were available in 94.6%, 91.9%, 54.1%, 40.5%, 29.7%, 13.5% and 81.1% of PSTUs, respectively. Availability of pediatric-trained surgeons, radiologists and pathologists were significantly associated with existence of MDTBs (p=0.037, 0.005, 0.022 respectively). Among 43/48 (89.6%) respondents from 24 PSTUs with MDTBs, 90.5% of oncologists reported >50% oncology-dedicated workload versus 22.7% of surgeons. Views on benefits and barriers did not significantly differ between both groups. Majority agreed MDTBs helped improve accuracy of treatment recommendations and team competence. Complex cases, insufficient radiology and pathology preparation, and need for supplementary investigations, were the top barriers. Conclusions Availability of pediatric-trained subspecialists was a significant prerequisite for pediatric MDTBs. Most PSTUs lacked pediatric-trained pathologists and radiologists. Correspondingly, gaps in radiographic and pathological diagnoses were the commonest limitations. Greater emphasis on holistic multidisciplinary subspecialty development is needed to advance pediatric solid tumor care in Southeast Asia.

We aim to evaluate the diagnostic value and time course response of the triple inflammatory markers: white blood cell count (WBC), neutrophil percentage (Neu), and C-reactive protein (CRP) in pediatric acute appendicitis. A retrospective review of clinical data pertaining to 1391 patients admitted with suspicion for pediatric appendicitis from 2012 to 2017 was conducted. Triple inflammatory markers were acquired upon admission. Appendicitis was confirmed histologically post-appendectomy. The diagnostic value and time course response of these markers was trended in relation to the duration of abdominal pain on admission. 718 patients had histologically confirmed appendicitis. WBC and Neu demonstrate high sensitivity for early appendicitis at 94.6% and 80.0% at Day 1, while CRP demonstrates highest sensitivity of 97.9% at Day 4. The triple markers had poor overall diagnostic value when interpreted individually, however, had a high combined sensitivity of 99.7% and negative predictive value of 98.7% regardless of duration of disease. Overall negative appendectomy rate was 6.7% (n = 52). Among 19 patients with triple markers negative who underwent appendectomy, 17 (89.5%) were histologically normal. The triple inflammatory markers have limited diagnostic value when interpreted individually, but are strong discriminators of pediatric appendicitis when combined. Their high sensitivity and negative predictive value could potentially help patients avoid unnecessary admissions or costly imaging studies, and reduce negative appendectomy rates. In addition, their objective nature confers an advantage over existing clinical scoring systems which comprise subjective elements.

We present a rare case of Klinefelter syndrome who presented with perinatal ascites, unilateral renal agenesis and a prostatic utricle cyst. The patient was born at term via emergency Caesarean section with gross abdominal distension. Antenatally, amniocentesis revealed a fetal karyotype of Klinefelter syndrome (47, XXY), and the 34-week ultrasound scan showed a cyst measuring 17×21×27 mm located inferior–posterior to the bladder. There was no ascites noted then, but a small left pelvic kidney was present. Ultrasound kidney, ureter and bladder as well as CT scan of the thorax, abdomen and pelvis done at birth showed a solitary right kidney with large-volume ascites and no evidence of a cyst adjacent to the bladder. These findings suggest urinary ascites from an involuting left renal system or a ruptured prostatic utricle cyst. We report the first case of Klinefelter syndrome associated with a prostatic utricle cyst and unilateral renal agenesis, presenting with neonatal ascites.

Patients with anorectal malformation (ARM) and Hirschsprung's disease (HD) face long-term disturbance in bowel function even after definitive surgery. This study evaluates the quality of life (QOL) of patients with ARM and HD, and compares them to healthy controls using self-report questionnaires.A prospective study was performed recruiting patients with ARM or HD from September 2013 to December 2014 who had primary surgery done in our institution at least 2 years prior to participation. Age-matched and gender-matched controls were enrolled from our patients with minor outpatient complaints. All participants completed the following PedsQL™ scales (maximum score 100): 4.0 Generic Core Scales, 3.0 General Well-Being (GWB) Scale and 2.0 Family Impact (FI) Module. All were also scored on bowel function (BFS), with a maximum score 20. Appropriate statistical analysis was performed, with significance level0.05.There were 193 participants: 87 controls, 62 ARM, 44 HD. When comparing Core, GWB and FI scores, there were no significant differences between groups although controls had best scores indicating best QOL and general wellbeing, with least impact of the child's health on the family. BFS was significantly different with controls having best and ARM worst scores. There were no significant differences in scores between parent and child indicating intradyad consistency. There was significant positive correlation between BFS and Core (p0.0001), and between BFS and GWB scores (p0.005); and significant negative correlation between BFS and FI scores (p0.0001).Bowel function impacts quality of life. Those with ARM and HD can achieve good quality of life comparable to controls, based on patient and caregiver self-reported outcomes.Prospective comparative study LEVEL OF EVIDENCE: Level II.

Introduction The impact of anorectal malformation (ARM) or Hirschsprung's disease (HD) in children continues into adulthood despite early surgical correction. We aimed to explore the physical, social, and emotional impacts of these conditions on youth to inform best transition care strategies. Materials and Methods Eligible participants were those aged between 14 and 21 years who had undergone surgery for ARM/HD in our institution. We conducted one-on-one in-depth interviews to saturation using a question guide developed from literature review and clinician expertise. Deidentified transcripts were coded by four coders (two pediatric surgeons, one psychiatrist, and one qualitative expert) for major themes using a constant comparison approach. A theoretical model for understanding the transition experience was developed using grounded theory. Results Out of 120 patients identified as eligible, 11 youth (6 males) participated in the study. Interviews lasted from 50 to 60 minutes. Four major themes emerged: (1) social support (subthemes: family as core, friends as outer support), (2) cognitive and emotional change (subthemes: realization/recognition of illness, matching emotional response), (3) impact of physical symptoms (subthemes: adverse effects of abnormal bowel habits, gaining bowel continence control leading to overall feeling of control, need to keep disease private), and (4) healthcare providers (viewed as important information sources). Themes did not differ by gender. Conclusion Our model suggests that participants' understanding of bowel disease evolved over time with a “lightbulb” moment in preteens or early teens accompanied by increasing disease ownership and self-management. Clinicians should independently engage with patients in late childhood to address evolving emotional and information needs and encourage increasing autonomy. Future studies should explore communication approaches to meet transition needs of patients.

Objective: Micturating cystourethrogram (MCUG) has traditionally been recommended as part of the preoperative evaluation of all cases of hydronephrosis. Several studies have shown that the majority of cases with pelviureteric junction obstruction (PUJO) and concomitant vesicoureteral reflux (VUR) were of low-grade and generally resolved spontaneously. We therefore retrospectively evaluated the need for routine MCUG in all cases of PUJO. Methods: We conducted a retrospective review of clinical records of all patients who underwent pyeloplasty in our institution between 2003 and 2015. Data collected included patient demographics, clinical presentation, radiological procedures performed, operative details as well as postoperative outcomes. Results: A total of 119 patients underwent pyeloplasty for PUJO during this study period. MCUG was performed in 88 patients (74%), of whom eight patients had VUR. All eight patients had unilateral PUJO and two patients had bilateral VUR. Only two patients had high-grade VUR (grade 4). These two patients also had hydroureter detected on ultrasound scan (US). All patients with VUR had spontaneous resolution of reflux. While comparing outcomes for patients with and without VUR, there was no statistically significant difference in terms of the need for redo surgery and improvement in differential renal function post-pyeloplasty. Conclusion: The outcome of pyeloplasty appears to be independent of the presence of concomitant VUR. Therefore, we conclude that MCUG does not need to be performed routinely for all PUJO patients. However, patients with history of recurrent urinary tract infection or findings of hydroureter on US should still be investigated with MCUG.

The aim of our study was to develop an appendicitis score incorporating a urine biomarker, Leucine rich alpha-2-glycoprotein (LRG), for evaluation of children with abdominal pain.From January to August 2017 we prospectively enrolled children aged 4-16 years old admitted for suspected appendicitis. Urine samples for LRG analysis were obtained preoperatively and quantified by enzyme-linked immunosorbent assay (ELISA) after correction for patient hydration status. The diagnosis of appendicitis was based on operative findings and histology. Logistic regression was used to identify prospective predictors.A total of 148 patients were recruited, of which 42(28.4%) were confirmed appendicitis. Our Appendicitis Urinary Biomarker (AuB) model incorporated urine LRG with 3 clinical predictors: 'constant pain', 'right iliac fossa tenderness', 'pain on percussion'. Area under the ROC curve for AuB was 0.82 versus 0.78 for the Pediatric Appendicitis Score (PAS) on the same cohort of patients. A model-calculated risk score of0.15 is interpreted as low risk of appendicitis. Sensitivity for the AuB at this cutoff was 97.6%, specificity 37.7%, negative predictive value 97.6%, positive predictive value 38.3%, and negative likelihood ratio 0.06.The noninvasive AuB score appears promising as a diagnostic tool for excluding appendicitis in children without the need for blood sampling.Study of diagnostic test.Level III.

Aim Studies report that most boys with undescended testis(UDT) are referred and operated beyond the recommended age of 1 year, possibly due to lack of awareness of treatment guidelines. We investigate the level of knowledge of UDT among potential referring health-care providers. Method We devised a survey on the clinical features and appropriate management of UDT. Using convenience sampling, we approached health-care professionals with regular contact with paediatric patients and final year medical students. Respondents were allowed to remain anonymous. They were categorised according to specialty and level of experience/training. Results Of 1179 approached, 203 responded. Thirty-six (24%) of 149 qualified doctors had never seen a case of UDT. Median score was 6 (range 1–9). There was no significant difference in scores when comparing specialty. Mean scores decreased significantly in trend according to level of experience. When questioned regarding timings of referral and orchidopexy, 24% of qualified doctors would not refer until 9 months of age, and 66% thought orchidopexy should be done after 1 year old. Half would stop examining for UDT after 2 years old. Conclusions Inexperience with UDT and outdated knowledge may contribute to delays in referral for UDT. Many would stop examining for UDT at 2 years old, placing undue reliance on accurate physical examination in early childhood and indicating lack of awareness of the ascending testis. Community health initiatives must emphasise recent changes in guidelines for management of UDT.

Vitellointestinal duct (VID) anomalies have been described extensively in the literature. However, an everted VID with prolapse of ileum arising from an omphalocele is rare, and its appearance at birth can be alarming and can present a diagnostic challenge. We describe a baby born to a teenage diabetic mother who was noted to have a strange exophytic mass arising from the abdominal wall. Antenatal scans had revealed multiple other malformations but not an omphalocele. He was operated on early, and the diagnosis of a patent VID with prolapse of the ileum arising from an omphalocele was only confirmed intraoperatively. The duct was resected, the ileum closed primarily and primary closure of the abdominal wall was performed without tension. He recovered well postoperatively. A brief review of similar cases is included.

Aim Our study aimed to compare the efficacy of two endoscopic techniques used for the correction of vesicoureteral reflux (VUR): subureteral transurethral injection (STING) and hydrodistension implantation technique (HIT). Methods A systematic review was conducted using MEDLINE, Google scholar, and Cochrane databases from 1984 to 2015. Meta-analysis of the selected studies was performed to compare the extent of reflux resolution following both techniques. Results Six observational studies met the inclusion criteria for content. These comprised 632 ureters treated by STING and 895 ureters treated by HIT procedure. All included studies utilized dextranomer/hyaluronic acid (Deflux) as the bulking agent. The overall resolution of VUR was significantly higher in HIT (82.5%) compared to STING (71.4%) [pooled odds ratio (OR)=0.54; 95% confidence interval (CI) 0.42–0.69; P 2 =8%]. A subgroup analysis showed that HIT had better outcomes than STING for both lower grade (I–III) [OR=0.43; 95% CI 0.23–0.82; P =0.01; I 2 =0%] and high-grade VUR (IV–V) [OR=0.43; 95% CI 0.20–0.91; P =0.03; I 2 =0%]. However, there was no statistical difference in the requirement of additional injections between STING and HIT groups. Conclusion HIT is superior to STING technique for resolution of VUR after Deflux injection. However, more randomized trials with longer follow-up are necessary to demonstrate the benefit of HIT compared to STING procedure. Level of evidence Retrospective comparative studies – level III.

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 4–14 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 = 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.

Malignant peripheral nerve sheath tumor is a rare neurogenic tumor that usually presents in geriatic patients. Typically, it is found in the trunk and extremities and rarely presents in the head and neck region. It may mimic a carotid body tumor when it presents in the neck. We report the first case of malignant peripheral nerve sheath tumor of the vagus nerve in an adolescent boy. He presented with an asymptomatic lateral neck lump that was thought to be a benign schwannoma on preoperative imaging. We describe the diagnostic dilemma and management difficulties in this patient and review the literature.

Summary Introduction Congenital pelviureteric junction obstruction (PUJO) is one of the most frequent causes of neonatal hydronephrosis. Obstruction at the PUJ has potential severe adverse outcomes, such as renal damage. While pyeloplasty has been established as the definitive treatment, the exact pathophysiology of congenital PUJO remains unknown. Recent research has proposed neuronal innervation defects as an etiological factor in congenital PUJO. We aim to study the expression of various neuronal markers in PUJO specimens compared with controls, and evaluate whether severity of renal disease or dysfunction pre-operatively is related to expression of neuronal markers in resected PUJO specimens. Materials and methods All consecutive patients who underwent dismembered pyeloplasty at KK Women's and Children's Hospital, Singapore, for intrinsic PUJO from 2008 to 2012 were included. Patients with other co-occurring renal pathologies were excluded. Controls were obtained from nephrectomy patients with Wilm's tumor or other benign renal conditions during the same period. Specimens were stained immunohistochemically with neuronal markers protein gene product 9.5 (PGP9.5), synaptophysin, and S-100, and with CD-117, a marker for interstitial cells of Cajal (Table). Levels of expression of the markers were assessed semiquantitatively (decreased, increased or no change) in comparison with controls by two independent observers. Pre-operative data of patients' renal anatomical (ultrasonography measurements of renal pelvis size) and functional parameters (differential renal function measured using MAG-3 renal scans) were obtained. Discussion Thirty-eight PUJO specimens (38 renal units) and 20 controls were studied. Mean patient age at pyeloplasty was 25.3 months (2.9–167.6 months). Median pre-operative pelvic size was 25.0 mm (17.0–50.0 mm). Both PUJO specimens and controls showed great heterogeneity in distribution of innervation. All four immunohistochemical markers were not predictive of significant pre-operative renal pelvis dilation or pre-operative diminished renal function of the operated kidney. Conclusions There exists marked variability in expression of neuronal markers synaptophysin, PGP9.5, and S-100, and CD-117 in PUJO specimens compared with controls. Our results show no clinical significance of the expression of neuronal markers in predicting degree of pre-operative renal pelvis dilation or differential renal function. The heterogeneity of expression of neuronal markers in PUJO specimens and controls in our population is at variance with prior studies. The etiology of PUJO is likely to be complex and multifactorial. Neuronal marker Function Synaptophysin - Most abundant integral membrane protein constituent of synaptic vesicles - Ubiquity in synapses allows for quantification of synapses - Function unknown PGP9.5 - Deubiquitinating enzyme in neurons and nerve fibers - Neuron-specific cytoplasmic marker CD-117 - Transmembrane tyrosine kinase growth factor receptor - Expressed in interstitial cells of Cajal, which generate and propagate electrical slow waves causing phasic contractions in gastrointestinal tract - Interstitial cells of Cajal present in renal pelvis and ureter S-100 - Function unknown - Specific marker for localizing cells of neural origin especially Schwann cells

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 LA group [mean, 45.4 hours (95% CI, 36.8-54)] than the OA group [mean, 77 hours (95% CI 56.7-97.3)] (P = 0.007). The mean duration for postoperative opioid analgesia was 2.5 days (95% CI, 2.2-2.7) for LA and 3.2 days (95% CI, 2.9- 3.6) for OA (P = 0.001). The resumption of oral feeds after surgery was at 3.1 days (95% CI, 2.8-3.3) for LA and 3.7 days (3.4-4.1) for OA (P = 0.005). The length of the hospital stay was shorter in the LA group [mean, 6.5 days (95% CI, 6.1-6.8)] as compared to that of the OA group [mean, 8.2 days (95% CI, 7.1-9.3)] (P = 0.006). Postoperative complications included wound infection, adhesive intestinal obstruction and pelvic abscess formation. The incidence of these complications was 5.6% in the LA group and 19.6% in the OA group (P = 0.01). Nine patients (9.8%) needed conversion to open surgery in the LA group. None of the LA patients had wound infection. Conclusion: LA is feasible, safe and beneficial in children with PA. Key words: Appendicitis, Complications, Treatment

Aim The aim of this study was to develop a new Children's Appendicitis Score (CAS) by combining 3 inflammatory markers and a set of predictors for suspected appendicitis in children. Methods 374 children aged 4–16years with suspicion of appendicitis were prospectively enrolled for the derivation cohort. Demographic characteristics, clinical features, laboratory, and histology data were collected. The outcome measure was the histological presence or absence of appendicitis. Backward logistic regression was employed to select predictors for construction of a score. Diagnostic performance of CAS was compared with the Pediatric Appendicitis Score (PAS) on a separate validation cohort. Results The combination of normal white blood cell count (WBC), neutrophil percentage, and C-reactive protein (CRP) had a 100% negative predictive value for appendicitis. We assigned ‘coefficient A' as ‘zero' when all triple markers were negative and ‘one' when any one markers was positive. A second component of 6 predictors was identified for construction of the ‘raw score': Localized right-lower-quadrant pain, generalized guarding, constant characteristic of pain, pain on percussion or coughing, WBC≥14000/L and CRP≥24g/L. CAS was generated by multiplying ‘coefficient A' by ‘raw score'. Conclusion CAS is superior to PAS in ruling out appendicitis. Risk stratification of equivocal patients could guide the need for further diagnostic imaging examination.

Bile duct perforation (BDP) with resultant biliary ascites in children is a rare clinical condition. The aetiopathogenesis is still an enigma, with increasing evidence suggesting anomalous union of pancreaticobiliary ductal (AUPBD) system as the prime causative factor.We report 2 cases of spontaneous perforation of the bile duct confirmed on histopathological examination as choledochal cyst, in a 6-month-old female child and a 4-year-old boy who presented with subtle clinical symptoms.Both patients were successfully managed by excision of the gall bladder and common bile duct and Roux-en- Y hepaticojejunostomy. This procedure was performed following initial cholecystostomy drainage in the second case.From the available literature and experience with our patients, BDP is not merely spontaneous but may be related to AUPBD and choledochal cyst.

Meckel's diverticulum (MD), a seemingly innocuous anomaly of the gastrointestinal tract, presents distinctive challenges to a clinician, as it is prone to varied complications that are frequently elusive to diagnosis with conventional diagnostic modalities. This case series illustrates the diverse presentations and advantages of laparoscopic-assisted management of Meckel's diverticular complications in children. Between October 2002 and April 2006, 36 patients (27 males and 9 females) aged 1.5 to 16 years (median 10 years) underwent laparoscopic-assisted trans-umbilical Meckel's diverticulectomy (LATUM). Sixteen (44.4%) patients presented with lower gastrointestinal bleeding (14 with painless bleed and 2 with perforated peptic ulcer in the ileum adjacent to the MD), six (16.7%) patients presented with intestinal obstruction (four due to a mesodiverticular band and one each due to intussusception and floppy giant cystic dilatation of MD causing intestinal compression) and four (11.1%) patients presented with features masquerading as appendicitis (one with Meckel's diverticulitis and perforation, one with perforated peptic ulcer adjacent to MD and two with a torted and gangrenous MD). In ten (27.8%) patients, incidental MD with a narrow base was noted at laparoscopic exploration for suspected appendicitis. All patients underwent successful LATUM along with appendicectomy in 15 (41.7%) patients. The operative duration ranged from 72 to 266 min (mean 125.9+/-48.4). There were no intra-operative complications and none required conversion to open surgery. The hospital stay was 3 to 9 days (mean 5.3+/-1.2). There were three (8.3%) cases of postoperative adhesive intestinal obstruction; two underwent successful laparoscopic adhesiolysis and one necessitated conversion to suprapubic laparotomy to release the pelvic adhesions. There were no other complications during the follow-up (median 16 months). LATUM is a safe, effective and an esthetic procedure offering timely diagnosis and cure for diverse Meckel's diverticular complications. The technique also allows palpation of the MD and avoids usage of expensive staplers.

Introduction: The emergence of operative laparoscopy has brought a great demand for training surgical residents, but there are no clear guidelines regarding choice of procedure for training, proficiency assessment and accreditation. We aim to examine from a trainee’s point of view, the safety and efficacy of laparoscopic appendicectomy (LA) as a laparoscopic training procedure. Materials and Methods: A retrospective analysis of all the consecutive cases of LA done by a trainee in paediatric laparoscopic surgery from September 2003 to February 2005 was done. Results: A total of 70 consecutive patients (37 males and 33 females) aged 3 to 15 years (mean, 10.5 ± 2.5) with suspected appendicitis underwent LA. Twelve (17.1%) patients had acute appendicitis, 25 (35.7%) had acute suppurative appendicitis adherent to the caecum with localised and/or pelvic pus pocketing, 29 (41.4%) had perforated appendicitis with generalised peritonitis and 4 (5.7%) had normal appendix [mesenteric adenitis (1), omental infarct (1), torted Meckel’s diverticulum (1) and primary peritonitis (1)]. There were no operative complications and none required conversion to open surgery. The operative duration ranged from 25 to 110 minutes (mean, 55.6 ± 23.4). There were two complications; one had adhesive intestinal obstruction and underwent successful laparoscopic adhesiolysis and one had umbilical wound infection. Conclusions: LA is a safe and effective laparoscopic training procedure, in addition to being effective for all stages of appendicitis, as well as concurrent lesions encountered in children with suspected appendicitis. Key words: Appendicitis, Laparoscopy, Training

We report a case of neonatal intestinal volvulus around a persistent right vitelline artery, presenting as an aberrant parieto-mesenteric band on exploratory laparotomy. To our knowledge, this is the first case report in the English literature of a persistent right vitelline artery causing axial intestinal volvulus in a neonate. A review of the literature and the embryopathogenesis is discussed, as well as the importance of emergent diagnoses of such lesions.

Background/Purpose We aim to justify the need for surgical intervention in our patients with childhood small bowel intussusceptions (SBIs) and review the current concepts in childhood SBI. Materials and Methods We retrospectively reviewed the clinical charts of all patients with surgically confirmed SBI between July 1999 and October 2002. Demographic data, clinical presentation and investigations, operative and pathologic findings, and outcome were analyzed. Results Of 173 patients with intussusception, 6 (3.5%) were diagnosed with SBI. Median age was 11 months. Ultrasonography revealed intussusceptions in all patients, but only 1 was diagnosed with SBI. Air enema reductions were attempted in 4 of 6 patients with all ending up in failure and surgery. Surgery revealed ileoileal intussusceptions in 4 patients and jejunojejunal intussusceptions in 2 patients. Two patients had long intussusceptions measuring between 30 and 50 cm in length. Five patients had pathologic lead points, and bowel complications occurred in 2 patients. All underwent bowel resection and primary anastomosis. Conclusion Despite reports on spontaneous reduction of SBI, surgery was unavoidable in all our patients with SBI because of the presence of pathologic lead points and/or bowel complications. Air enema reduction was ineffective in SBI. Due caution should be exercised when selecting patients for expectant management.

Objectives: Kikuchi disease is a benign, self-limiting condition of unknown aetiology, often manifesting as cervical lymphadenopathy and fever. The disease usually manifests itself in adulthood and paediatric reports are uncommon. The aims of this study are to report the features of Kikuchi disease in the local paediatric population, and to raise the awareness of this entity among clinicians involved in treating these children. Methods: This is a retrospective series of nine paediatric cases of Kikuchi disease treated in KK Women's and Children's Hospital, Singapore. The clinical presentation, subsequent clinical course and laboratory findings of these patients were reviewed. Results: The patients ranged in age from 7 to 16 years, and included six males and three females. All nine patients presented with fever and cervical lymphadenopathy. Hepatosplenomegaly was present in one child. The erythrocyte sedimentation rate was raised to variable extents, but there was no other significant haematological, serological or microbiological abnormality. In all cases the diagnosis was made on the basis of histological findings. Conclusions: Kikuchi disease in the paediatric population is not as uncommon as previously thought, and should be considered in the differential diagnosis of any child with fever of unknown origin or cervical lymphadenopathy. Early recognition will minimize unnecessary investigations and prolonged empirical treatments.

The management of an appendiceal mass remains controversial with 2 schools of thought; early surgical intervention vs nonoperative management with or without interval appendectomy. The aim is to determine the role and safety of early laparoscopic appendectomy (LA) in children with acute appendicitis presenting with an appendiceal mass.This is a prospective study of 88 consecutive pediatric patients who underwent attempted LA for suspected acute appendicitis at KK Women's and Children's Hospital, Singapore, between May and October 2003.A total of 88 patients with a mean age of 10 +/- 3 years (range, 3-16 years) underwent LA for an appendiceal mass (n = 22), simple appendicitis (n = 36), other complicated (gangrenous or perforated) appendicitis (n = 23), and a normal appendix (n = 7). There were 7 conversions to open appendicectomy, 3 of which occurred in patients with an appendiceal mass. There were no perioperative or postoperative mortalities. Morbidity occurred in only one patient who underwent LA for perforated appendicitis. He had prolonged sepsis that resolved after 2 weeks of intravenous antibiotics. None of the patients with an appendiceal mass developed complications. Patients who underwent early LA for an appendiceal mass had a statistically significant (P.05) longer operating time (median, 103 minutes; interquartile range, 90-151 minutes, vs median, 87 minutes; interquartile range, 71-112 minutes), prolonged time to ambulation (median, 2.0 days; interquartile range, 2-2.5 days, vs median, 1.0 days; interquartile, 1-2 days), increased time to resumption of diet (median, 4 days; interquartile, 3-5 days, vs median, 2 days; interquartile, 2-3 days), and longer postoperative stay (median, 6.0 days; interquartile, 5.5-6.5 days, vs median, 4.0 days; interquartile, 3-5.5 days) compared with patients presenting with appendicitis without mass formation. However, there was no statistical difference in these parameters when LA for an appendiceal mass was compared with LA for other complicated appendicitis (perforated and gangrenous).Although early LA for an appendiceal mass is a technically demanding procedure, it can be performed safely in children with minimal morbidity and mortality. In an era where patients' demand for "key-hole" surgery is rising, early LA is a safe and viable option in the management of children with an appendiceal mass. It also offers the advantage of avoiding misdiagnoses and the need for a second hospitalization.

Background: Traditionally, every patient with an acute scrotum needed surgical exploration for definitive exclusion of testicular torsion. Objective: In this study, we aimed to evaluate the improved accuracy in clinical diagnosis with colour Doppler Ultrasonography (US) added to normal clinical assessment. Materials and methods: We retrospectively reviewed 626 patients, who presented with acute scrotal pain between January 1998 and June 2004. Following history and physical examination, the patients either proceeded directly to surgery or underwent US examination. If clinical suspicion of testicular torsion persisted after US, the patients would still undergo scrotal exploration. Results: Of the 294 patients who had routine scrotal exploration without preliminary US, only 23 (7.8%) were found to have testicular torsion. Amongst the 332 cases that had initial US, 9 (2.7%) patients revealed testicular torsion that was confirmed at subsequent surgery. The remaining 323 patients had initial negative US, but 29 were explored eventually on clinical indications. Of these, 4 (1.2% of 323) cases were diagnosed intra-operatively as testicular torsion. None of the remaining 294 patients who were managed conservatively proved to have testicular torsion after a minimum follow-up of 2 weeks. For testicular torsion, US yielded a sensitivity of 69.2% (95% confidence interval =38.9–89.5), specificity of 100% (95% CI=98.5–100), positive predictive value of 100% and negative predictive value of 97.5%. Conclusions: US has proven to decrease the number of emergency scrotal explorations, length of hospital stay and hence reduce the cost of management of acute scrotum.

Intraoperative enteroscopy has been known to reduce reoperation rates in complicated Peutz- Jeghers polyposis. It is usually performed during a laparotomy. This case report illustrates the feasibility of performing intraoperative transenterotomy enteroscopy together with extracorporeal ileal resection using the transumbilical approach after successfully reducing an intussusception laparoscopically in a 10-year-old child with Peutz-Jeghers syndrome. This technique obviates the need for a laparotomy.

Our aim was to study the advantages of glue versus sutures for circumcision in children. A randomised prospective controlled study was conducted with 152 boys; glue was used on 80 and sutures on 72). The procedures were quicker and the duration and severity of postoperative pain were significantly less (p

Purpose We evaluated the incidence of congenital anomalies associated with anorectal malformations (ARMs) in relation to the anatomic type of ARM as defined by the Krickenbeck classification. Methods We reviewed 99 children with ARM in our institution from 2002 to 2011. Data were collected on patient demographics, type of ARM, and associated congenital anomalies, which were categorized according to organ systems. Statistical analysis was performed for comparison between groups using ‘perineal fistula' as the base group. Results There were 62 (63%) male patients. The majority had perineal fistulas (35, 35%). Seventy-seven (78%) had at least one associated malformation. The most frequent malformations seen were genitourinary (28, 28%) and spinal anomalies (26, 26%). Those with rectovesical fistula had the highest proportion of genitourinary malformations (Odds Ratio [OR], 41.3; 95% confidence interval [CI], 4.7–363.4). Those with cloaca (OR, 49.5; 95% CI, 3.4–718.9) and those with rectovestibular fistula (OR, 12.4; 95% CI, 2.3–65.6) were most likely to have major spinal abnormalities, with tethered cord seen in all groups. The rectovestibular group was also most likely to have other associated malformations (OR, 8.6; 95% CI, 2.2–32.8). Conclusion More than 75% of children with anorectal malformation have other associated malformations. Genitourinary anomalies are the most common. Major spinal anomalies are seen in all groups, affecting nearly half of those with rectovestibular fistula and those without fistula. The incidence of associated malformations in the rectovestibular group is higher than described in the literature. Thorough systematic evaluation of all infants with ARM should be done regardless of type of ARM.

Spontaneous perforation is a rare complication of choledochal cyst (CDC) which is difficult to diagnose due to its nonspecific clinical presentation. The surgical treatment can be either single-staged cyst excision or two-staged procedure with an initial drainage followed by delayed cyst excision. Both biliary duct obstruction and irritation due to refluxed pancreatic juice have been proposed as possible aetiology. In this report, we describe six cases of CDC perforation in hope to have a better understanding on the clinical features and cause of this complication. Medical records of six patients whose diagnoses of perforated CDC were confirmed with intra-operative findings were retrospectively reviewed. Clinical data, investigation results and post-operative outcomes were analysed. Vomiting and abdominal pain were the most common complaints. Few patients present with clinical jaundice. Overt sign of peritonitis was absent. Both single-staged and two-staged approach offered satisfactory outcome. Hyperbilirubinaemia and remote free intra-peritoneal fluid allude the diagnosis of perforated CDC. When presenting with cholangitis, it warrants timely surgical intervention to prevent perforation. Single-staged or two-staged surgical approach would depend on stability of patient and surgical expertise available. Reversible dilatation of intra-hepatic duct suggests that increased intra-ductal pressure is a contributing factor to the perforation.

Acute appendicitis in the immunosuppressed patients are often difficult to diagnose and are associated with increased morbidity and mortality. Recent debates on primary appendicitis and typhlitis-associated appendicitis have contributed to the diagnostic and therapeutic dilemma. We retrospectively reviewed all our immunosuppressed patients with appendicitis. The most frequent presenting symptom was fever followed by non-specific intermittent abdominal pain. The median delay in diagnosis was 4 days. CT scan was useful in making the diagnosis, but the presence of adjacent bowel thickening has contributed to the dilemma in diagnosis and treatment.

Acute suppurative thyroiditis (AST), a potential complication of pyriform sinus fistula (PSF), is a rare clinical condition as the thyroid gland is remarkably resistant to infections. Lack of awareness of the entity contributes to the rarity and frustrating recurrences. We performed a retrospective review of all cases of AST due to PSF treated at our institution over a 10-year period. The clinical data, investigations, operative findings and procedures, microbial culture reports and follow-up were recorded and analyzed. Between January 1997 and September 2006, 12 cases (8 males and 4 females) of AST due to PSF were treated. Nine patients (75%) underwent successful complete excision, seven of whom had initial incision and drainage procedures. In three patients (25%) with recurrence, one underwent complete excision at a later procedure, one patient had multiple recurrences with six incision and drainage procedures and two failed attempts of excision of PSF before final successful complete excision. The third patient is awaiting re-excision of the PSF tract. All patients, except the one awaiting re-excision, are well with no further recurrences during the follow-up period that ranged from 18 to 96 months (median, 46.5 months). AST due to PSF is a challenging entity in terms of diagnosis and management as recurrences are common despite meticulous dissection. High index of suspicion and radiological investigations such as barium studies and computed tomography scan aid in the delineation and excision of the fistulous tract.

Background and Objectives: Meckel's diverticulum (MD) presents unique challenges for a pediatric surgeon, as it is prone to varied complications. This case series highlights the diverse presentations and laparoscopic management of MD in children. Methods: We performed a retrospective analysis of consecutive cases of laparoscopic-assisted transumbilical Meckel's diverticulectomy (LATUM) performed by the same surgeon for incidental as well as diverse Meckel's diverticular complications over 20 months. Results: Eight patients (5 males and 3 females) aged 3 years to 13 years (median, 12) underwent LATUM. Three patients had painless per-rectal bleeding and 1 presented with intestinal obstruction due to a mesodiverticular band and intestinal ischemia. Two patients had features masquerading as appendicitis; one had perforated MD with secondary inflammation of the appendix, and the other had a torsed, gangrenous MD. In 2 patients, incidental MD with a narrow base was noted at appendicectomy for appendicitis. All patients underwent successful LATUM along with appendicectomy in 4 patients. The operative duration was 72 minutes to 165 minutes (mean, 112.1±30.6). There were no operative complications, and no conversion to open surgery was required. The hospital stay was 4 days to 7 days (mean, 4.7±1.2). The patient with mesodiverticular band intestinal obstruction presented with adhesive intestinal obstruction 2 weeks after the surgery. Laparoscopic-assisted minilaparotomy was done to release the pelvic adhesions. There were no other complications during the follow-up (median, 11 months). Conclusions: LATUM is a simple, safe, and effective procedure with a better cosmetic outcome that can be performed for diverse manifestations of MD. The technique also allows palpation of the MD and avoids use of expensive staplers.

The emergence of operative laparoscopy has brought a great demand for training surgical residents, but there are no clear guidelines regarding choice of procedure for training, proficiency assessment and accreditation. We aim to examine from a trainee's point of view, the safety and efficacy of laparoscopic appendicectomy (LA) as a laparoscopic training procedure.A retrospective analysis of all the consecutive cases of LA done by a trainee in paediatric laparoscopic surgery from September 2003 to February 2005 was done.A total of 70 consecutive patients (37 males and 33 females) aged 3 to 15 years (mean, 10.5 +/- 2.5) with suspected appendicitis underwent LA. Twelve (17.1%) patients had acute appendicitis, 25 (35.7%) had acute suppurative appendicitis adherent to the caecum with localised and/or pelvic pus pocketing, 29 (41.4%) had perforated appendicitis with generalised peritonitis and 4 (5.7%) had normal appendix [mesenteric adenitis (1), omental infarct (1), torted Meckel's diverticulum (1) and primary peritonitis (1)]. There were no operative complications and none required conversion to open surgery. The operative duration ranged from 25 to 110 minutes (mean, 55.6 +/- 23.4). There were two complications; one had adhesive intestinal obstruction and underwent successful laparoscopic adhesiolysis and one had umbilical wound infection.LA is a safe and effective laparoscopic training procedure, in addition to being effective for all stages of appendicitis, as well as concurrent lesions encountered in children with suspected appendicitis.

Background Despite routine use of air enema reduction in childhood intussusceptions, some still require operative management. This study evaluated the role of surgery and identified factors associated with failed air enema reduction and bowel resection. Methods We reviewed 24 patients who underwent laparotomies for intussusception between 1 July 1999 and 31 July 2002. Demographic data, clinical presentations, investigations, surgical interventions and their outcomes were reviewed. Results Twenty-four (14.5%) of 166 patients treated for intussusceptions between 1 July 1999 and 31 July 2002 underwent laparotomies. A significant proportion (45.8%) was younger than 3 months and older than 36 months of age. Intussusception was diagnosed on ultrasonography in 21 patients. Eighteen underwent attempted air enema reduction. Ileocolic intussusceptions occurred in 54.2% of patients. Five patients had small bowel intussusceptions, all of whom required bowel resection. Seven patients (29.2%) had pathological lead points. Presence of pathological lead points and intussusceptions occurring outside the ileocolic region strongly predicted the need for bowel resection. Conclusion Air enema reductions are less likely to succeed in patients less than 3 months old and those more than 3 years old. Bowel resection is most likely required when pathological lead points are present and when intussusceptions occur outside the ileocolic region. Early surgical intervention may obviate the need for bowel resection in selected patients, thereby reducing surgical morbidity.

We report an unusual case of acute abdomen due to axial torsion and infarction of a Meckel's diverticulum in a 13-year-old boy and illustrate the versatility of laparoscopy in the diagnosis and management of acute surgical abdomen in children. We believe that this is only the third case reported in a child of torsion of a Meckel's diverticulum and the first to be managed by laparoscopic resection.

Tissue adhesives have gained favour for quicker and painless closure of lacerations. To compare the tissue adhesive 2-octylcyanoacrylate with our current standard subcuticular suture for closure of surgical incisions in children, looking at outcome measures of time efficiency, cosmesis, and wound complications, a prospective, randomised, controlled trial was conducted at our institution's ambulatory surgery centre. All healthy patients undergoing unilateral or bilateral herniotomies were recruited prospectively with informed consent and randomly allocated to suture or glue. The exclusion criteria were neonates or children with allergy to tissue glue. Time of wound closure was measured from the subcutaneous layer to application of the dressing. An independent, blinded observer assessed cosmesis at 2 to 3 weeks using a validated wound scale ranging from worst (0) to best (6). Parent satisfaction with wound appearance was recorded on a 100-mm visual analogue scale (VAS). A total of 59 patients were recruited into the study with 26 in the glue group and 33 in the suture group. There was no difference in mean time of closure (glue 181 +/- 62 s vs suture 161 +/- 45 s, P = 0.18). Two patients in each group had a suboptimal Hollander wound score of 5 (7.7% glue, 6.1% suture). There was also no difference in parent satisfaction (VAS: glue 78 +/- 19 mm vs suture 81 +/- 15 mm, P = 0.68). No patient reported any rash, wound infection, or dehiscence. Tissue glue is easy to use with no complications and has equivalent cosmetic results, but is not faster than a subcuticular suture.

The carbon dioxide laser for circumcision was introduced by our department in 1989. This study aims to review our experience with laser circumcision for children and to evaluate its cost effectiveness as compared to conventional methods. A retrospective study of 30 patients who underwent conventional circumcision in 1985 and another 30 patients who underwent laser circumcision in 1995 was undertaken. The operating times in both groups were compared. The total cost of use of the laser machine was calculated, taking into account maintenance costs, estimated life span of laser machines (10 years) and costs of disposables used during each circumcision. This was weighed against the cost savings from shorter operating times and reduced operating theatre facility charges. Also, morbidity data from 2781 laser circumcisions done between May 1997 and April 2000 was collected. There was a significant decrease of 5 minutes in operating time for the group of patients who underwent laser circumcision. Calculated cost savings per laser circumcision from the reduced operating theatre time was S dollars 31/-. Of the 2781 cases of laser circumcision performed, there was an overall complication rate of 1.15%. Twenty-nine cases (1.04%) had post circumcision bleeding, of which 10 cases (0.36%) required unplanned return to operating theatre for hemostasis. Three cases (0.11%) had wound infection, requiring admission to hospital. Laser circumcision is a simple method with reduced operative time translating into cost effectiveness. Morbidity rates of laser circumcision compare favourably to those of conventional circumcision based on reports from other institutions.

Background Continuous surveillance for intussusception (IS) is important for monitoring the safety of second-generation rotavirus vaccines. The present study aimed to assess the incidence of IS in Singaporean children aged < 2 years. Methods This was a prospective, hospital-based, multi-center surveillance conducted in seven hospitals - two public hospitals and five private medical centers between May 2002 and June 2010 in Singapore. Diagnosis of IS (definite, probable, possible, suspected) was based on the case definition developed by the Brighton Collaboration. Children < 2 years of age who were diagnosed with IS were enrolled in this study. Incidence of IS was calculated per 100,000 child-year with its 95% confidence interval. Results Of the 178 children enrolled, 167 children with definite IS cases were considered for final analyses; 11 were excluded (six diagnosed as probable IS and four diagnosed as suspected IS; one child’s parents withdrew consent). Mean age of children with definite IS was 11.6 ± 6 months; 67.7% were males. The overall incidence of IS was 28.9 (95% CI: 23.0–34.8) and 26.1 (95% CI: 22.2–30.0) per 100,000 child-year in children < 1 year and < 2 years of age, respectively. The majority of IS cases (20 [12.0%]) were reported in children aged 6 months. Most children (98.2% [164/167]) recovered, two (1.2%) children recovered with sequelae and one (0.6%) child died of septic shock. Conclusions The incidence of IS remained low and stable in Singaporean children aged < 2 years during the study period (May 2002 to June 2010). Trial registration NCT01177839