Dan Poenaru

Primary spontaneous pneumothorax in children.

In the absence of pediatric data, spontaneous pneumothorax is managed according to adult guidelines. Fifty-eight patients with primary spontaneous pneumothorax (PSP) were treated in our center over the last 20 years. The median age was 16.7 years, and the male:female ratio was 1.9:1. A total of 102 PSP were treated; 63% were left-sided. The risk of recurrence was 51% after one PSP and 56% after two. There were four metachronous bilateral PSP. Nonoperative management included tube drainage in 57% of the cases (mean extent of PSP, 53%). Forty percent of patients were treated by supplemental oxygen and observation, without drainage (mean extent of PSP, 23%). Eleven patients were treated as outpatients, with Heimlich valves (mean extent of PSP, 64%). Fourteen patients (28%) underwent bullectomy, with or without pleurodesis. Thirteen of the surgically treated patient had experienced at least two episodes of PSP. Primary spontaneous pneumothorax in children has male predominance. The risk of recurrence after one episode is greater than that for adults. Operative management by bullectomy, with or without pleurodesis, carries little morbidity, has a high success rate, and is recommended after the first recurrence. It is safe to manage younger children conservatively because the chance of recurrence is lower; thoracotomy was not necessary in children under 9 years of age.

Outcomes of ventriculoperitoneal shunt insertion in Sub-Saharan Africa.

OBJECT Ventriculoperitoneal (VP) shunts in Sub-Saharan Africa are traditionally associated with high complication rates and poor outcomes. The aim of this study was to review one large institutional experience with VP shunts, to evaluate the feasibility of shunt insertion procedures with acceptable long-term outcomes in Africa, and to identify factors correlated with good and/or poor outcomes. METHODS A retrospective study was conducted by reviewing the charts of all children who underwent primary (93%) or subsequent VP shunt insertions at the Kijabe Hospital between November 2004 and March 2007. Epidemiological data, clinical investigations, etiology of the hydrocephalus, details of the VP shunt insertion, outcome at follow-up, and morbidity and mortality data were collected. Outcomes were graded as good, fair, or poor, according to visual, motor, and seizure criteria. RESULTS The authors analyzed 593 VP shunt insertions in 574 patients. The sex distribution was 53% male and 47% female. The mean age at shunt insertion was 8.5 months (range 0–309 months). The commonest etiologies for hydrocephalus were spina bifida (43.4%) and postinfectious (27.7%). Follow-up was available in 76% of children, with a mean follow-up period of 8.9 months (range 2–30.5 months). The median patient age was 3.3 months. The overall shunt function rate at 2 years was 65%, and the complication rate per procedure was 20%, with infection encountered in 9.1% and shunt malfunction in 11%. Complications were significantly related to hydrocephalus etiology and to sex (p = 0.03 and p = 0.01, respectively). Overall outcomes were good in 40.2% and poor in 59.8%. Overall mortality in the group was 7.1%. Younger patients who survived had an overall good outcome (p = 0.0001). Only 10% of patients with a head circumference greater than 60 cm had a good outcome. CONCLUSIONS Despite limited resources, VP shunt procedures can be carried out in Sub-Saharan Africa with acceptable complication rates and fair long-term outcomes.

The burden of pediatric surgical conditions in low and middle income countries: a call to action.

Recently, the role of surgery in global health has gained greater attention, although pediatric surgery has received little specific emphasis. This paper highlights pediatric surgical conditions as a part of global public health, and identifies gaps in knowledge and possible areas of action for the global pediatric surgical community. The burden of disease concept is discussed with examples of its application to pediatric surgery, and further information required to improve measurement of the global burden of pediatric surgical conditions. In addition, selected tools to measure access to surgical care and the unmet need for surgery in low and middle-income countries (LMICs) are reviewed, with recent innovative approaches and other possible adaptations to pediatric surgery. Finally, some of the strategies used to improve access to care for pediatric surgical conditions are discussed, with possible future directions.

The pediatric bowel management clinic: Initial results of a multidisciplinary approach to functional constipation in children

The multifactorial nature of functional constipation in children suggests that a multidisciplinary management approach may be effective. The authors tested this hypothesis in a newly created pediatric Bowel Management Clinic (BMC). Detailed data were collected prospectively on all patients seen in the clinic over the first 16 months. Both quantitative and qualitative analyses were performed to describe the index population and to demonstrate the impact of the intervention. Satisfaction with care in the clinic was measured using the Measure of Processes of Care tool, then compared with a normative sample. One hundred fourteen patients, all previously treated unsuccessfully for constipation, were referred to a team comprised of a physician, nurse practitioner, nurse educator, dietitian, and psychosocial nurse specialist. The mean age was 5.4 years with equal gender distribution. Between the first and last visits recorded, several variables including stool consistency and frequency, soiling frequency, abdominal pain, rectal pain, and rectal bleeding all showed statistically significant (P < .05) improvement. Qualitative data analysis showed the significant psychosocial impact of constipation on patients and their families. In the Measures of Processes of Care questionnaire, scores for the BMC were higher than normal on all scales except in provision of information. A multidisciplinary approach to functional constipation leads to both patient and parent satisfaction and significant short-term improvement. Further studies will examine the long-term impact of the clinic.

Laparoscopic management of the impalpable abdominal testis

Laparoscopy is useful in both diagnosis and management of impalpable testes. Intra-abdominal testicles can be removed laparoscopically if atrophic or can be partly devascularized by spermatic vessel clipping if apparently normal. Assessment of testicular revascularization would be desirable prior to subsequent orchiopexy. A second-stage vasal-based orchidopexy than can be performed once adequate testicular reperfusion via the deferential pedicle is believed to have occurred. We have used both diagnostic and therapeutic laparoscopy in the management of 103 non-palpable testes over a period of six years. Open procedures following laparoscopy included 57 orchidopexies, 11 orchiectomies, and 1 microvascular testicular autotransplant. Thirteen laparoscopic interventions were performed: 5 orchietomies for atrophic testes and 8 testicular vessel clippings followed by 6 second-stage open inguinal orchidopexies. Color Doppler duplex ultrasonography was not found to be reliable for assessment of testicular revascularization following spermatic vessel clipping. There were 3 complications which were all related to puncture with the Veress needle.

Impact of magnetic resonance imaging on the surgical management of cystic hygromas

BACKGROUND The surgical management of cystic hygromas can be challenging, and accurate diagnosis and anatomic localization is essential. The literature on the use of magnetic resonance imaging (MRI) in pediatric cystic hygromas is sparse and mostly limited to radiological descriptions. METHODS The authors present five cases of cystic hygromas in children ranging in age from 1 to 13 years. The preoperative MRI scans and patient charts were reviewed with attention to the clinical, radiological, surgical, and histological findings. RESULTS MRI produced highly detailed multiplanar renderings of the cystic hygromas that were both diagnostic and predictive of the subsequent intraoperative findings. This modality helped specifically in some cases to identify lesion extensions that required specific surgical attention. There were no recurrences or complications at a mean follow-up of 18 months. CONCLUSION The use of MRI in cystic hygromas can facilitate accurate diagnosis and assist in the preoperative planning, thereby contributing to the successful treatment of these lesions.

A Square Peg in a Round Hole? Challenges with DALY-based “Burden of Disease” Calculations in Surgery and a Call for Alternative Metrics

IntroductionIn recent years, surgical providers and advocates have engaged in a growing effort to establish metrics to estimate capacity for surgical services as well the burden of surgical diseases in resource-limited settings. The burden of disease (BoD) studies have established the disability-adjusted life year (DALY) as the primary metric to measure both disability and premature mortality. Nonetheless, DALY-based approaches present methodological challenges, some of which are unique to surgical conditions, not fully addressed through the multiple iterations of the BoD studies, including the most recent study.Methods and ResultsThis paper examines these challenges in detail, including issues around age-weighting and discounting, and estimates of disability-weights for specific conditions. Surgical burden measurements of specific conditions, or through the assessment of hospital wards as platforms for service delivery, still have unresolved methodological hurdles. The 2010 BoD study addresses some of these issues, but many questions still remain. Other methods estimating surgical prevalence, backlogs in treatment, and disability incurred by delays in care may provide more practical approaches to disease burden that can be useful tools for clinicians and health advocates.ConclusionsThese approaches warrant further exploration in LMICs and these debates require active engagement by surgical providers and advocates globally.

Anal fistula in infants: Etiology, features, management

Anal fistulas in infants are poorly understood. A high incidence of recurrence has been attributed to a congenital abnormality of the anal crypts. To verify this hypothesis, we reviewed all anal fistulas seen in children less than 2 years of age and treated between 1980 and 1991. All patients were males with a mean age of 9.5 months, and only 3 had other illnesses. Ninety-two percent have had previous anorectal abscesses. The fistulas were single in 31 patients and double in 5. Their origin in the crypts was clearly identified in 14 cases. When anoscopy was routinely performed, deep thick-walled crypts were found in 47% of the cases. In most instances only one crypt was abnormal. The operative management included fistulotomy in 17 patients and fistulectomy in 9. Cryptotomies besides fistula excision were performed in 9 cases, and concurrent abscess drainage in 6. Follow-up was available in 31 patients for a mean length of 20 months. There were 4 complications (11%): one abscess requiring drainage, one wound infection treated conservatively, one granuloma, and one postoperative laryngitis. No recurrences were observed and none of the patients had fistula-related complaints at the last visit. Anal fistulas in infants are observed exclusively in males and are often related to abnormal crypts. Although 92% of fistulas are preceded by a perianal abscess, only 42% of perianal abscesses will result in fistula formation. Anal fistulas can be treated by either fistulotomy or fistulectomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Unilateral ovarian agenesis and fallopian tube maldescent

Abstract Unilateral ovarian agenesis (UOA) and fallopian descent problems are very rare congenital defects. We present an unusual case of UOA associated with fallopian-tube maldescent discovered incidentally during a laparotomy in a female infant for a persistent heterogeneous right ovarian cyst refractory to needle aspiration. A necrotic, hemorrhagic paratubal cyst was found associated with a normal right adnexa. The left ovary was absent and a rudimentary left fallopian tube was found tightly stretched over the sigmoid colon to the left retroperitoneum. This previously unreported constellation of anomalies may carry significant potential risks for bowel obstruction and later fertility.

Burden of surgical congenital anomalies in Kenya: A population-based study

BACKGROUND Congenital malformations are a significant component of the global burden of disease among children, accounting for 25 million disability-adjusted life years (DALYs) worldwide. Unfortunately, efforts to estimate the burden of pediatric surgical disease in Africa are limited by the absence of population-based data. The objective of this study was to estimate both the prevalence and the disease burden of several common congenital surgical malformations among children in Kenya. METHODS Community volunteers randomly surveyed households at sites across Kenya. Caretakers were asked to identify on a photographic portfolio, several congenital malformations present among the children in their household, including club foot, hypospadias, hydrocephalus, spina bifida/encephalocele, cleft lip, bladder exstrophy and imperforate anus. DALYs were then calculated based on life expectancy tables and published and estimated disability weights for the conditions encountered. RESULTS The caregivers of 5559 children (54% female) were surveyed in 1909 households, 56% of which were rural, 31% suburban and 12% urban. The overall prevalence of congenital malformations was 6.3 per 1000 children, amounting to 54-120 DALYs per 1000 children, depending on the life tables used. The most prevalent condition in the survey was club foot, whereas spina bifida had the highest burden of disease. DISCUSSION This study is the first to document the prevalence of selected surgical congenital malformations among children in Kenya and the burden of disease associated with them. The results will serve to inform strategies aimed at reducing the unmet burden of surgical disease in resource-limited regions.