Adrian Bianchi

Transscrotal orchidopexy: orchidopexy revised

In a study of 120 orchidopexies for palpable undescended testes, the observation of Schuller [9] and Bevan [1, 2] that most testicular undescent was associated with a shorter than normal processus vaginalis was confirmed. Division of the processus vaginalis allowed 1.5–3.5 cm of further testicular descent. The testicular vascular pedicle was always long enough to allow tension-free placement of the testis in an ipsilateral extradartos pouch except in those testes that had been retained at a high level within the inguinal canal. It is proposed that the majority of orchidopexies for palpable undescended testes should commence with a scrotal incision, and that an additional groin incision and retroperitoneal vascular pedicle mobilisation be reserved for the few high testes that will not otherwise reach the scrotum. The technique has the advantage of a single incision, much less dissection and disruption of tissue, greater comfort for the “day-case” child, rapid healing with excellent cosmesis, and a well maintained testicular position in the scrotum. The high scrotal incision allows such easy direct access to the processus vaginalis and external inguinal ring that we also recommend this approach for routine inguinal herniotomy in children.

Intestinal rehabilitation and bowel reconstructive surgery: improved outcomes in children with short bowel syndrome.

Background and Aim: Short bowel syndrome poses a great challenge to pediatric teams. Several innovative techniques in the management of total parenteral nutrition (TPN) and bowel reconstructive surgery have improved the outcomes of these children. The authors present their experience during the last decade as a specialist unit using improved techniques and multidisciplinary approaches in the management of this condition. Methods: All of the children presenting with short bowel syndrome between 2000 and 2009 were identified. Diagnosis, length of residual gut, age at definitive surgery, length of gut prelengthening, length of gut postlengthening, TPN status, and survival were recorded. Median values were calculated. Results: Twenty-seven children were identified (14 boys, 13 girls). Overall survival was 92%. Two children died. Nineteen children required bowel lengthening and 8 children had simple bowel reconstruction while on our protocol. Overall median age at definitive surgery was 12 months. Overall median residual gut length for these was 35.5 cm, whereas the median residual gut length for patients undergoing bowel lengthening was 25 cm. Postbowel lengthening, the median gut length was 90 cm. TPN data were unavailable for 2 patients. Overall, excluding the 2 patients who died and the 2 we have no TPN data on, of 23 patients, 21 (91%) are now off TPN. Conclusions: Our series shows improved results not only with survival but also in the number of patients that are off TPN. Multidisciplinary approach consisting of both medical and surgical expertise is necessary in the management of these patients. The authors advocate centralisation of short gut services to experienced centers with multidisciplinary expertise.

The scrotal approach

This paper presents results from a case record review of the transcrotal approach to undescended testes, hydrocoecle, and hernia in 457 children at the Royal Manchester Childrens Hospital between 1984 and 1991. Our results show that orchidopexy for the palpable undescended testis and routine inguinal herniotomy in children can be safely performed through a single high scrotal incision. This approach involves much less dissection. Healing is excellent and complications are minimal. The procedure lends itself to the day-case child.

Controlled Tissue Expansion in the Initial Management of the Short Bowel State

The treatment of short gut syndrome has evolved dramatically during the past decade. The combination of surgical techniques and medical management in the context of a multidisciplinary approach has improved the outcomes of these children. The authors describe in detail their technique of controlled tissue expansion of the bowel before lengthening procedures. Monitoring of the child and troubleshooting actions during the controlled tissue expansion program also are discussed.

Difficult management choices for infants with short bowel syndrome and liver failure.

Short bowel syndrome (SBS) exists when malabsorption occurs as a result of bowel loss (1). The main causes in children are intestinal atresias, gastroschisis, volvulus, and necrotizing enterocolitis (2–3). After massive bowel loss, the remaining bowel undergoes a process of adaptation that includes an increase in bowel diameter, mucosal villous height, and bowel length (4). The mainstay of management for children with SBS consists of well-monitored parenteral nutrition (PN), avoidance of infections, and dietary adjustments until a degree of intestinal adaptation compatible with life and sustained growth on enteral nutrition alone has been achieved (2). These objectives are most easily achieved at centers with an established nutritional care team (5,6). Unfortunately some infants develop serious complications (e.g., catheter-related sepsis, vascular access thrombosis, liver disease) before intestinal adaptation has occurred (7–14). This has encouraged the development of alternative modalities of treatment of which two main alternatives enable independence from PN. The first is the various nontransplant surgical procedures designed to improve intestinal function (2,10,15). Among those procedures is longitudinal isoperistaltic intestinal tailoring and lengthening (Bianchi procedure), first described in 1980 (16). Small series and case reports since then have suggested that most such patients improve within 3 to 9 months of the procedure, in terms of enteral feeding and ability to wean from PN (2,17–25). The second option is small bowel transplantation, which may be combined with simultaneous liver transplantation. This approach would appear to be the most logical solution to short bowel syndrome and its hepatic sequelae, but the highly immunogenic nature of the intestinal epithelium means that patients are maintained on high levels of immunosuppression. Increased exposure to immunosuppressant agents puts patients at risk for opportunistic infections, which can be fatal. Consequently, transplant teams have been circumspect in recommending intestinal transplantation, and in general only patients with life-threatening complications have been accepted in small bowel transplant programs (26,27). We report a case that illustrates a management dilemma in a patient with SBS who was dying of liver failure and propose a third option for treatment.

Spiral intestinal lengthening and tailoring — first in vivo study

INTRODUCTION Spiral Intestinal Lengthening and Tailoring (SILT) offers a new opportunity for the surgical treatment of short bowel syndrome. SILT requires less manipulation on the mesentery than the Bianchi procedure and does not alter the orientation of the muscle fibers like serial transverse enteroplasty (STEP). This study reports the first SILT results in a surviving animal model. MATERIAL AND METHODS Vietnamese minipigs (n=6) underwent interposition of a reversed intestinal segment to produce proximal small bowel dilation. Five weeks later the reversed segment was resected, and the wall of the dilated intestine was cut spirally at 45°-60° to its longitudinal axis. The bowel was lengthened longitudinally, and the spiral shaped intestinal wound was sutured. Five weeks later, the animals were explored, and the lengthened segments were measured. Haematoxylin and eosin, picrosirius, neuron specific enolase, S-100, C-kit, and immunohistochemistry were performed. RESULTS Mean lengthening was 74.8% ± 29.5% and mean tailoring (lumen reduction) was 56.25% ± 18.8%. No instances of necrosis, perforation, suture break down, or peritonitis were observed in 6/6 animals. Four of six animals recovered uneventfully with viable lengthened segments. Statistical analysis showed no significant difference in length (p=0,078) and width (p=0,182) after 5 weeks. Two animals developed bowel obstruction due to narrowed lumen, adhesion, and strangulation after 14 and 24 days of surgery. In both animals the lumen was tailored by more than 70% to less than 1.5 cm diameter. The mucosa and the muscle layers in the operated segment had become hypertrophic, but the orientation of the circular and longitudinal muscle fibres remained normal after the SILT procedure. There were no signs of chronic ischemia or collagen accumulation after the SILT. The myenteric and submucosal plexuses and the Cajal cell network appeared normal. CONCLUSION The bowel remained viable macroscopically and microscopically after SILT, such that SILT may be an alternative or an addition to the present technical repertoire of intestinal lengthening. However the limitations of tailoring should be kept in mind.

Ramstedt's pyloromyotomy: circumumbilical versus transverse approach

Three hundred twenty infants underwent a Ramstedt pyloromyotomy for hypertrophic pyloric stenosis, 182 via a transverse right hypochondrial incision and 138 via a circumumbilical incision. The overall rate of wound infections was 16% for operations performed via the umbilical approach compared with 5.5% for operations via a transverse approach despite a higher use of antibiotic prophylaxis (64% vs 13%). The rate of serious infections was similar (5.8% vs 4.9%) and there was no difference in average duration of hospital stay (4.1 vs 4.4 days). The incidence of post-operative incisional hernia was less when performed via the umbilical approach (0.7% vs 2.7%) and all umbilical incisions healed well, resulting in an apparently unscarred abdomen.

Management of the impalpable testis

AbstractOver an 8-year period at the Royal Manchester Childrens Hospital, 38 intra-abdominal testes in 32 children aged 2–15 years have been transferred to the scrotum with full revascularisation by microvascular anastomosis of the testicular to the inferior epigastric vessels. Eight children had bilateral microvascular orchidopexy. Follow-up has extended from 1 to 7 years. Three testes, in boys aged 4,

Uro-genital bleeding in pre-menarcheal girls: dilemmas of child abuse

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