Anthony Lander

Appendicitis in children: a comparative study between a specialist paediatric centre and a district general hospital

PURPOSE The study aimed to compare paediatric appendicectomy practice in a specialist paediatric centre (SPC) with a district general hospital (DGH). METHODS This was a retrospective study of children younger than 16 years treated between January 1, 2005, and September 30, 2007. RESULTS Two hundred seven patients (SPC) and 264 (DGH) had an operation for suspected appendicitis. Thirty-one percent of SPC patients were female vs 41% in the DGH (P = .03). Median age (range) was 10.3 years (1.2-15.9 years) in the SPC and 11.8 (3.3-16.0 years) in the DGH (P < or = .0001). The negative appendicectomy rate was 4% at the SPC and 20% at the DGH (P < or = .0001). Perforated appendicitis was found in 37% of children at the SPC compared with only 18% at the DGH (P < or = .0001). Median (range) length of stay was 5 days at the SPC (1-21 days) compared with 2 days at the DGH (1-21 days) (P < or = .0001). CONCLUSION Our findings have important implications for local practice in our 2 centres but may also have wider implications for the national organisation of the surgical care of children and for the training of general surgeons.

Single-system ectopic ureter: a 15-year review.

Abstract. Ectopic ureters present in childhood with symptoms related to an abnormal site or structure (refluxing, obstructed) of the ureteric orifice. The majority drain duplex kidneys. The diagnosis is relatively easy if the poles are functioning or hydronephrotic. Associated malformations are rarely seen and the results of surgery are gratifying. If an ectopic ureter drains a single kidney, it is called a single-system ectopic ureter (SSEU). We reviewed a 15-year experience (1980–1995) with 127 ectopic ureters from our hospital:11 SSEUs in ten consecutive children were managed during this period. Our data lead us to believe that SSEUs are a special subset of ectopic ureters. Diagnosis is often delayed because the ectopic ureter may be associated with a single small, dysplastic, poorly-functioning, non-visualised kidney and the child may be thought to have a contralateral normal ‘solitary kidney’. Associated systemic malformations are common. Residual symptoms of wetting may persist in the early postoperative period. A high degree of suspicion must be maintained for this entity when a child presents with urinary symptoms of wetting or recurrent infection and a “solitary kidney”. Early endoscopic examination of the genitourinary tract will clinch the diagnosis in the majority of cases. Residual symptoms of wetting in the postoperative period generally resolve with passage of time.

Conservative management of exomphalos major with silver dressings: are they safe?

Historically, some dressings used in exomphalos major were associated with toxicity. These have been abandoned in favor of safer dressings. Silver toxicity has not been described following the use of silver dressings in infants. We, however, found disconcerting serum silver levels in 2 consecutive patients during treatment with silver salt containing dressings.

The primary management of testicular maldescent in gastroschisis

Abstract Gastroschisis (GS) is the commonest abdominal-wall defect in the Western world. The conventional practice has been reduction of the viscera and closure of the abdominal wall as an emergency procedure. The testis is often a part of the prolapsed viscera along with the bowel loops, stomach, fallopian tube, etc. The primary management of prolapsed (PT) (3) and intra-abdominal (5) testes (IAT) in this condition was studied in 16 consecutive male babies with GS, each was managed by simple reposition of the testes and closure of the abdominal wall. The babies were followed up for spontaneous descent of the testes. At 18-month follow-up, all five IAT had descended into the scrotum spontaneously and were palpably normal. Of the three extra-abdominal PT, two had descended into the scrotum and were normal in size and on palpation. One was palpable in the superficial inguinal pouch. Simple reposition of the testes into the abdomen and closure of the abdominal defect is the correct approach for primary management of PT or IAT in a newborn with GS.

Management of gastroesfophageal reflux associated with malrotation in children

AIM Children being investigated for gastroesophageal reflux (GOR) have a high incidence of malrotation. Current literature suggests these patients should be managed with a combined antireflux and Ladds procedure. We review our experience, the largest series to date, of performing an elective Ladds procedure as the first-line intervention. METHOD Retrospective case note review of 20 children with significant symptoms of GOR and an incidental finding of malrotation. Children presenting immediately with bilious vomiting were excluded. All patients underwent a Ladds procedure as their sole primary operative intervention. RESULTS Median age at operation was 7 months (21 days-12 years). Fifteen patients (75%) had evidence of reflux on barium contrast study. All children were followed up for at least 6 months. Eighteen (90%) had resolution or significant improvement of their symptoms postsurgery. Only 3 have not managed to tolerate a full oral diet, all unrelated to GOR. None of our series required an antireflux procedure. CONCLUSION In children with debilitating vomiting necessitating surgical management, a contrast study is imperative in the work up. The high incidence of GOR and the significant improvement after correction of malrotation show the relationship between delayed gastric emptying and GOR. We suggest that when an abnormally placed duodenojejunal flexure is found, a Ladds procedure alone is sufficient and may obviate the need for a more invasive antireflux procedure.

Giant-cell fibroblastoma in a patient with a bone-marrow transplant

Abstract. A case of an epigastric giant-cell fibroblastoma is reported in a 6-year-old girl who had undergone a bone-marrow transplant for severe combined immunodeficiency secondary to adenosine deaminase deficiency. A small subcutaneous nodule had been excised from the epigastrium at age 12 months.

Characterization of the upper pouch tracheo–oesophageal fistula in oesophageal atresia

AIM A small proportion of infants with oesophageal atresia (OA) are thought to have a proximal tracheoesophageal fistula (TOF). Failure to recognize these can hamper mobilization of the upper pouch and lead to life-threatening episodes of aspiration once oral feeding starts. We reviewed our experience of upper pouch fistulae to identify characteristic features of proximal TOF. METHODS A retrospective review of TOF/OA patient notes and bronchoscopy photographs and videos, identified from our database from 01/01/2006 to 12/31/2015, was performed. RESULTS Eight (6.1%) infants were identified (M:F 5:3) from a total population of 131 newly diagnosed TOF/OA infants during the period. Their median gestational age was 33 (range 28-39) weeks, and median birth weight was 1647g (range 1100-3400g). Five were initially diagnosed with pure OA and 3 with a distal TOF. All patients underwent rigid bronchoscopy at the initial surgery but only one proximal fistula was identified. The 7 missed proximal fistulae were subsequently found either during on-table oesophagograms for gap assessment (n=2), at the time of thoracotomy when mobilizing the upper pouch (n=3), or during subsequent bronchoscopy for symptoms post OA repair (n=2). Two patients needed a further operation to divide the fistula. Review of the bronchoscopy videos identified four characteristic differences between upper and lower pouch fistulae. Proximal fistulae are found just distal to the vocal cords, are very small, often no more than a pit, do not open and close with ventilation, and are best identified by insufflation of the esophagus. CONCLUSION Upper pouch fistulae are relatively easy to miss because of different characteristics compared with H-type or distal fistulae that have not previously been mentioned in the literature. LEVEL OF EVIDENCE level IV.

Paediatric IINecrotizing enterocolitis

Necrotizing enterocolitis is the commonest serious gastrointestinal disease seen in neonatal ICUs and is one of the commonest neonatal surgical emergencies. The disease may resolve with intensive medical support, but surgery is needed to save some babies who would otherwise die. The epidemiology, presentation and management are outlined.

CONGENITAL DIAPHRAGMATIC HERNIA: THE IMPACT OF THIS CONGENITAL ANOMALY ON PAEDIATRIC MORBIDITY AND MORTALITY

When an antenatal diagnosis of a fetal anomaly is made, the parents need accurate and clear information regarding prognosis and possible outcomes, to help them make decisions. The healthcare professionals, who are involved in their care and counselling, also need this information.