Andrew J. A. Holland

Laser Doppler imaging prediction of burn wound outcome in children

The ability of laser Doppler imaging (LDI) to evaluate burn depth in children was investigated. Fifty-seven patients were prospectively studied over a 10-month period. Each patient was clinically assessed, photographed and independently scanned between 36 and 72 h of the burn. Patients were reviewed until wound healing had occurred within 12 days or skin grafting had been performed. The median age was 1 year and 10 months (range 5 months to 15 years and 8 months). The median body surface area burnt was 7.0% (range 0.5-30%). In 30 patients, the burn did not heal within 12 days, 17 of which were grafted. Clinical examination correctly determined 66% of deep partial or full thickness burns between 36 and 72 h of injury compared to 90% using LDI. The LDI was also more specific; correctly diagnosing 96% of superficial partial thickness burns as opposed to 71% on clinical examination. Moderate degrees of movement did not appear to limit the accuracy of the scan.

EFFECT OF THE DEPTH AND WIDTH OF THE URETHRAL PLATE ON TUBULARIZED INCISED PLATE URETHROPLASTY

PURPOSE We determined the effect of the depth and width of the urethral groove on tubularized incised plate urethroplasty for distal hypospadias. MATERIALS AND METHODS We retrospectively reviewed the records of 48 patients who underwent tubularized incised plate urethroplasty for distal hypospadias between September 1996 and December 1998 for whom preoperative evaluation of the depth and width of the urethral groove was available. Patients were examined by an independent clinician a median of 28 months after surgery when the neourethra was calibrated and urinary stream assessed. RESULTS Of the 48 patients 46 were available for clinical examination. The urinary stream was straight in 40 boys and angled in 8, while none sprayed. Urethral fistula developed in 6 patients with a urethral plate of less than 8 mm. wide (p = 0.001). The urethral groove was deep in 13 cases, moderate in 20 and shallow in 15. There were no differences among these 3 groups in regard to urinary stream direction or fistula rate. Of the boys with a shallow urethral groove 6 (40%) have a neourethral caliber of 6Fr or less versus 3 (15%) with a moderate and 0 with a deep groove. This difference was statistically significant (p = 0.028). Each patient in whom meatal stenosis developed had a shallow urethral groove. CONCLUSIONS Urethral groove depth appears to influence neourethral caliber after tubularized incised plate urethroplasty. A shallow groove predisposes to a narrower neourethra and meatal stenosis subsequently. We observed no evidence that incising the urethral plate increases the final urethral diameter. Urethral fistula after tubularized incised plate urethroplasty was associated with an initially narrow urethral plate.

Gastroschisis: an update

Gastroschisis (GS) continues to increase in frequency, with several studies now reported an incidence of between 4 and 5 per 10,000 live births. The main risk factor would seem to be young maternal age, and it is in this group that the greatest increase has occurred. Whilst various geographical regions confer a higher risk, the impact of several other putative risk factors, including smoking and illicit drug use, may be less important than when first identified in early epidemiological studies. Over 90% of cases of GS will now be diagnosed on antenatal ultrasound, but its value in determining the need for early delivery remains unclear. There would appear no clear evidence for either routine early delivery or elective caesarean section for infants with antenatally diagnosed GS. Delivery at a centre with paediatric surgical facilities reduces the risk of subsequent morbidity and should represent the standard of care. The relative roles of primary closure, staged closure and ward reduction, with or without general anaesthesia, appear less clear with considerable variation between centres in both the use of these techniques and subsequent surgical outcomes. Survival rates continue to improve, with rates well in excess of 90% now routine. The limited long-term developmental data available would suggest that normal or near-normal outcomes may be expected although there remains a need for further studies.

HOSE : an objective scoring system for evaluating the results of hypospadias surgery

Objective To determine the accuracy and utility of a scoring system designed to allow an objective appraisal of the outcome of hypospadias repair, based on evaluating meatal location, meatal shape, urinary stream, straightness of erection, and the presence and complexity of any complicating urethral fistula.

Incisional hernias are more common in aneurysmal arterial disease

OBJECTIVE To test the hypothesis that incisional hernia was a more frequent complication following aortic reconstructive surgery in patients with aneurysmal as opposed to occlusive aortic disease. DESIGN A retrospective review. MATERIALS AND METHODS All patients having aortic reconstructive surgery at a teaching hospital between 1988 and 1992 were identified and recalled to be examined for evidence of an incisional hernia. RESULTS Of the 134 patients having aortic reconstructive surgery, 87 were available to be examined by an independent clinician. The overall incisional hernia rate was 28%. Patients with aneurysmal disease were significantly more likely to develop an incisional hernia after elective surgery than patients with occlusive disease (p = 0.04). None of the other variables investigated, including age, chronic obstructive airways disease, diabetes, smoking, wound infection, obesity, length of intensive care unit stay and number of units of blood transfused, were significantly related to the complication of incisional hernia. CONCLUSION Incisional hernia is a common complication of aortic reconstructive surgery, especially in patients with aneurysmal disease.

Facial fractures in children.

Objective To determine the pattern of injury of facial fractures in children, the relative contribution of plain radiography and CT scanning in the diagnosis of these injuries, and factors leading to delayed diagnosis. Design Retrospective case note review. Participants All children with facial fractures identified using the trauma and medical record databases at our institution. Results Forty-six children with 59 facial fractures presented over a 4-year, 2-month period from November 1995 to December 1999. The median age was 10 years, with a range from 1 to 14. There was a 2-to-1 male-to-female sex ratio. A motor vehicle accident (MVA) involving a child as passenger, pedestrian, or cyclist accounted for 63% of cases. In seven of these, the child was either a front seat passenger or inappropriately restrained for their age and size. In all but one case, the presence of a fracture was associated with an overlying laceration, abrasion, or significant soft tissue edema. Initial examination and plain radiologic assessment by a pediatric clinician led to diagnostic delay in nine children. Facial CT was performed in 38 children, and all results were positive. Twenty-six patients required operative intervention for their facial fracture. Associated injuries, particularly of the head and limbs, were present in all but six patients. Conclusions Facial fractures were uncommon overall but occurred more frequently in children with major trauma. Plain facial radiographs provided limited additional diagnostic information to careful clinical examination and often fail to detect or clearly define a facial fracture in children. In the correct clinical setting, a facial CT scan allows accurate diagnosis of the injury and can reveal previously unsuspected additional fractures.

Assessment of Cooling on an Acute Scald Burn Injury in a Porcine Model

The current Australian and New Zealand Burn Association (ANZBA) recommended Burns First Aid Treatment is place the burn under cool running water for 20 minutes. Wet towels and water spray also have been used frequently. No scientific data exist to compare the effectiveness of these methods of cooling. This study sought to determine experimental evidence for current Burns First Aid Treatment recommendations and the optimal mode of cooling. Four partial-thickness scald burn injuries were induced in 10 piglets each. First aid was then applied for 20 minutes via cool running water, wet towels, or water spray, with no treatment as a control. At day 1 and day 9, biopsies and clinical photographs were assessed in a blinded manner. The control group showed worsening or no change of depth over the course of 9 days. The outcomes with wet towels and water spray were variable. Cool running water consistently demonstrated improvement in wound recovery over the course of 9 days (P < .05). This study demonstrated that cool running water appeared the most effective first aid for an acute scald burn wound in a porcine model compared with wet towels and water spray.

Oesophageal atresia and tracheo-oesophageal fistula: current management strategies and complications

The successful operative management of oesophageal atresia and tracheo-oesophageal atresia has been available for approximately 70 years. During this time neonatal intensive care has evolved, surgical techniques have improved and consequently near 100% survival for this condition may now be achieved. In keeping with promising results, the co-morbidities of the condition have gained increasing recognition. In this article, the clinical course from antenatal assessments, neonatal surgery and co-morbidities from infancy to adulthood are reviewed to provide a broad overview of the condition.

Pelvic fractures and associated injuries in children.

BACKGROUND Pelvic fractures occur uncommonly in children. Despite serious sequelae, they have been infrequently reviewed. METHODS We conducted a retrospective review of admissions to our institution from January 1983 to December 2000. RESULTS One hundred twenty children with pelvic fractures were identified. Median age was 9 years (range, 1-16 years) and 66% (n = 80) were boys. Pedestrian-motor vehicle injury accounted for 68% (n = 82) of cases. Associated injuries were present in 78% (n = 94). Management of the pelvic fracture was nonoperative in 113 (94%). Thirty-two children (27%) required surgery for associated injuries. Complications during admission occurred in 28% (n = 34). Five children died as a result of their injuries. With a mean follow-up of 36 months (range, 7-156 months), 27% (n = 32) of children suffered an adverse outcome, including neurologic dysfunction and leg-length discrepancies. CONCLUSION The majority of pelvic fractures in children may be satisfactorily treated nonoperatively. Operative interventions were more frequently required for associated injuries. Long-term review is indicated because of delayed complications in children that are continuing to grow and develop.

Surgical outcomes of esophageal atresia without fistula for 24 years at a single institution

PURPOSE The aim of the study was to evaluate the surgical outcome of esophageal atresia (EA) without fistula for 24 years at a single tertiary center for pediatric surgery. METHODS The study used a retrospective chart review of infants diagnosed with EA without fistula between 1981 and 2005. RESULTS Of 33 patients with EA without fistula, 31 charts were available. Mean birth weight was 2327 g (range, 905-3390 g), and 71% were male. Most common associated anomalies were cardiac (n = 6; 19%) and renal (n = 5; 16%), followed by vertebral (n = 4; 13%) and anorectal (n = 2; 7%). The median initial esophageal gap was 5 vertebral bodies. Six had a primary repair, and 25 patients had esophageal replacement at a median age of 7 months. This involved gastric transposition in 20 (1 followed failed jejunal interposition), colonic interposition in 5, jejunal interposition in 1 (after a failed colonic), and repair at another center in 1. With a median review of 9 years, 21 patients had long-term sequelae with the need for multiple further surgical procedures including an antireflux procedure in 5. One patient died. CONCLUSIONS Management of EA without fistula remains challenging. Most patients required staged treatment that included esophageal replacement. The frequency of late complications indicates the need for programmed long-term review.