Graham Haddock

Patch incorporation in diaphragmatic hernia.

BACKGROUND/PURPOSE Biomaterial insertion often is required for closure of congenital diaphragmatic hernia (CDH). The optimal biomaterial remains uncertain. This study was designed to compare a commonly used patch (polytetrafluoroethylene) with a recently available fabric, fluorinated polyester. The aim of this study was to determine the clinical performance, histological tissue-polymer interaction, bacterial adhesion, and shrinkage rates of biomaterial inserted endoscopically into a CDH lamb model. METHODS Polytetrafluoro-ethylene (PTFE) and fluorinated polyester (FP) were randomised for laparoscopic patch insertion into 12 lambs. All lambs (age <4 weeks) underwent 3-port laparoscopy, surgical creation of diaphragmatic hernia, and sutured patch placement. Two PTFE and 2 FP lambs were killed at 1-, 3-, and 6-month intervals postoperatively. Postmortem examination histopathology, electron microscopy, and specific bacterial broth immersion (Escherichia coil, Staphylococcus aurens, and epidermidis) were performed. RESULTS All 12 lambs completed the study with intact patches that were fully peritonised. One abdominal adhesion was noted in a FP lamb at 6 months. FP was comparatively easier to insert, manipulate, and suture endoscopically. Histopathology findings showed that PTFE patches created a strong peripheral foreign body reaction with dystrophic calcification, whereas FP was well incorporated with intrapatch fibroblastic activity and neovascularsation. No significant difference in resistance to bacterial adhesion of relevant organisms was noted between the materials. Graft shrinkage for FP was 7% in one direction only, evident by 3 months. CONCLUSIONS Fluorinated polyester has advantages in this laparoscopic lamb model. It shows rapid and sustained incorporation with intrapatch neovascularisation when compared with polytetrafluoro-ethylenes significant foreign body reaction. It was preferred for its endoscopic handling and suturing properties. The laparoscopic techniques used may contribute to the general lack of adhesions, and insufficient data are available to comment on the comparative effect of the materials on adhesion formation. No difference was demonstrated in resistance to bacterial adherence in the harvested materials.

Campylobacter jejuni 81-176 forms distinct microcolonies on in vitro-infected human small intestinal tissue prior to biofilm formation.

Human small and large intestinal tissue was used to study the interaction of Campylobacter jejuni with its target tissue. The strain used for the study was 81-176 (+pVir). Tissue was processed for scanning and transmission electron microscopy, and by immunohistochemistry for light microscopy. Organisms adhered to the apical surface of ileal tissues at all time points in large numbers, in areas where mucus was present and in distinct groups. Microcolony formation was evident at 1-2 h, with bacteria adhering to mucus on the tissue surface and to each other by flagellar interaction. At later time points (3-4 h), biofilm formation on ileal tissue was evident. Flagellar mutants did not form microcolonies or biofilms in tissue. Few organisms were observed in colonic tissue, with organisms present but not as abundant as in the ileal tissue. This study shows that C. jejuni 81-176 can form microcolonies and biofilms on human intestinal tissue and that this may be an essential step in its ability to cause diarrhoea in man.

Separation of renal fragments by a urinoma after renal trauma: percutaneous drainage accelerates healing

Background. Two boys suffered blunt abdominal trauma resulting in renal injury. In both cases the damaged kidney was fractured through its mid-portion, and the upper and lower fragments of the kidney became widely separated by a urinoma. Materials and methods. US-guided drainage of the urinoma resulted in immediate apposition of the renal fragments. The drains were left on free drainage by gravity for 1 week before removal. Results. The urinomas did not reaccumulate and follow-up DMSA scans showed good residual function. Conclusion. We suggest that drainage of urinomas that separate renal fragments should be considered since this may accelerate healing and help preserve renal function.

Tobogganing injuries in children

AIM To undertake a retrospective review of tobogganing-related injuries in children requiring admission to the Hospital for Sick Children, Toronto. MATERIALS AND METHODS Twenty-two children with tobogganing-related injuries were admitted between December 1991 and December 1993. There were 13 boys and 9 girls (median age, 10 years; range, 3 to 17 years). Their charts were reviewed using a structured proforma. RESULTS Nine patients (41%) sustained injuries by striking a tree, 8 struck other objects, and 5 fell from the toboggan. Only 1 was wearing protective headgear. The initial site of impact was the head in 13 patients (59%), the trunk in 5, and the extremities in 4. Major injuries were sustained in all body systems. Thirteen patients (59%) required surgical treatment and two patients died, one of cerebral edema and the other of acute renal failure and subsequent multiorgan failure. CONCLUSION Tobogganing-related injuries represent a small fraction of all injuries in children who require hospitalization. However, such injuries can be serious and can cause significant morbidity and mortality. Better public awareness of the risks of tobogganing is required and simple safety guidelines should be developed to reduce the risks of this popular winter pastime.

Treatment of tracheomalacia with aortopexy in children in Glasgow

OBJECTIVE The aim of this study was to assess outcomes of infants and children undergoing aortopexy and to try and establish which children would derive the greatest benefit from this complex intervention. Materials and METHODS This is a retrospective case series in a pediatric tertiary referral hospital between 1993 and 2012. A case sheet review was performed to collect demographic data and identify outcomes for each child. The effects of the subtype of tracheomalacia, weight at surgery, symptoms at presentation, surgical approach, and preoperative ventilation were considered. RESULTS There were 30 children who underwent aortopexy during the study period. Of the 30 children in the study, 21 children (70%) were male. The gestational age at birth ranged between 25 and 41 weeks (9 children [30%] were preterm). Age at surgery was between 2 and 140 weeks (mean; 31.5 weeks, median; 26 weeks). The onset of symptoms was between birth and 18 months (mean; 3.8 months, median; 3.5 months). The presenting symptoms were stridor (n = 9; 30%), failed extubation (n = 4; 13%), death attacks (n = 8; 27%), and cyanosis (n = 9; 30%). The underlying pathology was primary in 10 children (33%) and secondary in 18 children. The diagnosis was made by bronchoscopy in 26 children (93%). Imaging was performed in 25 children (83%). Aortopexy in our institution is performed by general pediatric surgeons (n = 8; 27%) and cardiothoracic surgeons (n = 22; 73%). In the immediately postoperative period, 25 children (83%) were thriving. Of the children that required another procedure; 1 child was reintubated (3%), 2 children had a tracheostomy (6%), 1 child had a stent (3%), and 2 children died (6%). Clinical follow-up of these children was between 1 month and 12 years. Long term, in 22 children (73%) were asymptomatic. CONCLUSION There were no clinical predictors of outcome identified, but aortopexy is a safe effective procedure for children with severe tracheomalacia.

A multidisciplinary team model of caring for patients with perianal Crohn's disease incorporating a literature review, topical therapy and personal practice

Background Crohns disease (CD) is characterised by periods of relapse and remission. Over time the disease leads almost inevitably to the complications of stricturing, penetration and fistulisation. Perianal CD involves areas of chronic abscess formation, ulceration, skin tags or fistula formation. This can be a particularly challenging and complex problem to manage, and a range of potential treatment modalities exist. Methods This review covers the management of perianal CD and provides recommendations for practice for the multidisciplinary team (MDT), including the use of wound management products and relevant clinical images. Results Current practice focuses predominantly on the use of antibiotic therapy, immunosuppression, immunomodulation and surgery. These therapies are used individually or in combination. The majority of evidence suggests that a combination of medical and surgical management produces the best disease outcomes. However, this treatment regime can be debilitating for the patient and compliance can be difficult. Published work on the use of topical therapy in the management of perianal CD focuses specifically on topical drug therapy; it does not, however, address the basic guiding principles of chronic wound management—in particular, optimal moisture control and the management of bacterial burden on the wound surface. Honey and silver-containing wound management products act as topical antimicrobial agents and therefore address these principles. Conclusions Perianal CD is the archetypal condition that exemplifies the need for an MDT approach in caring for patients with inflammatory bowel disease. A combination of treatment modalities that includes topical wound management is likely to produce the best patient outcomes.

Choledochal malformations: the Scottish experience.

INTRODUCTION Excisional surgery for choledochal malformations in Scotland is currently performed in three specialist pediatric surgical centers using open or laparoscopic-assisted techniques. We reviewed the outcome of children who had excisional surgery in Scotland between 1992 and 2010. MATERIALS AND METHODS Case notes for all patients undergoing excisional surgery in any of the three specialist pediatric surgical centers in Scotland between 1992 and 2010 were retrospectively reviewed. RESULTS A total of 25 patients were identified, with a female preponderance of 4:1. Of these, three patients (12%) were diagnosed by antenatal ultrasound scan. The commonest presenting symptoms were anorexia (56%), abdominal pain (52%), and jaundice (52%). Only 20% had the classical triad of abdominal pain, jaundice, and a palpable mass. Using the Kings College Hospital classification, 14 patients had type 1 malformations, 8 had type 4 malformations, and 3 had type 2 malformations. Median age at operation was 2 years (range 35 days to 13.5 years). Two centers performed open excision while the third center used primarily a laparoscopic-assisted technique. Median follow-up was 2.1 years (range 30 days to 11.9 years). Three patients (12%) required repeat laparotomy. The wound infection rate was 8% (n=2). The recurrent cholangitis rate was 8% (n=2). There was one late death due to adhesive small bowel obstruction, 4 years after surgery. To date, no patient has developed biliary tree stones or liver failure. CONCLUSIONS Choledochal malformation excisional surgery, either open or laparoscopic assisted, can be safely performed in appropriately equipped, pediatric surgical centers in Scotland by experienced pediatric surgeons.

F10 Open Orchidopexy

• Perform an examination under anaesthetic (EUA) of the inguinal region to confirm the position of the testes

F2 Inguinal Hernia and Ligation of Patent Processus Vaginalis

• General anaesthesia is used, but consider spinal anaesthesia in ex-preterm infants and patients with significant cardiorespiratory comorbidity.