Recent efforts have sought to streamline gastrostomy insertion care, particularly length of stay (LOS). We report our initial experience with day-case gastrostomy (DCG) insertion. Retrospective review (April 2018–2024) of all primary gastrostomy insertions. Patients discharged the same day as the procedure were defined as DCG. Demographic, operative, and clinical data were recorded. All cases were treated according to a standardized feeding pathway. Of 432 gastrostomies formed, 15 were DCG; median age 3.5 (0.7–16.9) years, LOS 12 h (9–15 h). The most common indication was nutritional supplementation (n = 9). Gastrostomy technique was single-stage percutaneous rapid insertion of gastrostomy button (SPRING n = 5) or percutaneous endoscopic gastrostomy (PEG n = 10). Prior to insertion, 6/15 DCG were established on nasogastric (NG) feeding, 8 did not use NG feeding, and 1 had occasional NG feeds. The majority (13/15) were performed on morning operating lists. There were 4 minor complications; 2 required readmission. DCG in selected cases is feasible and safe. Most cases were performed on morning operating list, but fewer than half had prior experience of nasogastric tube feeding. We suggest additional pathway modifications to improve DCG uptake.

Background: Perianal abscess (PA), with or without fistula-in-ano (FIA) is common in infants. Treatment options include incision and drainage under general anaesthesia or non-operative treatments, such as antibiotics and/or aspiration under local anaesthetic, which avoid the risks of surgery. Current management is based on surgeon preference due to a poor underlying evidence base. In this study we aimed to compare outcomes for non-operative and operative management of infant PA. Methods: 10-year retrospective review (2012-2022) of infants aged <= 12 months presenting with PA to two paediatric surgery centres in the United Kingdom. Clinical features, management and outcome data were extracted from electronic records. Results: 116 infants were identified; 113/116 (97 %) were male. Median age at presentation was 2 (IQR 1 -6) months. Initial management was non-operative in 73/116 (63 %) and operative in 43/80 (37 %). Median follow-up was 3 (IQR 2-6) months. Recurrence occurred in 49/116 (42 %) at a median time of 1 (IQR 0-3) month and was significantly higher in the non-operative compared to the operative group (39/ 73 [53 %] versus 10/43 [23 %], p = 0.001). Operative management was independently associated with a reduced risk of PA recurrence (OR 0.25 [95 % confidence interval 0.09-0.68], p = 0.007). Further surgery was performed in 26/73 (36 %) in the non-operative group and 7/43 (16 %) in the operative group (p = 0.026). Subsequent FIA rates were not significantly different (23/73 [32 %] versus 8/43 [19 %], p = 0.129). Conclusions: In this study, PA recurrence and the requirement for further operative intervention were significantly higher when a PA was initially managed non-operatively, although subsequent FIA rates were similar. (c) 2024 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

Background: Immunohistochemistry (IHC) markers are employed to improve the diagnostic yield when testing for Hirschsprung disease (HSCR). Yet, a superior test has not been identified. Objectives: We aimed to determine the diagnostic test accuracy (DTA) of IHC markers. Methods: We conducted database search for studies reporting IHC staining on rectal biopsy investigating for HSCR. We constructed 2 x 2 contingency tables, and calculated DTA estimates in pooled and paired testing using random-effect model meta-analysis. Results: Twenty eight IHC markers from 107 studies were used to investigate for HSCR in 10891 children. In pooled analysis; calretinin sensitivity and specificity were superior to acetylcholinesterase, S100, and peripherin [98 % (CI; 0.95-0.99) & 99 % (CI; 0.97-0.99)], [94 % (CI; 0.86-0.97) & 99 % (CI; 0.96-0.99)], [92 % (CI; 0.85-0.96) & 97 % (CI; 0.89-0.99)] and [91.7 % (CI; 0.54-0.98) & 94.8 % (CI; 0.59-0.99)], respectively. In paired analysis calretinin diagnostic odds ratio was superior to hematoxylin and eosin (H&E), acetylcholinesterase and S100: [3349 (PI; 551.3-22667.2) vs 345.3 (PI; 54.9-2394.2)], [300.9 (PI; 13.3-4146.9) vs 34.6 (PI; 2.2-363.9)] and [696.9 (PI; 91.2-3401.7) vs 196.9 (PI; 29.8-890.5)], respectively. In biopsies labelled inadequate for H&E testing, calretinin specificity to rule out HSCR reached 92 % (CI; 0.288-0.998). Conclusions: IHC provides additional diagnostic value over H&E. Calretinin appears to be, currently, a superior IHC marker. The available literature is of variable quality, cautious interpretation of the findings should be considered. Level of Evidence: III. (c) 2024 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

PurposeRecent series of newborn Oesophageal Atresia (OA) repair continue to report widespread use of chest drains, gastrostomy, routine contrast studies and parenteral nutrition (PN) despite evidence suggesting these are superfluous. We report outcomes using a minimally interventional approach to post-operative recovery.MethodsEthically approved (15/WA/0153), single-centre, retrospective case-note review of consecutive infants with OA 2000-2022. Infants with OA and distal trache-oesophageal fistula undergoing primary oesophageal anastomosis at initial surgery were included (including those with comorbidities such as duodenal atresia, anorectal malformation and cardiac lesions). Our practice includes routine use of a trans-anastomotic tube (TAT), no routine chest drain nor gastrostomy, early enteral and oral feeding, no routine PN and no routine contrast study. Data are median (IQR).ResultsOf total 186 cases of OA treated during the time period, 157 met the inclusion criteria of which 2 were excluded as casenotes unavailable. TAT was used in 150 infants. A chest drain was required in 13(8%) and two infants had a neonatal gastrostomy. Enteral feeds were started on postoperative day 2(2-3), full enteral feeds established by day 4(4-6) and oral feeds started on day 5(4-8). PN was required in 15%. Median postoperative length of stay was 10 days (8-17). Progress was quicker in term infants than preterm. One infant died of cardiac disease prior to neonatal discharge.Two planned post-operative contrast studies were performed (surgeon preference) and a further 7 due to clinical suspicion of anastomotic leak. Contrast study was therefore avoided in 94%. There were 2 anastomotic leaks; both presented clinically at day 4 and day 8 after oral feeds had been started.ConclusionOur minimally interventional approach is safe. It facilitates prompt recovery with lower resource use, reduced demand on nursing staff, reduced radiation burden, and early discharge home compared to published series without adversely affecting outcomes.Level of EvidenceLevel 4

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 .

BACKGROUND:Oral manifestations of paediatric Crohn's disease (CD) are reported in up to 60% of cases. Lip biopsy can be used to histologically diagnose oral CD. We evaluated the utility of lip biopsy in children under initial investigation for potential CD. METHODS:A 10-year retrospective review of electronic patient records at a single tertiary paediatric surgery centre was performed. All patients aged ≤16 years who underwent lip biopsy were included. Clinical features, histology, and diagnostic details were extracted. RESULTS:Forty-two children underwent lip biopsy. Median age at biopsy was 13.3 years (11.0-14.9). Final diagnosis was CD in 21/42 (50%) children, indeterminant colitis in 3/42 (7%), orofacial granulomatosis (OFG) in 3/42 (7%), coeliac disease in 1/42 (2%), and eosinophilic oesophagitis in 1/42 (2%). Thirteen children (31%) received no formal diagnosis. The most common symptoms reported were oral ulceration (33/42, 79%), lip swelling (21/42, 50%), and abdominal pain (19/42, 45%). Lip biopsy histology was normal in 11/42 (26%). In 24/42 (57%), non-granulomatous inflammation was seen. In 7/42 (17%) lip biopsy identified granulomatous inflammation: three (7%) had endoscopic biopsies concordant for CD, three (7%) had negative endoscopic biopsies but were diagnosed with CD, and one was diagnosed with OFG (2%). Sensitivity was 29% and specificity was 95%. CONCLUSION:Lip biopsy has low sensitivity but high specificity for diagnosing CD. Lip biopsy diagnosed CD in 7% when endoscopic biopsies were negative, enabling treatment. LB is a useful diagnostic test for CD in children presenting with oral symptoms. LEVEL OF EVIDENCE:III.

Appendicitis is the most common pediatric surgical emergency and has traditionally been managed with appendicectomy. Nonoperative management of uncomplicated, or simple, appendicitis has been proven to be safe and effective in several randomized controlled trials in adults.1 This management strategy, particularly during the COVID-19 pandemic, has been used increasingly in children. This article summarizes recent literature, highlighting the controversies and active areas of research. Definitions Whilst definitions vary, simple appendicitis generally refers to an inflamed appendix without perforation, gangrene or generalized peritonitis. Complicated appendicitis is a broad definition that variably includes perforated appendicitis, gangrenous appendicitis, appendicitis with generalized peritonitis, appendix mass or appendix abscess. Perforation has been defined as visualization of a hole in the appendix, and/or the presence of an exteriorized faecolith.2 This distinction is often only made intraoperatively, posing some difficulty when attempting to decide which patients would be suitable for nonoperative management, if the aim is to only treat children with simple appendicitis. Loukogeorgakis et al.3 have derived a clinical decision aid to distinguish between uncomplicated and complicated appendicitis. This aid uses duration of pain, temperature, rebound tenderness, neutrophil count and C-reactive protein to generate a complicated appendicitis score. A score of <4 was found to have a positive predictive value for simple appendicitis of 98%.3 Furthermore, the exact pathogenesis of complicated and uncomplicated appendicitis has been debated. There is some evidence that these may be 2 distinct conditions rather than a well-defined clinical course where uncomplicated appendicitis will always evolve into complicated appendicitis with time.4 This is contradictory to surgical dogma that, if left untreated, simple appendicitis will always progress to complicated appendicitis with gangrene and subsequent perforation. Interestingly, as many as 82% of patients and caregivers believe that surgical delay will lead to perforation.5 "Conservative," "medical" and "nonoperative" management are used interchangeably in the literature, and usually refer to appendicitis managed initially with intravenous antibiotics without surgery alongside supportive treatment including fluid resuscitation and analgesia as needed. Impact of the COVID-19 Pandemic At the start of the COVID-19 pandemic, guidelines were issued recommending that nonoperative treatment should be considered in all cases of appendicitis to reduce operations and the potential risk to patients and staff by minimizing the use of "aerosol-generating procedures." The CASCADE study from the United Kingdom found that 560 of 2002 children (28%) with appendicitis were initially treated nonoperatively between April and July 2020, with 22% of these patients ultimately undergoing appendicectomy during their index hospital admission.6 This represented a significant increase in the use of nonoperative management when compared to a similar cohort from 2017, where nonoperative management was not undertaken in any children. Importantly, this increased uptake of nonoperative management did not appear to have a negative impact on patient outcomes.6 This enforced change in practice for many surgeons has possibly increased the acceptability of this treatment modality. Recent Literature Although the safety and efficacy of nonoperative management of appendicitis in adults has been demonstrated in multiple randomized controlled trials, it is a relatively new concept in children. The first randomized controlled trial in adults was published in the Lancet in 2011 and showed an overall (histologically confirmed) recurrence rate of 26% after initial conservative treatment.1 The most recent meta-analysis, which includes data from 8 randomized controlled trials and over 3000 adult patients, reported the overall success rate of antibiotics alone as 63% at 1 year. There was a 6-fold increase in hospital readmissions within 1 year in participants in the nonoperative group.7 Aside from a few earlier publications, much of the research regarding the nonoperative management of acute appendicitis in children has been published in the last 10 years. Huang et al.8 published a meta-analysis in 2017 demonstrating that nonoperative management of acute, uncomplicated appendicitis was initially successful in 90% of children. They defined treatment success as resolution of symptoms within 24 hours and no recurrence within 1 month. However, 26% of cases managed nonoperatively underwent appendicectomy within 1 year (although 17% of the excised appendices were histologically normal). They defined uncomplicated appendicitis as a short history (<48 hours), white blood cell count <18 109/L and absence of peritonitis.8 A systematic review by Gorter et al.9 found similar results, with nonoperative management being deemed successful after 1 year in 60%–80% of cases. A later systematic review also had similar findings, reporting an initial effectiveness of nonoperative management of 92% and an overall appendicectomy rate of 16% (follow-up ranged between 8 weeks and 4.5 years).10 In their prospective, nonrandomized, multicenter study, Minneci et al.11 looked specifically at the difference in disability days (defined as each day that a patient is not able to participate in normal activities) following operative and nonoperative management. There was a significant difference between the 2 groups favoring nonoperative management (6.6 days vs. 10.9 days). Of 370 patients managed nonoperatively, 85% still had their appendix in situ following their index admission, and this dropped to 67% at 1 year. All patients had a restricted diet for 12 hours and a minimum of 7 days antibiotics.11 Almost none of the aforementioned data regarding children featured randomization, with most studies relying on parental (or patient) choice. Interestingly, over a 1-year period in 1 study, 100% of patients chose nonoperative management, however just over half failed this during their initial admission and proceeded with appendicectomy.12 This study had a strict 12-hour reassessment protocol and recommended interval appendicectomy for all patients. In the most recently published systematic review, 12 studies were included that defined initial treatment success as "resolution of acute appendicitis leading to hospital discharge without the need for surgical intervention."13 The reported initial success rate of just over 90% was similar to other published figures. They defined recurrence as "the percentage of patients who experienced recurrent appendicitis after completing the initial antibiotic course." This occurred in 21% of patients in whom nonoperative management had been initially successful. 72% of patients still had their appendix in situ at follow-up of up to 52 months (one of the longest follow-up periods reported in the literature). There were only 2 appendiceal perforations in the 469 (0.4%) patients in the nonoperative group, and the authors therefore concluded that nonoperative management is safe.13 The first randomized controlled trial in children was published in 2020 and included 50 patients.14 92% of patients treated with antibiotics alone had initial resolution of symptoms. Only 1 patient underwent appendicectomy for recurrent appendicitis in the first year. A further 6 patients underwent appendicectomy for recurrent abdominal pain or parental choice. Overall, 62% of patients still had their appendix after 1 year, but this dropped to 54% at 5 years. Only 2 further patients underwent appendicectomy between 1 and 5 years, and in both these cases, acute appendicitis was confirmed histologically.14 A subsequent randomized controlled trial from Pakistan demonstrated an overall success rate of nonoperative management of 84% with 10 patients requiring appendicectomy within 6 months following initial discharge from the hospital (all had appendicitis confirmed histologically).15 Several studies have included cost analysis. Using a decision tree model, Wu et al.16 concluded that nonoperative management is more cost-effective. Even when allowing for a recurrence rate of over 40%, operative management costs $2277 more per patient than initial nonoperative management. Barriers Many of the published series in children have utilized parental (or patient) choice models for treatment allocation, rather than randomization. There are arguments for and against this approach. Although recruitment rates are likely to be higher if parents can choose their child's treatment, the impact of bias will also be greatly increased. However, it appears that randomization is often a significant barrier to recruitment to trials. Using a parental views questionnaire, Kyaw demonstrated that although 62% of parents would choose nonoperative management for their child, 80% would be against randomization.17 Use of terms such as "gold standard" in the context of operative management (as is common in the literature) may also impair recruitment to trials or instigation of a nonoperative treatment approach.18 The CONTRACT study from the United Kingdom included a qualitative substudy looking specifically at barriers to recruitment.19 The study protocol evolved over time with some initial data used to create bespoke training for those involved in recruitment to the study. This enabled recruiters to provide a more balanced presentation of the treatment arms and led to a significant improvement in recruitment rates from 50% to just over 70% of patients who were approached to participate.19 Ongoing Research There is a multicenter, randomized controlled trial currently recruiting participants in the United Kingdom—the CONTRACT-2 study. The primary objective of this study is to determine whether nonoperative treatment of children with uncomplicated appendicitis is noninferior to appendicectomy. A number of secondary outcomes, including comparison of cost, and some patient/family-centered outcomes will also be measured. Similar studies, the APAC, APRES and APPY trials are underway in the United States, Australia and internationally, respectively. The CONTRACT-2 is not prescriptive regarding antibiotic choice, instead taking a pragmatic approach. It is recommended that participating units use their usual, first-line, broad-spectrum antibiotics for the treatment of appendicitis. The CONTRACT-2 study was preceded by a feasibility randomized controlled trial, which also included a communication substudy, development of a core outcome set, health economic analysis, a survey of pediatric surgeons based in the United Kingdom, and a comprehensive description of the patient/public involvement in the study.19 19/27 patients (70%) of those randomized to nonoperative treatment were deemed to have responded and were discharged home without undergoing appendicectomy. The remaining 8/27 (30%) patients in this group underwent appendicectomy, mainly for clinical deterioration but also for parental choice and lack of improvement. Interestingly, half of these patients were found to have perforated appendicitis at the time of operation. A further 7/27 (26%) patients in the nonoperative arm underwent appendicectomy for recurrent appendicitis. Overall, 12/27 (44%) of participants had their appendix in situ at the conclusion of the study.19 An outcome set was developed as part of this study to determine the overall success of uncomplicated appendicitis treatment in children—intra-abdominal abscess, reoperation, bowel obstruction, readmission to hospital, death, quality of life, recurrent appendicitis, antibiotic failure, wound infection, negative appendicectomy, wound complication, patient stress/psychological impact, length of hospital stay and time away from full activity. Surgeons, patients and parents all contributed to a Delphi process.19 Patients were able to return to normal activities more quickly following nonoperative treatment, and their parents were able to return to work more quickly. The mean total cost estimates per patient for the nonoperative treatment arm and the appendicectomy arm were £2190 and £4464, respectively.19 A survey of pediatric surgeons mainly assessed attitudes towards nonoperative management. Overall, those that responded were broadly supportive of a future trial and believed that there was enough equipoise to justify proceeding. However, this opinion was not universal and surgeon attitudes and opinions are likely to be barriers to some centers participating in CONTRACT-2, and to patient recruitment in some centers where surgeons hold polarized views. Clinical Implications Nonoperative management of uncomplicated appendicitis in children has been demonstrated to be safe in multiple studies. The reported efficacy is variable but initial success rates of over 90% are encouraging. The overall, histologically-proven, recurrence rate appears to be around 20%, however around 50% of patients managed nonoperatively initially, ultimately have their appendix taken out for other reasons such as parental/patient choice or persistent abdominal pain. This must be weighed against the clear benefits of avoiding surgical complications and surgical scars. More importantly, patients managed successfully nonoperatively return to normal activities more quickly than their counterparts who are managed surgically.20 It also cannot be overemphasized that having an operation is often a traumatic and stressful experience for many children. Nonoperative management also avoids unnecessary surgery in the form of negative appendicectomy. One limitation, when drawing conclusions from this data, is that it is mostly published from high-Human Development Index countries. The delays in obtaining surgical care inherent in many low and middle Human Development Index countries, combined with potential diagnostic delays and lack of escalation, make appendicectomy exclusively the mainstay of treatment for acute appendicitis.21 CONCLUSION Whilst it has been known for well over 100 years that appendicectomy is a safe and effective treatment for acute appendicitis, it is only more recently that nonoperative management has been considered a comparable alternative in children. There is increasing evidence that nonoperative management is a viable treatment option for some children with simple appendicitis and ongoing research will hopefully further quantify the risks and benefits associated with this management strategy compared to surgery.

The management of anal fissure: ACPGBI position statement was written 15 years ago. [KLR Cross et al., Colorectal Dis , 2008]. Our aim was to update the guideline and provide recommendations on the most effective treatment for patients with anal fissures utilising a multidisciplinary, rigorous guideline methodology. The development process consisted of six phases. In phase 1 we defined the scope of the guideline. The patient population included patients with acute and chronic anal fissure. The target group was all practitioners (primary and secondary care) treating patients with fissures and, in addition, healthcare workers and patients who desired information regarding fissure management. In phase 2 we formed a guideline development group (GDG) including a methodologist. In phase 3 review questions were formulated, using a reversed PICO process, starting with possible recommendations based on the GDG's knowledge. In phase 4 a comprehensive literature search focused on existing systematic reviews addressing each review question, supplemented by more recent studies if appropriate. In phase 5 data were extracted from the included papers and checked by the GDG. If indicated, meta-analysis of systematic review data was updated by the GDG. During phase 6 the GDG members decided what recommendations could be made based on the evidence in the literature and strength of the recommendation was assessed using ‘grade’. This guideline is divided into two sections: Primary care which includes (i) diagnosis; (ii) basic treatment; (iii) topical treatment; and secondary care which includes (iv) botulinum toxin therapy; (v) surgical intervention and (vi) special situations (including pregnancy and breast-feeding patients, children, receptive anal intercourse and low-pressure fissures). A total of 23 recommendations were formulated. A new term clinically healed was described by the GDG. This guideline provides an up-to-date evidence-based summary of the current knowledge of the management of anal fissure and may serve as a useful guide for clinicians as well as a potential reference for patients.

INTRODUCTION:Laparoscopy is used in as many as 95% of adult appendicectomies. There is level I evidence showing that it reduces wound infection, postoperative ileus and length of inpatient stay in children compared with the open approach. The aim of this study was to report the uptake of laparoscopy for paediatric appendicectomy in England and to determine whether this was similar for general surgeons (GS) and specialist paediatric surgeons (SPS).METHODS:Hospital Episode Statistics data were obtained for all children aged <16 years who had an OPCS 4.6 code for emergency appendicectomy from 1997 to 2015 (18 years). Data are analysed to compare rate of laparoscopic vs open procedures for GS and SPS over time and to investigate factors associated with the use of laparoscopy.RESULTS:There were 196,987 appendicectomies and where specialty was available, 133,709 (79%) cases were undertaken by GS and 35,141 (21%) by SPS. The rate of cases undertaken with laparoscopy for both specialties combined increased from 0.8% in 1998 to 50% in 2014 (p<0.0001). In 2014, this rate was 41% for GS compared with 71% for SPS (p<0.0001). Female gender (odds ratio (OR)=1.84, 95% confidence interval (CI) 1.80-1.90), increasing age (OR=1.18, 95% CI 1.18-1.19 per year) and treatment by SPS (OR=3.71, 95% CI 3.60-3.82) were all factors positively associated with use of laparoscopy in multivariate analysis.CONCLUSIONS:There has been a vast increase in the proportion of appendicectomies undertaken laparoscopically in children. Despite adjusting for patient factors, laparoscopy was used significantly less by GS when compared with SPS. This difference is most apparent in younger children.

Consensus on the optimal management of asymptomatic congenital pulmonary airway malformation (CPAM) is lacking, and comparison between studies remains difficult due to a large variety in outcome measures. We aimed to define a core outcome set (COS) for pediatric patients with an asymptomatic CPAM. An online, three-round Delphi survey was conducted in two stakeholder groups of specialized caregivers (surgeons and non-surgeons) in various European centers. Proposed outcome parameters were scored according to level of importance, and the final COS was established through consensus. A total of 55 participants (33 surgeons, 22 non-surgeons) from 28 centers in 13 European countries completed the three rounds and rated 43 outcome parameters. The final COS comprises seven outcome parameters: respiratory insufficiency, surgical complications, mass effect/mediastinal shift (at three time-points) and multifocal disease (at two time-points). The seven outcome parameters included in the final COS reflect the diversity in priorities among this large group of European participants. However, we recommend the incorporation of these outcome parameters in the design of future studies, as they describe measurable and validated outcomes as well as the accepted age at measurement.

Objectives: To determine how the use of biological therapy is associated with surgical intervention for paediatric inflammatory bowel disease (PIBD) at a population level. Methods: Hospital Episode Statistics data were obtained for all admissions within England (1997-2015), in children aged 0-18 years, with an ICD-10 code for diagnosis of Crohn disease (CD), ulcerative colitis (UC), or inflammatory bowel disease-unclassified (IBD-U). Office of Population Censuses and Surveys Classification of Surgical Operations and Procedures codes for major surgical resection associated with PIBD and for biological therapy were also obtained. Data are presented as median values (interquartile range). Results: In total, 22,645 children had a diagnosis of PIBD of which 13,722 (61%) had CD, 7604 (34%) had UC, and 1319 (5.8%) cases had IBD-U. Biological therapy was used in 4054 (17.9%) cases. Surgical resection was undertaken in 3212 (14%) cases, more commonly for CD than UC (17.5 vs 10.3%, P < 0.0001). Time from diagnosis to major surgical resection was 8.3 (1.2-28.2) months in CD and 8.2 (0.8-21.3) months in UC. As the time-frame of the dataset progressed, there was a decreased rate of surgical intervention (P = 0.04) and an increased use of biological therapy (P < 0.0001). Additionally, the number of new diagnoses of PIBD increased. Conclusions: The introduction of biologic agents has been associated with a reduction in cases undergoing surgery in children with a known diagnosis of PIBD. As time progresses we will be able to determine whether biological therapies prevent the need for surgery altogether or just delay this until adulthood.

Background: Although non-operative treatment is known to be effective for the treatment of uncomplicated acute appendicitis in children, randomised trial data comparing important outcomes of non-operative treatment with those of appendicectomy are lacking. Objectives: The objectives were to ascertain the feasibility of conducting a multicentre randomised controlled trial comparing the clinical effectiveness and cost-effectiveness of a non-operative treatment pathway with appendicectomy for the treatment of uncomplicated acute appendicitis in children. Design: This was a mixed-methods study, which included a feasibility randomised controlled trial, embedded and parallel qualitative and survey studies, a parallel health economic feasibility study and the development of a core outcome set. Setting: This study was set in three specialist NHS paediatric surgical units in England. Participants: Children (aged 4–15 years) clinically diagnosed with uncomplicated acute appendicitis participated in the feasibility randomised controlled trial. Children, their families, recruiting clinicians and other health-care professionals involved in caring for children with appendicitis took part in the qualitative study. UK specialist paediatric surgeons took part in the survey. Specialist paediatric surgeons, adult general surgeons who treat children, and children and young people who previously had appendicitis, along with their families, took part in the development of the core outcome set. Interventions: Participants in the feasibility randomised controlled trial were randomised to a non-operative treatment pathway (broad-spectrum antibiotics and active observation) or appendicectomy. Main outcome measures: The primary outcome measure was the proportion of eligible patients recruited to the feasibility trial. Data sources: Data were sourced from NHS case notes, questionnaire responses, transcribed audio-recordings of recruitment discussions and qualitative interviews. Results: Overall, 50% (95% confidence interval 40% to 59%) of 115 eligible patients approached about the trial agreed to participate and were randomised. There was high acceptance of randomisation and good adherence to trial procedures and follow-up (follow-up rates of 89%, 85% and 85% at 6 weeks, 3 months and 6 months, respectively). More participants had perforated appendicitis than had been anticipated. Qualitative work enabled us to communicate about the trial effectively with patients and families, to design and deliver bespoke training to optimise recruitment and to understand how to optimise the design and delivery of a future trial. The health economic study indicated that the main cost drivers are the ward stay cost and the cost of the operation; it has also informed quality-of-life assessment methods for future work. A core outcome set for the treatment of uncomplicated acute appendicitis in children and young people was developed, containing 14 outcomes. There is adequate surgeon interest to justify proceeding to an effectiveness trial, with 51% of those surveyed expressing a willingness to recruit with an unchanged trial protocol. Limitations: Because the feasibility randomised controlled trial was performed in only three centres, successful recruitment across a larger number of sites cannot be guaranteed. However, the qualitative work has informed a bespoke training package to facilitate this. Although survey results suggest adequate clinician interest to make a larger trial possible, actual participation may differ, and equipoise may have changed over time. Conclusions: A future effectiveness trial is feasible, following limited additional preparation, to establish appropriate outcome measures and case identification. It is recommended to include a limited package of qualitative work to optimise recruitment, in particular at new centres. Future work: Prior to proceeding to an effectiveness trial, there is a need to develop a robust method for distinguishing children with uncomplicated acute appendicitis from those with more advanced appendicitis, and to reach agreement on a primary outcome measure and effect size that is acceptable to all stakeholder groups involved. Trial registration: Current Controlled Trials ISRCTN15830435. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 10. See the NIHR Journals Library website for further project information.

The precise role of periostin, an extra-cellular matrix protein, in inflammatory bowel disease (IBD) is unclear. Here, we investigated periostin in paediatric IBD including its relationship with disease activity, clinical outcomes, genomic variation and expression in the colonic tissue. Plasma periostin was analysed using ELISA in 144 paediatric patients and 38 controls. Plasma levels were assessed against validated disease activity indices in IBD and clinical outcomes. An immuno-fluorescence for periostin and detailed isoform-expression analysis in the colonic tissue was performed in 23 individuals. We integrated a whole-gene based burden metric ‘GenePy’ to assess the impact of variation in POSTN and 23 other genes functionally connected to periostin. We found that plasma periostin levels were significantly increased during remission compared to active Crohn’s disease. The immuno-fluorescence analysis demonstrated enhanced peri-cryptal ring patterns in patients compared to controls, present throughout inflamed, as well as macroscopically non-inflamed colonic tissue. Interestingly, the pattern of isoforms remained unchanged during bowel inflammation compared to healthy controls. In addition to its role during the inflammatory processes in IBD, periostin may have an additional prominent role in mucosal repair. Additional studies will be necessary to understand its role in the pathogenesis, repair and fibrosis in IBD.

INTRODUCTION:Ileal pouch-anal anastomosis (IPAA) following colectomy for ulcerative colitis (UC) achieves restoration of intestinal continuity with potential return of continence. It is undertaken relatively infrequently in children. We aimed to investigate the national frequency of IPAA in paediatric UC and report outcomes useful for surgeon/centre benchmarking. METHODS:Hospital Episode Statistics data were obtained for all admissions in England (1997-2015) in children (< 18 years) who underwent IPAA for UC using OPCS-4 procedural codes. Surgeon specialty, readmission, and reoperation rates were identified. Data are median (interquartile range). RESULTS:UC was diagnosed in 7604 children in whom 346 (4.6%) underwent IPAA at age 15 [13-17] years. Laparoscopy was used in 55 (15.9%) cases and in the most recent 10 years more commonly by specialist paediatric surgeons (SPS) than general surgeons (GS) (34.3%vs14.7%, p = 0.001). National frequency of IPAA ranged from 12 to 34 annually. Where specialty was available, 95/342 (57%) cases were undertaken by GS and 147/342 (43%) cases by SPS. The proportion of cases undertaken by SPS increased significantly compared to GS over the study period, p = 0.0003. Post-operative length of stay was 8 [6-11] days. During the index admission, unplanned return to theatre was required in 25/346 (7.2%). Following discharge 58 (16.8%) were readmitted within 30 days. Overall return to theatre rate within 30 days of pouch surgery was 11.0% (38/346). CONCLUSION:IPAA for UC within childhood is undertaken infrequently in England, with a shift towards SPS undertaking surgery. These data can be used by surgeons to benchmark outcomes. LEVEL OF EVIDENCE:IV.