Gregor Walker

Intestinal malrotation and volvulus in infants and children

The parents of a 2 week old term baby presented to the out of hours general practice service late in the evening with a two hour history of green vomiting. As the baby looked well, had been passing stools and urine normally, and had a soft non-tender abdomen, they were advised to attend their own general practice the following morning. The baby arrived in the local emergency department by ambulance six hours later with intractable shock. After aggressive resuscitation, the baby was taken to theatre for emergency laparotomy that revealed intestinal ischaemia from midgut volvulus associated with malrotation. Intestinal malrotation occurs because of failure of the normal sequence of rotation and fixation of the bowel (fig 1⇓). Duodenal obstruction can occur due to extrinsic compression from bands leading from the caecum to the lateral abdominal wall (Ladd’s bands) or from small bowel volvulus, which also leads to ischaemia of the midgut from superior mesenteric artery occlusion (fig 2⇓).1 Midgut volvulus can lead to irreversible intestinal necrosis, which is potentially fatal.1 Fig 1 Left: Diagram of normal intestinal rotation. The third part of the duodenum (a) should cross the midline, with the fourth part (b) ascending on the left of the midline to the same level as the pylorus. Shaded part of bowel represents the midgut that is exclusively supplied by the superior mesenteric artery (c). Right: Normal upper gastrointestinal contrast study Fig 2 Left: Diagram of classic intestinal malrotation with abnormal duodenal fixation, Ladd’s bands crossing the duodenum (a), and narrow base of mesentery (b). Centre: Diagram of small bowel volvulus …

Extracorporeal life support – state of the art

Extracorporeal life support (ECLS) has become an accepted therapeutic measure in the treatment of infants, children and adults with reversible respiratory or cardiac failure. The principle behind ECLS involves obtaining access to drain blood from the venous circulation into the extracorporeal circuit where it is oxygenated and cleansed of carbon dioxide before being returned to the circulation. The UK Collaborative ECMO Trial showed that an ECLS policy was clinically effective in terms of improved survival without a rise in severe disability at age 1 year. Long-term follow-up has confirmed these benefits. The value of ECLS in paediatric and, more recently, adult respiratory failure is becoming clearer. ECLS has a vital role to play in the support of paediatric cardiac surgery programmes. Recent advances include newer oxygenators, greater use of less invasive veno-venous support and the use of ECLS to support novel therapies used to treat severe congenital diaphragmatic hernia.

Colour of bile vomiting in intestinal obstruction in the newborn: questionnaire study.

Abstract Objectives To identify the colour that different groups of observers thought represented bile in a newborns vomit. Design Questionnaires displaying eight colours (pale yellow to dark green). Setting General practices in Glasgow, postnatal ward and level III special care baby unit in a university teaching hospital, and mother and toddler groups in Glasgow. Participants 47 general practitioners, 29 nurses on the baby unit, 48 midwives, and 41 mothers of babies and infants. Outcome measures Participants indicated which colour would represent bile in a babys vomit. More than one colour could be chosen. Respondents were also asked to indicate one colour that was the best match for bile. Results When any colour could be chosen, 12 (25%) general practitioners, 1 (3%) nurse on the baby unit, 5 (10%) postnatal midwives, and 23 (56%) parents did not consider green an appropriate colour for a babys vomit containing bile. Twenty three (49%) general practitioners, 7 (24%) neonatal nurses, 15 (31%) postnatal midwives, and 29 (71%) parents thought yellow was the best colour match. Conclusions There is little agreement about the colour of bile vomit in a newborn. It is more pertinent to ask parents about the colour of vomit rather than whether it contained bile. Many general practitioners and parents do not recognise green as an appropriate colour for bile in the vomit of newborns, which may delay surgical referral. Though yellow vomit does not exclude intestinal obstruction, the presence of green vomiting in a baby is a surgical emergency and requires expeditious referral.

Laparoscopic assistance for primary transanal pull-through in Hirschsprung's disease: a systematic review and meta-analysis.

Objective To compare outcomes following totally transanal endorectal pull-through (TTERPT) versus pull-through with any form of laparoscopic assistance (LAPT) for infants with uncomplicated Hirschsprungs disease. Design Systematic review and meta-analysis. Setting Five hospitals with a paediatric surgical service. Participants 405 infants with uncomplicated Hirschsprungs disease. Interventions TTERPT versus LAPT. Primary and secondary outcome measures Primary outcomes: mortality, postoperative enterocolitis, faecal incontinence, constipation, unplanned laparotomy or stoma formation, and injury to abdominal viscera. Secondary outcomes Haemorrhage requiring transfusion of blood products, abscess formation, intestinal obstruction, intestinal ischaemia, enteric fistula formation, urinary incontinence or retention, impotency and duration of procedure. Results Five eligible studies comprising 405 patients were identified from 2107 studies. All studies were retrospective case series, with variability in outcome assessment quality and length of follow-up. Operative duration was 50.29 min shorter with TTERPT (95% CI 39.83 to 60.74, p<0.00001). There were no significant differences identified between TTERPT and LAPT for incidence of postoperative enterocolitis (OR=0.78, 95% CI 0.44 to 1.38, p=0.39), faecal incontinence (OR=0.44, 95% CI 0.09 to 2.20, p=0.32) or constipation (OR=0.84, 95% CI 0.32 to 2.17, p=0.71). Conclusions This meta-analysis did not find any evidence to suggest a higher rate of enterocolitis, incontinence or constipation following TTERPT compared with LAPT. Further long-term comparative studies and multicentre data pooling are needed to determine whether a purely transanal approach offers any advantages over a laparoscopically assisted approach to rectosigmoid Hirschsprungs disease. Trial registration number PROSPERO registry- CRD42013005698.

Cycled enteral antibiotics reduce sepsis rates in paediatric patients on long‐term parenteral nutrition for intestinal failure

Aliment Pharmacol Ther 2011; 34: 1005–1011

The long-term outcome of patients diagnosed with sacrococcygeal teratoma in childhood. A study of a national cohort

Background/Purpose The improved survival of sacrococcygeal teratoma (SCT) has led to increased awareness of its long-term sequelae. Our aim was to assess the long-term outcome of a national cohort using detailed questionnaires. Methods The three paediatric surgery centres in Scotland were contacted to identify all SCT patients ≥5 years of age. Case notes were reviewed. Detailed separate questionnaires were used to assess long-term bowel, urinary and obstetric outcomes and were completed during an arranged interview. Groups were statistically compared using Z-tests or Fishers exact test. Results Overall, 48 patients were identified but only 31 were available for follow-up. Age ranged from 5–35 years (median 12 years and 8 months). There were 25 (81%) females and 5 (16%) patients had malignant disease. Abnormal bowel function was noted in 42% of patients, with constipation being the commonest complaint (39%) with no obvious predictive features at presentation. Urinary symptoms were reported in 55% of the patients. A total of nine (29%) patients suffered from urgency and/or wetting. Confirmed urinary tract infections (UTIs) were reported by nine patients. Successful pregnancies were reported by two females and neither of their children had SCT. Conclusions This is one of the largest national studies assessing the long-term outcome of patients with SCT. It highlights the significant gastrointestinal and urological long-term morbidities of SCT patients, which is useful for counselling families.

Prolonged two-man basic life support may result in hypocarbia in the ventilating rescuer.

OBJECTIVES To determine whether the quality of expired air given during mouth-to-mouth ventilation differs between one- and two-person basic life support. METHODS 15 young fit volunteers performed 15-min simulated resuscitation on a manikin. The oxygen and carbon dioxide concentration of their expired breath and the total ventilation was continuously monitored. Compression:ventilation ratios of 15:2 for one-person and 5:1 for two-person resuscitation were used. RESULTS In two-man resuscitation, where the rescuer who is ventilating the patient is not performing chest compressions, the oxygen content of the expired breath rises (P<0.01), and the carbon dioxide content falls (P<0.01). The carbon dioxide concentration declined gradually throughout the 15-min session. Most participants complained of light-headedness on completion of the two-man session. Total ventilation did not differ between the two methods (P=0.757, 95% CI=-0.329, 0.242). CONCLUSION Trainees in basic life support should be informed that symptoms of hypocarbia may occur in prolonged mouth-to-mouth ventilation, when acting in a two-man team. We would advise rescuers using these protocols to change places every 5 min to avoid these symptoms. These findings add further weight to the recommendations that all resuscitation should be carried out using 15:2 compression:ventilation ratio.

Hirschsprung's disease in the UK and Ireland: incidence and anomalies.

Objectives To describe clinical characteristics and preoperative management of a national cohort of infants with Hirschsprungs disease (HD). Design Population-based cohort study of all live-born infants with HD born in the UK and Ireland from October 2010 to September 2012. Setting All 28 paediatric surgical centres in the UK and Ireland. Participants 305 infants presenting before 6 months of age with histologically proven HD. Main outcome measures Incidence, clinical characteristics including gestational age, birth weight, gender, associated anomalies; age and clinical features at presentation; and use of rectal washouts or stoma. Results The incidence of HD in the UK and Ireland was 1.8 per 10 000 live births (95% CI 1.5 to 1.9). Male to female ratio was 3.3:1. An associated anomaly was identified in 23% (69), with 15% (47) having a recognisable syndrome. The proportion of infants who presented and were diagnosed in the neonatal period was 91.5% (279) and 83.9% (256), respectively. 23.9% (73) and 44.2% (135) passed meconium within 24 and 48 hours of birth. 81% (246) first presented to a hospital without tertiary paediatric surgical services, necessitating interhospital transfer. Initial colonic decompression was by rectal washouts in 86.2% (263) and by defunctioning stoma in 12.8% (39). Subsequently, 27.4% (72) of infants failed management with rectal washouts and required a delayed stoma, resulting in 36.4% (111) of infants having a stoma. Conclusions In this population-based cohort, presentation outside the neonatal period was rare. Nearly half of the infants with HD passed meconium within 48 hours of birth and over one third were managed with a stoma.

A UK wide cohort study describing management and outcomes for infants with surgical Necrotising Enterocolitis.

The Royal College of Surgeons have proposed using outcomes from necrotising enterocolitis (NEC) surgery for revalidation of neonatal surgeons. The aim of this study was therefore to calculate the number of infants in the UK/Ireland with surgical NEC and describe outcomes that could be used for national benchmarking and counselling of parents. A prospective nationwide cohort study of every infant requiring surgical intervention for NEC in the UK was conducted between 01/03/13 and 28/02/14. Primary outcome was mortality at 28-days. Secondary outcomes included discharge, post-operative complication, and TPN requirement. 236 infants were included, 43(18%) of whom died, and eight(3%) of whom were discharged prior to 28-days post decision to intervene surgically. Sixty infants who underwent laparotomy (27%) experienced a complication, and 67(35%) of those who were alive at 28 days were parenteral nutrition free. Following multi-variable modelling, presence of a non-cardiac congenital anomaly (aOR 5.17, 95% CI 1.9–14.1), abdominal wall erythema or discolouration at presentation (aOR 2.51, 95% CI 1.23–5.1), diagnosis of single intestinal perforation at laparotomy (aOR 3.1 95% CI 1.05–9.3), and necessity to perform a clip and drop procedure (aOR 30, 95% CI 3.9–237) were associated with increased 28-day mortality. These results can be used for national benchmarking and counselling of parents.

The use of stomas in the early management of Hirschsprung disease: Findings of a national, prospective cohort study

BACKGROUND/PURPOSE Primary pull-through without a stoma has become preferred practice in managing Hirschsprung disease (HD). The aims of this study were to establish stoma rate and identify factors associated with stoma formation in a population-based cohort in the UK and Ireland. METHODS Live-born infants with HD were prospectively identified in all 28 specialist pediatric surgical units in the UK and Ireland between October 2010 to September 2012. Method of colonic decompression was recorded and multivariable logistic regression was used to identify factors associated with stoma formation. RESULTS 305 infants with HD were identified. Rectal washouts were initially used in 86% (263) with a defunctioning stoma formed as the primary management in 13% (39). Ultimately, 36% (111) required a stoma prior to definitive surgery. Compared to infants managed with rectal washouts alone; infants managed with a stoma were more likely to have a transition zone proximal to the splenic flexure, Down (or another) syndrome, and HD diagnosis established more than 28days after presentation. CONCLUSIONS Although rectal washouts are commonly employed, a stoma prior to definitive surgery was required in 36% of infants in a national cohort. Delayed diagnosis, aganglionosis proximal to the splenic flexure and presence of other anomalies are associated with stoma formation. TYPE OF STUDY AND LEVEL OF EVIDENCE Prognosis study (high-quality prospective cohort study with 80% follow-up and all patients enrolled at same time point in disease).