To evaluate the clinical relevance of the nonvisualized appendix on ultrasound imaging in childre... more To evaluate the clinical relevance of the nonvisualized appendix on ultrasound imaging in children with right lower quadrant pain. We reviewed 1359 children admitted for abdominal pain between January and December 2013 who had abdominal ultrasound imaging for right lower quadrant pain. Patients who had scans for genitourinary symptoms or intussusception were excluded from the study. When the appendix was not visualized, secondary signs indicating right lower quadrant inflammatory pathology were noted. Of all admissions for abdominal pain, 810 had ultrasound scans. Thirty-eight did not evaluate the appendix and 131 were excluded for suspected intussusception, leaving 641 reports for children with a median age of 10.8 years (range, 1.3-21.3); 297 were boys (46.3%). There were 17 of 160 patients with a nonvisualized appendix (10.6%) who underwent appendectomy. Of these, 14 had secondary signs on ultrasound imaging and 3 (1.9%) had normal ultrasound reports. The 3 patients with normal u...
A 55-day-old boy was transferred to our unit with intestinal obstruction and obstructive jaundice... more A 55-day-old boy was transferred to our unit with intestinal obstruction and obstructive jaundice after two neonatal operations for duodenal atresia and intestinal malrotation. Abdominal ultrasound showed dilated intrahepatic and extrahepatic ducts with cut-off at the distal common bile duct (CBD). He underwent emergency laparotomy for adhesive intestinal obstruction with a contained abscess from mid-jejunal perforation. Biliary dissection was not attempted due to poor preoperative nutritional status. Tube cholecystostomy was created for biliary decompression. Postoperative magnetic resonance cholangiopancreatography showed dilated CBD with cut-off at the ampulla but did not demonstrate pancreaticobiliary maljunction (PBMJ). The diagnostic dilemma was whether our patient had congenital PBMJ or had developed biliary stricture from perioperative ischaemic scarring. He underwent definitive surgery at 7 months: excision of dilated CBD with Roux-en-Y hepaticojejeunal reconstruction, exci...
Biliary atresia (BA) has preponderance in Asian populations with Kasai portoenterostomy (KP) rega... more Biliary atresia (BA) has preponderance in Asian populations with Kasai portoenterostomy (KP) regarded as the first-line standard of care. Yet reports from Southeast Asia remain scant. This study reviews the demographics, short- and medium-term outcomes for our cohort, and evaluates prognostic factors for outcome. All patients diagnosed with BA between January 1997 and December 2013 were included. Clinical data were obtained from medical records. Jaundice clearance was defined as total bilirubin < 20 µmol/L within 6 months after KP. Two-year and 5-year native liver survival (NLS) were determined. Prognostic factors examined included gender, ethnicity, associated anomalies, age at KP, post-KP cholangitis and clearance of jaundice within 6 months. Of 58 patients studied, 31(53.4%) were male. Median age at time of KP was 53 days (range: 28-127). Ethnic distribution showed 32 (55.2%) Chinese, 16 (27.6%) Malays and 10 (17.2%) others. Twenty-one (36.2%) patients achieved jaundice cleara...
We compare the outcomes of fundoplication with gastrostomy vs gastrostomy alone and review the ne... more We compare the outcomes of fundoplication with gastrostomy vs gastrostomy alone and review the need for subsequent fundoplication after the initial gastrostomy alone. We searched studies published from 1969 to 2016 for comparative outcomes of concomitant fundoplication with gastrostomy (FGT) vs gastrostomy insertion alone (GT) in children. Gastrostomy methods included open, laparoscopic, and endoscopic procedures. Primary aims were minor and major complications. Secondary aims included post-operative reflux-related complications, fundoplication specific complications, and need for subsequent fundoplication after GT. We reviewed 447 studies; 6 observational studies were included for meta-analysis, encompassing 2730 children undergoing GT (n = 1745) or FGT (n = 985). FGT was associated with more minor complications [19.9 vs 11.4%, OR 2.02, 95% confidence interval (CI) 1.43-2.87, p ≤ 0.0001, I (2) = 0%], minor complications requiring revision (6.8 vs 3.0%, OR 2.27, 95% CI 1.28-4.05, p = 0.005, I (2) = 0%), and more overall complications (21.3 vs 12.0%, OR 1.99, 95% CI 1.43-2.78, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001, I (2) = 0%). Incidence of major complications (1.8 vs 2.0%, OR 1.39, 95% CI 0.62-3.11, p = 0.42, I (2) = 5%) and reflux-related complications (8.8 vs 10.3%, OR 0.75, 95% CI 0.35-1.68, p = 0.46, I (2) = 0%) in both groups was similar. Incidence of subsequent fundoplication in GT patients was 8.6% (mean). Gastrostomy alone is associated with fewer minor and overall complications. Concomitant fundoplication does not significantly reduce reflux-related complications. As few patients require fundoplication after gastrostomy, current evidence does not support concomitant fundoplication.
World journal of gastroenterology : WJG, Jan 14, 2013
To evaluate the clinicopathological features and treatment outcomes of cap polyposis in the pedia... more To evaluate the clinicopathological features and treatment outcomes of cap polyposis in the pediatric population. All pediatric patients with histologically proven diagnosis of cap polyposis were identified from our endoscopy and histology database over a 12 year period from 2000-2012 at our tertiary pediatric center, KK Women's and Children's Hospital in Singapore. The case records of these patients were retrospectively reviewed. The demographics, clinical course, laboratory results, endoscopic and histopathological features, treatments, and outcomes were analyzed. The study protocol was approved by the hospital institutional review board. The histological slides were reviewed by a pediatric histopathologist to confirm the diagnosis of cap polyposis. Eleven patients were diagnosed with cap polyposis. The median patient age was 13 years (range 5-17 years); the sample included 7 males and 4 females. All of the patients presented with bloody stools. Seven patients (63%) had co...
Spontaneous perforation is a rare complication of choledochal cyst (CDC) which is difficult to di... more 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 assoc... more 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.
Kikuchi disease is a benign, self-limiting condition of unknown aetiology, often manifesting as c... more 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. This is a retrospective series of nine paediatric cases of Kikuchi disease treated in KK Women&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s and Children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s Hospital, Singapore. The clinical presentation, subsequent clinical course and laboratory findings of these patients were reviewed. 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. 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.
To improve understanding of the implications of testicular microlithiasis (TM) in paediatric pati... more To improve understanding of the implications of testicular microlithiasis (TM) in paediatric patients diagnosed incidentally on scrotal ultrasonography (US).
Adjuvant steroid therapy has become popular in the postoperative management of biliary atresia. H... more Adjuvant steroid therapy has become popular in the postoperative management of biliary atresia. However, the benefits of steroid therapy are still not clear. We performed a systematic review and meta-analysis to determine the effect of steroids on bile drainage posthepatoportoenterostomy. Studies published from 1968 to 2014 were searched from MEDLINE, EMBASE, Google scholar and Cochrane databases. A meta-analysis of randomized controlled trials (RCT) and observational studies comparing bile drainage between steroid and nonsteroid therapies posthepatoportoenterostomy was performed. Seven studies (2 RCTs and 5 observational studies) were included, comprising 259 cases of nonsteroid and 228 cases of steroid therapies. There was no statistical improvement in jaundice clearance in the steroid group [pooled odds ratio (OR)=1.51; 95% confidence interval (CI) 0.95-2.41; P=0.08; I(2)=30%]. Among 7 studies, 4 studies applied similar moderate high-dose steroid regimens (prednisolone 4-5mg/kg/d...
To evaluate the clinical relevance of the nonvisualized appendix on ultrasound imaging in childre... more To evaluate the clinical relevance of the nonvisualized appendix on ultrasound imaging in children with right lower quadrant pain. We reviewed 1359 children admitted for abdominal pain between January and December 2013 who had abdominal ultrasound imaging for right lower quadrant pain. Patients who had scans for genitourinary symptoms or intussusception were excluded from the study. When the appendix was not visualized, secondary signs indicating right lower quadrant inflammatory pathology were noted. Of all admissions for abdominal pain, 810 had ultrasound scans. Thirty-eight did not evaluate the appendix and 131 were excluded for suspected intussusception, leaving 641 reports for children with a median age of 10.8 years (range, 1.3-21.3); 297 were boys (46.3%). There were 17 of 160 patients with a nonvisualized appendix (10.6%) who underwent appendectomy. Of these, 14 had secondary signs on ultrasound imaging and 3 (1.9%) had normal ultrasound reports. The 3 patients with normal u...
A 55-day-old boy was transferred to our unit with intestinal obstruction and obstructive jaundice... more A 55-day-old boy was transferred to our unit with intestinal obstruction and obstructive jaundice after two neonatal operations for duodenal atresia and intestinal malrotation. Abdominal ultrasound showed dilated intrahepatic and extrahepatic ducts with cut-off at the distal common bile duct (CBD). He underwent emergency laparotomy for adhesive intestinal obstruction with a contained abscess from mid-jejunal perforation. Biliary dissection was not attempted due to poor preoperative nutritional status. Tube cholecystostomy was created for biliary decompression. Postoperative magnetic resonance cholangiopancreatography showed dilated CBD with cut-off at the ampulla but did not demonstrate pancreaticobiliary maljunction (PBMJ). The diagnostic dilemma was whether our patient had congenital PBMJ or had developed biliary stricture from perioperative ischaemic scarring. He underwent definitive surgery at 7 months: excision of dilated CBD with Roux-en-Y hepaticojejeunal reconstruction, exci...
Biliary atresia (BA) has preponderance in Asian populations with Kasai portoenterostomy (KP) rega... more Biliary atresia (BA) has preponderance in Asian populations with Kasai portoenterostomy (KP) regarded as the first-line standard of care. Yet reports from Southeast Asia remain scant. This study reviews the demographics, short- and medium-term outcomes for our cohort, and evaluates prognostic factors for outcome. All patients diagnosed with BA between January 1997 and December 2013 were included. Clinical data were obtained from medical records. Jaundice clearance was defined as total bilirubin < 20 µmol/L within 6 months after KP. Two-year and 5-year native liver survival (NLS) were determined. Prognostic factors examined included gender, ethnicity, associated anomalies, age at KP, post-KP cholangitis and clearance of jaundice within 6 months. Of 58 patients studied, 31(53.4%) were male. Median age at time of KP was 53 days (range: 28-127). Ethnic distribution showed 32 (55.2%) Chinese, 16 (27.6%) Malays and 10 (17.2%) others. Twenty-one (36.2%) patients achieved jaundice cleara...
We compare the outcomes of fundoplication with gastrostomy vs gastrostomy alone and review the ne... more We compare the outcomes of fundoplication with gastrostomy vs gastrostomy alone and review the need for subsequent fundoplication after the initial gastrostomy alone. We searched studies published from 1969 to 2016 for comparative outcomes of concomitant fundoplication with gastrostomy (FGT) vs gastrostomy insertion alone (GT) in children. Gastrostomy methods included open, laparoscopic, and endoscopic procedures. Primary aims were minor and major complications. Secondary aims included post-operative reflux-related complications, fundoplication specific complications, and need for subsequent fundoplication after GT. We reviewed 447 studies; 6 observational studies were included for meta-analysis, encompassing 2730 children undergoing GT (n = 1745) or FGT (n = 985). FGT was associated with more minor complications [19.9 vs 11.4%, OR 2.02, 95% confidence interval (CI) 1.43-2.87, p ≤ 0.0001, I (2) = 0%], minor complications requiring revision (6.8 vs 3.0%, OR 2.27, 95% CI 1.28-4.05, p = 0.005, I (2) = 0%), and more overall complications (21.3 vs 12.0%, OR 1.99, 95% CI 1.43-2.78, p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.0001, I (2) = 0%). Incidence of major complications (1.8 vs 2.0%, OR 1.39, 95% CI 0.62-3.11, p = 0.42, I (2) = 5%) and reflux-related complications (8.8 vs 10.3%, OR 0.75, 95% CI 0.35-1.68, p = 0.46, I (2) = 0%) in both groups was similar. Incidence of subsequent fundoplication in GT patients was 8.6% (mean). Gastrostomy alone is associated with fewer minor and overall complications. Concomitant fundoplication does not significantly reduce reflux-related complications. As few patients require fundoplication after gastrostomy, current evidence does not support concomitant fundoplication.
World journal of gastroenterology : WJG, Jan 14, 2013
To evaluate the clinicopathological features and treatment outcomes of cap polyposis in the pedia... more To evaluate the clinicopathological features and treatment outcomes of cap polyposis in the pediatric population. All pediatric patients with histologically proven diagnosis of cap polyposis were identified from our endoscopy and histology database over a 12 year period from 2000-2012 at our tertiary pediatric center, KK Women's and Children's Hospital in Singapore. The case records of these patients were retrospectively reviewed. The demographics, clinical course, laboratory results, endoscopic and histopathological features, treatments, and outcomes were analyzed. The study protocol was approved by the hospital institutional review board. The histological slides were reviewed by a pediatric histopathologist to confirm the diagnosis of cap polyposis. Eleven patients were diagnosed with cap polyposis. The median patient age was 13 years (range 5-17 years); the sample included 7 males and 4 females. All of the patients presented with bloody stools. Seven patients (63%) had co...
Spontaneous perforation is a rare complication of choledochal cyst (CDC) which is difficult to di... more 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 assoc... more 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.
Kikuchi disease is a benign, self-limiting condition of unknown aetiology, often manifesting as c... more 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. This is a retrospective series of nine paediatric cases of Kikuchi disease treated in KK Women&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s and Children&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s Hospital, Singapore. The clinical presentation, subsequent clinical course and laboratory findings of these patients were reviewed. 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. 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.
To improve understanding of the implications of testicular microlithiasis (TM) in paediatric pati... more To improve understanding of the implications of testicular microlithiasis (TM) in paediatric patients diagnosed incidentally on scrotal ultrasonography (US).
Adjuvant steroid therapy has become popular in the postoperative management of biliary atresia. H... more Adjuvant steroid therapy has become popular in the postoperative management of biliary atresia. However, the benefits of steroid therapy are still not clear. We performed a systematic review and meta-analysis to determine the effect of steroids on bile drainage posthepatoportoenterostomy. Studies published from 1968 to 2014 were searched from MEDLINE, EMBASE, Google scholar and Cochrane databases. A meta-analysis of randomized controlled trials (RCT) and observational studies comparing bile drainage between steroid and nonsteroid therapies posthepatoportoenterostomy was performed. Seven studies (2 RCTs and 5 observational studies) were included, comprising 259 cases of nonsteroid and 228 cases of steroid therapies. There was no statistical improvement in jaundice clearance in the steroid group [pooled odds ratio (OR)=1.51; 95% confidence interval (CI) 0.95-2.41; P=0.08; I(2)=30%]. Among 7 studies, 4 studies applied similar moderate high-dose steroid regimens (prednisolone 4-5mg/kg/d...
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