CORESS is an independent charity, supported by AXA Health, the MDU and the Kirby Laing Foundation

We are grateful to those who have provided the material for these reports. The online reporting form is available on the website (coress.org.uk), which also includes previous Feedback reports, and via the CORESS app. Published cases will be acknowledged by a Certificate of Contribution, which may be included in the contributor's record of continuing professional development, or which may form part of appraisal or annual review of competence progression portfolio documentation. Trainee contributions are particularly welcome.

CORESS is an independent charity, supported by AXA Health, the MDU and the Kirby Laing Foundation

We are grateful to those who have provided the material for these reports. The online reporting form is available on the website (coress.org.uk), which also includes previous Feedback reports, and via the CORESS app. Published cases will be acknowledged by a Certificate of Contribution, which may be included in the contributor's record of continuing professional development, or which may form part of appraisal or annual review of competence progression portfolio documentation. Trainee contributions are particularly welcome.

Patient-centred outcomes following non-operative treatment or appendicectomy for uncomplicated acute appendicitis in children

While non-operative treatment has emerged as an alternative to surgery for the treatment of uncomplicated acute appendicitis in children, comparative patient-centred outcomes are not well documented. We investigated these in a feasibility randomised trial. Of 57 randomised participants, data were available for 26. Compared with appendicectomy, children allocated to non-operative treatment reported higher short-term quality of life scores, shorter duration of requiring analgesia, more rapid return to normal activities and shorter parental absence from work. These preliminary data suggest differences exist in recovery profile and quality of life between these treatments that are important to measure in a larger RCT. Trial registration number is ISRCTN15830435.

CONservative TReatment of Appendicitis in Children: a randomised controlled feasibility Trial (CONTRACT)

OBJECTIVE

To establish the feasibility of a multicentre randomised controlled trial to assess the effectiveness and cost-effectiveness of a non-operative treatment pathway compared with appendicectomy in children with uncomplicated acute appendicitis.

DESIGN

Feasibility randomised controlled trial with embedded qualitative study to inform recruiter training to optimise recruitment and the design of a future definitive trial.

SETTING

Three specialist paediatric surgery centres in the UK.

PATIENTS

Children (aged 4-15 years) with a clinical diagnosis of uncomplicated acute appendicitis.

INTERVENTIONS

Appendicectomy or a non-operative treatment pathway (comprising broad-spectrum antibiotics and active observation).

MAIN OUTCOME MEASURES

Primary outcome measure was the proportion of eligible patients recruited. Secondary outcomes evaluated adherence to interventions, data collection during follow-up, safety of treatment pathways and clinical course.

RESULTS

Fifty per cent of eligible participants (95% CI 40 to 59) approached about the trial agreed to participate and were randomised. Repeated bespoke recruiter training was associated with an increase in recruitment rate over the course of the trial from 38% to 72%. There was high acceptance of randomisation, good patient and surgeon adherence to trial procedures and satisfactory completion of follow-up. Although more participants had perforated appendicitis than had been anticipated, treatment pathways were found to be safe and adverse event profiles acceptable.

CONCLUSION

Recruitment to a randomised controlled trial examining the effectiveness and cost-effectiveness of a non-operative treatment pathway compared with appendicectomy for the treatment of uncomplicated acute appendicitis in children is feasible.

TRIAL REGISTRATION NUMBER

ISRCTN15830435.

Parental decisional satisfaction after hypospadias repair in the United Kingdom

BACKGROUND

In hypospadias, the aim of surgical treatment is to achieve both desirable functional and cosmetic outcomes; however, complications following surgery are common and 18% of boys require re-operation. In mild degrees of hypospadias, repair may be offered entirely to improve cosmesis, meaning parents should be fully informed of this and the potential for complications, during the consent process. Parents' decision-making may be aided by making them aware of how others in a similar position have felt about the decision that they made for their child. One method of measuring parental satisfaction is decisional regret (DR).

OBJECTIVES

To assess parental satisfaction following hypospadias surgery in the United Kingdom by assessing DR and to determine the feasibility of obtaining meaningful data via a mobile phone survey.

STUDY DESIGN

The National Outcomes Audit in Hypospadias database was commissioned by the British Association of Paediatric Surgeons to capture clinical information from hypospadias repairs. Following ethical approval (16/NW/0819), a text message was sent to mobile numbers in the database inviting participation in a questionnaire incorporating the validated DR scale (DRS). The primary outcome measure was mean DRS score, which was correlated with clinical information, a score of zero indicated no regret and 100 indicated maximum regret.

RESULTS

There were 340 (37%) responses. The median age at the primary procedure was 16 (interquartile range 13-20) months. No DR (score = 0) was detected in 186 (55% [95%CI 49-60]) respondents; however, moderate-to-severe DR (score = 26-100) was seen in 21 (6.2% [95%CI 3.6-8.7]) respondents. On multivariate analysis, a distal meatus, a small glans and developing complications requiring repeat surgery were all associated with increased levels of regret (Table). There was no association between DR and cases performed per surgeon.

DISCUSSION

Around half of respondents demonstrated no DR and postoperative complications requiring surgery were associated with the highest levels of DR, which is similar to a Canadian study. Lorenzo et al. however found that DR was associated with circumcision, which was undertaken in all boys; however, in this UK study, around a third of boys were circumcised and regret levels between those circumcised and those not circumcised were similar. The limitations of this work include the following: surgeons submitting their own data on complications and there is potential of selection bias between respondents and non-respondents as with any survey.

CONCLUSIONS

Data from this study can be used to improve pre-operative counselling during the consent process. Smart mobile phone technology can be used successfully to distribute and collect parent-reported outcomes.

A review of novel STING bulking agents

OBJECTIVE

The objective of this study was to review the literature to compare the efficacy and complications of polyacrylate-polyalcohol copolymer (PPC) and polyacrylamide hydrogel (PAHG) with the current standard of care, dextranomer/hyaluronic acid (Dx/HA), when used to treat VUR in the paediatric population.

METHODS

PubMed, Embase and Cochrane databases were searched. Keywords included Vesicoureteral reflux (VUR), endoscopic; endoscopic injection, endoscopic treatment, dulking material, dextranomer/hyaluronic acid copolymer, polyacrylate-polyalcohol copolymer, Deflux, Dexell, Vantris, Bulkamid, outcome, treatment and children. Prospective or retrospective studies comparing PAHG/PPC directly with Dx/HA were included for review.

RESULTS

Four studies were identified comparing PPC with Dx/HA. All studies showed superior efficacy (on micturating cystourethrogram (MCUG) at 3 months) of PPC over Dx/HA. However, 1 study identified a significantly higher rate of vesicoureteric junction obstruction (VUJO) in the PPC group. One study was identified comparing PAHG with Dx/HA which showed similar efficacy on 3-month MCUG.

CONCLUSIONS

Current data suggest PPC confers a higher resolution rate of VUR and PAHG confers comparable resolution rates for VUR compared with Dx/HA in the paediatric population. However, the incidence of late-onset VUJO in one study is concerning, and high-quality randomised controlled trials with long-term follow-up are needed before making further recommendations.

CONTRACT Study - CONservative TReatment of Appendicitis in Children (feasibility): study protocol for a randomised controlled Trial

BACKGROUND

Currently, the routine treatment for acute appendicitis in the United Kingdom is an appendicectomy. However, there is increasing scientific interest and research into non-operative treatment of appendicitis in adults and children. While a number of studies have investigated non-operative treatment of appendicitis in adults, this research cannot be applied to the paediatric population. Ultimately, we aim to perform a UK-based multicentre randomised controlled trial (RCT) to test the clinical and cost effectiveness of non-operative treatment of acute uncomplicated appendicitis in children, as compared with appendicectomy. First, we will undertake a feasibility study to assess the feasibility of performing such a trial.

METHODS/DESIGN

The study involves a feasibility RCT with a nested qualitative research to optimise recruitment as well as a health economic substudy. Children (aged 4-15 years inclusive) diagnosed with acute uncomplicated appendicitis that would normally be treated with an appendicectomy are eligible for the RCT. Exclusion criteria include clinical/radiological suspicion of perforated appendicitis, appendix mass or previous non-operative treatment of appendicitis. Participants will be randomised into one of two arms. Participants in the intervention arm are treated with antibiotics and regular clinical assessment to ensure clinical improvement. Participants in the control arm will receive appendicectomy. Randomisation will be minimised by age, sex, duration of symptoms and centre. Children and families who are approached for the RCT will be invited to participate in the embedded qualitative substudy, which includes recording of recruitment consultants and subsequent interviews with participants and non-participants and their families and recruiters. Analyses of these will inform interventions to optimise recruitment. The main study outcomes include recruitment rate (primary outcome), identification of strategies to optimise recruitment, performance of trial treatment pathways, clinical outcomes and safety of non-operative treatment. We have involved children, young people and parents in study design and delivery.

DISCUSSION

In this study we will explore the feasibility of performing a full efficacy RCT comparing non-operative treatment with appendicectomy in children with acute uncomplicated appendicitis. Factors determining success of the present study include recruitment rate, safety of non-operative treatment and adequate interest in the future RCT. Ultimately this feasibility study will form the foundation of the main RCT and reinforce its design.

TRIAL REGISTRATION

ISRCTN15830435 . Registered on 8 February 2017.

Enterostomy-related complications and growth following reversal in infants

BACKGROUND

Infant enterostomies are used to manage various neonatal surgical conditions where it is not suitable or safe to form a primary anastomosis. Complications are common and there is no consensus regarding optimal timing of enterostomy reversal. Stoma reversal is thought to allow patients to thrive; however, this has not been demonstrated robustly.

AIM

The study aimed to identify risk factors for enterostomy-related complications and to determine the relationship between enterostomy complications, enterostomy reversal and weight gain in infants with enterostomies.

METHODS

A retrospective case note review of 58 infants who underwent enterostomy formation and reversal during a 6-year period was undertaken; demographic data, diagnosis, enterostomy complications and serial weights were noted. Standardised growth charts were used to calculate z scores.

RESULTS

Enterostomy complications were documented in 24 infants (41%). Infants of low birth weight and low gestational birth age were significantly more likely to have an enterostomy-related complication (1110 vs 2125 g, 28.5 vs 35 weeks, respectively); they were more likely to have longer inpatient stays and remain dependent on parenteral nutrition prior to closure (median 92.5 vs 52 days, 40% vs 16%, respectively). Irrespective of diagnosis, gestation and presence of an enterostomy complication, the mean z score prior to enterostomy closure was -0.747 vs +0.892 following closure.

CONCLUSIONS

Around 40% of infants with an enterostomy will have an enterostomy-related complication. Whatever their weight, gestation or underlying pathology, most infants thrive after enterostomy closure and this should be considered when planning the optimal timing for this procedure.

Bleeding after circumcision is more likely in children with lichen sclerosus (balanitis xerotica obliterans)

INTRODUCTION

Over 27,000 circumcisions were performed in England in 2012-13. The complication rate is generally perceived to be low, although published figures vary widely. Balanitis xerotica obliterans, more correctly termed Lichen Sclerosus et atrophicus (LS), is one of the commonest indications for medical circumcision. To test the hypothesis that children undergoing circumcision for LS have a higher rate of postoperative bleeding than those undergoing the procedure for other reasons, we retrospectively reviewed records for patients undergoing circumcision.

METHODS

The disease and procedure coding system was used to identify patients who underwent circumcision (ICD10 code N303) between 2000-2010. Cases with a diagnosis unrelated to circumcision and children circumcised during hypospadias repair were excluded. Bleeding which required return to theatre for surgical arrest was considered significant. Cases were identified by review of medical records if there was: a second procedure during the same admission, or readmission coded for circumcision within 2 weeks. Only cases with histologically confirmed LS were included in the LS cohort. GraphPad online calculator was used for statistical analysis (two tailed Fisher's exact test.

RESULTS

2385 boys with a median age of 4 years (range 0-16) were included in the study. Indication for circumcision included religious (1305, 54.7%), phimosis or redundant prepuce (512, 21.5%), suspected LS (366, 15.4%) and balanoposthitis (202, 8.5%). LS was histologically confirmed in 262 (10.9%) boys. Fourteen (0.6%) patients returned to theatre for surgical arrest of bleeding following circumcision; 6 had LS and 8 did not (Table 1). The bleeding rate was higher in those with LS (2.3%) than in those without (0.3%), P = 0.0003 with a relative risk of 6.08.

CONCLUSION

Post-operative complications are distressing, especially if further surgery is required. Published figures for complications following circumcision vary widely making counseling regarding risk difficult. Since LS includes an inflammatory element and circumcision in widespread LS can be challenging, the observation of more post-operative bleeding in patients with histologically confirmed LS during a previous audit prompted the hypothesis that this may be a significant finding. Thus we reviewed all patients requiring return to theatre within 2 weeks of circumcision, finding that whilst the overall bleeding rate was low, circumcision for LS significantly increased the risk. Although factors such as the severity of LS and surgical technique were not assessed, this is still a notable finding which should be reflected during pre-operative counseling.

Crohn's disease presenting as enterovesical fistula

Enterovesical fistulae in Crohn's disease are relatively rare. We present the first report of a child presenting with an enterovesical fistula as the initial presentation of Crohn's disease. Management comprises of timely diagnosis, and treatment involving surgical resection with adjunctive medical management including immunomodulators. This case highlights the need to be aware of the rare but important occurrence of Crohn's enterovesical fistula as a cause for urinary symptoms in a child with inadequate weight gain.

Allantoic cyst - an unusual umbilical cord swelling

We report a baby with an unusual umbilical cord swelling. On the antenatal scans, a cystic area within the umbilical cord near its insertion onto the abdominal wall was detected. Postnatally an unusually thick umbilical cord with a yellow fluid filled cyst at the base was noted. The fluid from the cyst was confirmed as urine and ultrasound confirmed patent urachus. The baby underwent a cystoscopy and excision of patent urachus with associated allantoic cyst. Allantoic cyst is a rare swelling formed at the base of umbilicus associated with a patent urachus which results from an allantoic remnant. Paediatricians need to be aware about this condition as investigation is required to differentiate allantois cysts from umbilical pseudocysts. A patent urachus with allantoic cyst requires surgical excision.

Interaction between oral hydralazine and propranolol. II. Assessment of altered splanchnic blood flow as the determinant of altered presystemic extraction

Coadministration of p.o. hydralazine and d-propranolol or dl-propranolol in six conscious dogs caused a significant increase in peak plasma concentration and area under the p.o. plasma concentration-time curve of propranolol (P less than .01, P less than .01, peak plasma concentration; P less than .01 and P less than .05, area under the plasma concentration-time curve; d-propranolol and dl-propranolol, respectively). Coadministration of p.o. hydralazine with p.o. dl-propranolol resulted in a small trend toward an increase in systemic clearance of i.v. dl-[3H]propranolol; however, this did not reach statistical significance (P less than .2, P less than .1, d-propranolol and dl-propranolol, respectively). When a mixture of d-propranolol and 14C-labeled dl-propranolol was administered into the jejunum of seven anesthetised dogs, the absorption into portal vein of the 14C-labeled dl-propranolol paralleled closely that of d-propranolol both in terms of time to peak and absorption as measured by a percentage of total area under the plasma concentration-time curve at an arbitrary time (10 min) postdose. Assessment of hepatic extraction (E) showed similar close parallels (d-propranolol, E = 0.85 +/- 0.02; dl-[14C]propranolol, E = 0.86 +/- 0.03: mean +/- S.E.M., n = 5, P less than .70). Hepatic extraction of propranolol and blood flow in mesenteric artery and hepatic artery were measured in 23 anesthetised dogs given a constant infusion of d-propranolol into portal vein (11 micrograms/kg/min), made up to 6 control and 17 hydralazine-treated dogs.(ABSTRACT TRUNCATED AT 250 WORDS)

Interaction between oral hydralazine and propranolol. I. Changes in absorption, presystemic clearance and splanchnic blood flow

A study was undertaken of propranolol pharmacokinetics in dogs before and after oral coadministration of hydralazine to determine whether interactions described in humans could be reproduced in an animal model. Additionally, physiological parameters considered to be relevant to the pharmacokinetic handling (absorption rate and splanchnic hemodynamics) were studied. Coadministration of oral hydralazine and propranolol in conscious dogs caused an increase in peak plasma concentration ( Cpmax ) and area under the oral plasma concentration-time curve (AUC) of propranolol ( Cpmax = 19.2 +/- 5.8 ng/ml, control; Cpmax = 91.5 +/- 12.8 ng/ml, posthydralazine : AUC = 65.7 +/- 14.6 ng X hr/ml, control; AUC = 152.4 +/- 23.9 ng X hr/ml, posthydralazine : mean +/- S.E.M., n = 5; P less than .01 and P less than .01), without change either in the peak plasma level, time to peak or plasma AUC of [14C] propranolol and metabolites (P greater than .70, P greater than .90 and P greater than .60, respectively) or in urinary recovery (urinary recovery = 39.7 +/- 4.3% dose, control; urinary recovery = 41.8 +/- 6.2% dose, posthydralazine ). When propranolol was administered i.v., hydralazine caused a small (42.3 +/- 18%), but significant (P less than .025), increase in systemic clearance. Oral bioavailability increased from 7.3 +/- 2.1 to 23.6 +/- 5.1% (mean +/- S.E.M., n = 5, P less than .025), hepatic extraction showed correspondingly inverse changes and estimated hepatic blood flow increased from 34.9 +/- 3.8 to 63.3 +/- 10.8 ml/min/kg (P less than .025).(ABSTRACT TRUNCATED AT 250 WORDS)