Anthony Dilley

Ultrasound-guided transversus abdominis plane blocks for laparoscopic appendicectomy in children: a prospective randomized trial

BACKGROUND The effect of adding transversus abdominis plane (TAP) blocks to local anaesthetic infiltration on morphine consumption and postoperative pain in children undergoing laparoscopic appendicectomy is unknown. METHODS After random allocation, 93 children aged 7-16 were randomized to receive ultrasound-guided TAP blocks placed before surgery or not (control). All subjects had port sites infiltrated with ropivacaine and were prescribed i.v. patient-controlled analgesia (PCA) with morphine and oral paracetamol for postoperative pain. The primary outcome was the proportion of subjects using >200 µg kg(-1) morphine. Secondary outcomes included PCA morphine use, pain scores, time intervals to the first use of PCA and other analgesics, sedation scores, postoperative nausea or vomiting, and time to hospital discharge. RESULTS The procedure duration was longer in the TAP group (111 compared with 97 min for controls, P=0.03). The duration in the recovery ward and that of the hospital stay were similar. There was no difference in the proportion of subjects requiring >200 µg kg(-1) of PCA morphine [control 31/45 (69%), TAP 29/42 (69%), P=0.99]. There was no significant difference in PCA morphine use, time intervals to the first use of PCA or other analgesics, or amounts of other analgesics. More patients in the TAP group had complicated appendicitis [TAP 13/42 (31%), control 5/45 (11%), P=0.02]. Pain scores were reduced for the TAP group in the recovery ward only (median score 0 vs 2, 95% confidence interval 0-3, P=0.03). CONCLUSIONS TAP blocks increased anaesthesia time by 14 min on average but offered no clinically important benefit over local anaesthetic port-site infiltration to paediatric patients undergoing laparoscopic appendicectomy.

The radiologist says malrotation: does the surgeon operate?

Abstract The management of malrotation when it is an incidental finding is unclear. This retrospective study reports an analysis of radiological and operative findings in a series of 71 patients. There were no deaths. We report a false-positive rate of 15% for upper gastrointestinal contrast studies reported as showing malrotation. Our findings and a review of the literature demonstrate that in the asymptomatic child over 2 years of age, the evidence supporting mandatory correction of malrotation is weak.

Ultrasound‐guided rectus sheath block and catheter placement

We enjoyed the recent paper by Cornish and Deacon.1 Use of the rectus sheath block has become a common part of our practice in patients requiring midline abdominal surgery. Both the rectus sheath block and rectus sheath catheter placement can be easily achieved with the aid of a portable ultrasound scanner. We use a 38-mm broadband (13–6MHz) linear array transducer (Sonosite Micromax; SonoSite, Bothell, WA, USA). Regional anaesthesia requires local anaesthetics to be placed in close proximity to nerves without injury to the target nerves or adjacent structures. Ultrasonography allows anaesthetists and surgeons to accurately identify target and adjacent structures. Traditionally, nerves have been localized using anatomical landmarks or nerve stimulation. Nerve stimulation is only possible where there is a motor nerve. Successful block of sensory nerves or structures containing sensory nerves, such as the rectus sheath, has relied on blind landmark-based needle placement by a skilled operator or surgically placed catheters as described in your recent publication. Ultrasound guidance avoids the need for surgical placement and has advantages over traditional nerve localization techniques. These include higher block success rates,2–4 shorter block onset times,3–5 lower total dose of local anaesthetics,2 assessment of local anaesthetic spread and reduced complications.3 Ultrasound-guided rectus sheath block is carried out with the ultrasound probe placed in the longitudinal plane near the lateral edge of the rectus sheath (Fig. 1). The region is prepared with 0.5% chlorhexidine in 70% alcohol (Pharmacia, Perth, WA, Australia) and the ultrasound probe is covered with a 10 · 14 cm IV3000 Standard (Smith and Nephew, Hull, UK). Sterile ultrasound conductive gel is placed between the skin and the ultrasound probe. Needle observation may be difficult in ultrasound-guided regional anaesthesia. In our technique, the needle is maintained in the plane of the ultrasound beam allowing continuous observation of the needle (Fig. 2).

The 2010 Royal Australasian College of Physicians' policy statement 'Circumcision of infant males' is not evidence based.

Infant male circumcision (MC) is an important issue guided by Royal Australasian College of Physicians (RACP) policy. Here we analytically review the RACPs 2010 policy statement ‘Circumcision of infant males’. Comprehensive evaluation in the context of published research was used. We find that the Statement is not a fair and balanced representation of the literature on MC. It ignores, downplays, obfuscates or misrepresents the considerable evidence attesting to the strong protection MC affords against childhood urinary tract infections, sexually transmitted infections (human immunodeficiency virus, human papilloma virus, herpes simplex virus type 2, trichomonas and genital ulcer disease), thrush, inferior penile hygiene, phimosis, balanoposthitis and penile cancer, and in women protection against human papilloma virus, herpes simplex virus type 2, bacterial vaginosis and cervical cancer. The Statement exaggerates the complication rate. Assertions that ‘the foreskin has a functional role’ and ‘is a primary sensory part of the penis’ are not supported by research, including randomised controlled trials. Instead of citing these and meta‐analyses, the Statement selectively cites poor quality studies. Its claim, without support from a literature‐based risk‐benefit analysis, that the currently available evidence does ‘not warrant routine infant circumcision in Australia and New Zealand’ is misleading. The Statement fails to explain that performing MC in the neonatal period using local anaesthesia maximises benefits, safety, convenience and cost savings. Because the RACPs policy statement is not a fair and balanced representation of the current literature, it should not be used to guide policy. In the interests of public health and individual well‐being, an extensive, comprehensive, balanced review of the scientific literature and a risk‐benefit analysis should be conducted to formulate policy.

An experimental study of optimal parameters for bipolar electrocoagulation

The role of artery diameter, probe force application (94, 250 or 491 g), coagulation time (2, 10, or 20 secs) and BICAP generator output (5, 10) were studied in rabbit arteries of 3 to 5 mm hemicircumference. Arterial welds were then tested to destruction by increasing intraluminal pressure. The best arterial welds were achieved by the highest force and coagulation time; high generator output did not improve weld strength. These in vitro experiments suggest that when treating a bleeding peptic ulcer, BICAP therapy should be done with a low generator output of 5 or less, for at least 20 seconds per site, and with as great a compression force as possible. (Gastrointest Endosc 1995;42:27-30.).

Saccharomyces boulardii in a child with recurrent Clostridium difficile.

Correspondence: Andrew S. Day, MB, ChB, MD, FRACP, Department of Gastroenterology, Sydney Children’s Hospital, School of Women’s and Children’s Health, University of New South Wales, Randwick, NSW 2031, Australia. Email: andrew.day@unsw.edu.au Received 8 January 2007; revised 14 March 2007; accepted 26 April 2007. doi: 10.1111/j.1442-200X.2008.02782.x organisms need to be acid stable, resistant to bile and to be able to colonize the bowel. There is evidence to support the use of probiotics in various gastrointestinal disorders, including the treatment and prevention of Clostridium diffi cile infection. We report the use of the probiotic Saccharomyces boulardii for recurrent C. diffi cile infection in a child with surgically treated Hirschsprung’s disease.

Enhanced repair of UV-induced DNA damage by 1,25-Dihydroxyvitamin D3 in skin is linked to pathways that control cellular energy.

Inadequately repaired post-UV DNA damage results in skin cancers. DNA repair requires energy but skin cells have limited capacity to produce energy after UV insult. We examined whether energy supply is important for DNA repair after UV exposure, in the presence of 1α,25-dihydroxyvitamin D3 (1,25(OH)2D3), which reduces UV-induced DNA damage and photocarcinogenesis in a variety of models. After UV exposure of primary human keratinocytes, the addition of 1,25(OH)2D3 increased unscheduled DNA synthesis, a measure of DNA repair. Oxidative phosphorylation was depleted in UV-irradiated keratinocytes to undetectable levels within an hour of UV irradiation. Treatment with 1,25(OH)2D3 but not vehicle increased glycolysis after UV. 2-Deoxyglucose-dependent inhibition of glycolysis abolished the reduction in cyclobutane pyrimidine dimers by 1,25(OH)2D3, whereas inhibition of oxidative phosphorylation had no effect. 1,25(OH)2D3 increased autophagy and modulated PINK1/Parkin consistent with enhanced mitophagy. These data confirm that energy availability is limited in keratinocytes after exposure to UV. In the presence of 1,25(OH)2D3, glycolysis is enhanced along with energy-conserving processes such as autophagy and mitophagy, resulting in increased repair of cyclobutane pyrimidine dimers and decreased oxidative DNA damage. Increased energy availability in the presence of 1,25(OH)2D3 is an important contributor to DNA repair in skin after UV exposure.

Defining normal neonatal abdominal wall musculature with ultrasonography

INTRODUCTION The development of new surgical approaches for the management of congenital abdominal wall defects may be facilitated by using an animal model. However, because the anatomy of the neonatal abdominal wall has not been described, a suitable model is yet to be identified. We aimed to evaluate and define the neonatal abdominal wall musculature using ultrasound, to be used as a reference to identify an appropriate animal model for the neonatal abdominal wall in the future. METHODS Infants with a postconceptual age of less than one month weighing between 2 and 3 kg were eligible. With ethical approval, ultrasonography of three abdominal wall locations bilaterally was performed. The depth of the skin to external oblique and the thickness of the three abdominal wall muscles, external oblique (EO), internal oblique (IO) and transversus abdominis (TA), were measured. RESULTS Ten males and seven females were recruited with median postconceptual age of 36 weeks (IQR 36-38), median postnatal age of 8 days (IQR 3-30) and median weight of 2.35kg (IQR 2.26-2.56). The mean depth of EO from skin was 2.06 mm (± 0.44). The mean thicknesses of the muscles were: EO 1.02 mm (± 0.33), IO 1.16 mm (± 0.39) and TA 1.02 mm (± 0.37). There was no statistical difference between the thickness of EO, IO or TA (p= 0.43). CONCLUSIONS It is possible to consistently identify and measure the components of the neonatal abdominal wall musculature with ultrasonography. We hope this can aid in developing an appropriate animal model, with the ultimate aim of facilitating innovation in surgical management of neonatal abdominal wall pathology. LEVELS OF EVIDENCE Study of Diagnostic test, Level IV.