H. Rode

Blunt liver trauma in children: nonoperative management.

Since 1978, we have treated 19 of 23 (83%) children with blunt liver trauma nonoperatively. Management consisted of observation in an intensive care unit, repeated physical examination, frequent reevaluation of laboratory values, special investigations, and bed rest. The 19 patients all remained stable, required no surgical intervention, and showed resolution of the hepatic injuries with no early or delayed complications. Ultrasonography, although not as reliable a method as computed tomography or liver isotope scans for identification of hepatic trauma at first presentation, provided a very useful method for documenting subsequent progress and eventual healing of the lesions. The presence of an isolated hepatic injury is insufficient indication for surgery. If there is significant extrahepatic injury requiring surgery, or if the patient with hepatic trauma is deteriorating, operative intervention is mandatory.

Conjoined twins--the Cape Town experience.

This paper records our experience in the management of 25 sets of conjoined twins seen over a 32 year period (1964–1996). The twins were classified into 14 complete and symmetrical sets and 11 incomplete or heteropagus. The 14 symmetrical sets included 9 thoracopagus, 2 ischiopagus, I craniopagus and 1 omphalopagus twins. In the incomplete heteropagus group there was I ischiopagus, one twin being anencepahlic, 2 dipygus, 5 parasitic, 2 fetus-in-fetu and I cranial and caudal. The management is detailed case by case. Overall 10 of 14 symmetrical sets underwent attempts at separation with 16 surviving the procedure, but there were 3 late deaths. In the incomplete group 10 of 11 were operated on with 9 survivors. The importance of a multi-disciplinary approach, the extensive investigations required pre-operatively to define areas of organ and bony conjuction, congenital anomalies of each twin and surgical teamwork is emphasized. Specific problems encountered were indentified. In thoracopagus twins the hearts were of paramount importance as conjuction was usually fatal, being associated with major congenital defects. The greater the extent of thoracic cage fusion the greater the chance of associated severe anomaly. Skin expansion to assist coverage of the defects after separation was of great assistance, as was the use of collagen coated vicryl. Evaluation of the liver and pancreatico-biliary systems with isotope excretion scanning was crucial to pre-operative planning. Where there was fusion of the duodenum a single pancreatico-biliary system could be expected and prior strategies for separation and Rouxen-Y enteric drainage of both pancreatic and biliary secretion should be planned. Gastro-oesophageal reflux led to considerable morbidity in both twins of a thoraco-omphalopagus set. In ischiopagus and dipygus conjoined twins bilateral posterior iliac osteotomies were an essential component to anatomic reconstruction of the pelvic ring and wound closure. Also in this group, due to the frequency and extent of shared genital, urinary and ano-rectal structures, long-term morbidity was expected and a component of this might be due to spinal cord tethering, or as in one of our cases, a progressive hydrosyringomyelia. Timing of separation was ideally set at between 5 and 9 months with 6 to 8 weeks of prior tissue expansion but earlier operation was frequently required because of cardio-respiratory problems or organ failure in one twin. In most cases the goal of obtaining separate, independant and intact individuals was achieved.

Esophageal pH assessment of gastroesophageal reflux in 18 patients and the effect of two prokinetic agents: Cisapride and metoclopramide

Foregut drug receptors permit inotropic manipulation of the dysmotility pattern associated with gastroesophageal reflux (GER). Two prokinetic agents, ie, Metoclopramide and Cisapride were assessed in 18 infants with severe GER (mean age 6.5 months) by means of 18-hour continuous intraesophageal pH monitoring. Six parameters were recorded, and the results compared before and during pharmacologic stimulation. Both agents improved the parameters measured, but Cisapride was found to be more effective in enhancing lower esophageal sphincter competence and esophageal motor function. Long-term assessment of both agents in the management of GER in infants is indicated.

Circumcision complications associated with the Plastibell device.

To the Editor: Sociocultural or non-medical circumcision continues to be a common practice in the Western Cape. The Plastibell (Hollister Inc., Libertyville, Ill., USA) is the most frequently used device in the local community setting. Hollister South Africa (Pty) Ltd sold 6 050 Plastibell devices in South Africa in 2003. Popularity of the device can be ascribed to its claimed ‘ease of use’. It involves a technique that can be performed under local anaesthetic.

Intrahepatic fetus-in-fetu: A case report and review of the literature

The authors report the third case since 1964 of fetus-in-fetu presenting at Red Cross Childrens Hospital. A fetal liver abnormality was detected during routine antenatal ultrasound scan, and the postnatal diagnosis of an intrahepatic, multiple fetus-in-fetu was made with abdominal ultrasound scan, plain radiograph of the abdomen and computed tomography. The mass was removed surgically by hemihepatectomy when the patient was 4 months of age. Imaging and the macroscopic and microscopic appearances of the abnormality confirmed the diagnosis and amplified it to include an adjacent teratoma. Multiple small subcapsular and perimass vascular hamartomas were coincidentally discovered in the liver. Two of the 3 nodules within the amniotic-lined cavity of the intrahepatic mass individually comply with the accepted criteria for fetus-in-fetu, and the third nodule has the accepted features of a benign teratoma. The existence of multiple fetus-in-fetu and fetus-in-fetu combined with a teratoma, is recorded in the medical literature. The imaging as well as the macroscopic and microscopic features are illustrated.

Management of pancreatic pseudocysts in children

The management of 25 children with pseudocyst of the pancreas presenting over a 30-year period is reviewed. Nearly a third could be managed nonoperatively, monitoring clinical signs, serum amylase, and in recent years the findings of ultrasound and CT scan. Persistence of symptoms, signs, and hyperamylasemia for more than 4 weeks indicated failed resolution in all but one case. Endoscopic retrograde cholangiopancreatography (ERCP) done in those who did not improve spontaneously facilitated operative strategy. Early operation and internal drainage in selected cases was well tolerated. Individualization of treatment is emphasized.

The use of diverting colostomies in paediatric peri-anal burns.

Over a 3 yr period we performed colostomies in 13 paediatric perineal burn patients out of a total of 1544 patients admitted to our Burns Unit during that period. The mean total body surface area (TBSA) burn was 34% (14-65%); ten patients sustained fire burns and the remaining three hot water burns. We performed prophylactic colostomies in seven children, therapeutic colostomies (to counteract deep wound infection and septicaemia with gut-derived organisms) in five patients and one colostomy in a cerebral palsy child with a left hemiparesis. A sigmoid end-colostomy with Hartmanns closure of the distal segment was the preferred method of choice. In all children but one (died from multi-organ failure 13 days after admission) there was a marked improvement in the clinical appearance of the burn wounds and subsequent graft-take and healing. There was a change in the bacterial profile away from predominantly gut-derived Gram negative organisms to either Pseudomonas aeruginosa or no pathological organisms grown. Complications were few--two children suffered prolapse of their colostomy requiring manual reduction. We advocate diverting colostomies in a highly select group of paediatric burn patients in whom continual faecal soiling is threatening to both graft and life.

Whole gut lavage in children using an iso-osmolar solution containing polyethelene Glycol (Golytely)

Whole-gut irrigation with an iso-osmolar solution was assessed in 53 children. The lavage was well tolerated without evidence of fluid or electrolyte shift. The rate of infusion to achieve a clear bowel within six to ten hours was 25 to 35 mL/kg/h.

The manometric evaluation of the rectosphincteric reflex in total colonic aganglionosis

The manometric assessment of rectosphincteric function in 33 patients with histologically proven aganglionosis is reviewed. The age of the patient at first assessment and the presence of total colonic aganglionosis influenced the results obtained. Overall, a 67% accuracy rate was achieved at first assessment. This rate fell to 43% when the test was carried out during the first 7 days of life. Six cases had total colonic aganglionosis. In only a single patient of this group was the first test result positive for aganglionosis. Attention is drawn to this finding.

Perianal candidosis—a comparative study with mupirocin and nystatin

Objective To assess the efficacy and clinical outcome of 2% mupirocin in a polyethylene glycol base and nystatin cream as treatment regimens in diaper candidosis. n nDesign A prospective randomized comparative study. n nMethodsIn vitro. The susceptibility of 20 clinical isolates of Candida albicans to 2% mupirocin, nystatin, and five additional antifungal agents was evaluated using the Nathan agar-well diffusion assay. The minimum inhibitory concentration (MIC) of mupirocin against the Candida species was determined using a tube dilution method. In vivo. Twenty patients (mean age, 12 months; range, 1 month to 4 years) with moderate to severe Monilia diaper dermatitis either had mupirocin ointment or nystatin cream applied to the infected area every 8 h or after every diaper change for a period of 7 days. Microscopic examination of skin scrapings and mycologic and microbiological cultures were performed before treatment and daily for 7 days, and progress was clinically assessed. n nResultsIn vitro. Topical mupirocin produced a greater zone of inhibition than nystatin cream, i.e.xa0a mean of 27.2xa0mm (SD 1.55) compared with a mean of 17.3xa0mm (SD 1.08) for nystatin cream. MIC for mupirocin of 512 μg/mL in one case, 256 μg/mL in six cases, 200 μg/mL in 10 cases and 400 μg/mL in three cases were obtained for the 20 clinical isolates. C.xa0albicans also displayed a universal sensitivity to mupirocin and nystatin. Inxa0vivo. Eradication of all Candida organisms was achieved within 2–6 days (mean, 2.6 days) in 10 patients receiving topical mupirocin therapy with rapid healing of the excoriated wounds (mean, 4.7 days). Both Gram-positive and Gram-negative bacteria were eradicated from the infected area within the trial period. Ten patients received topical nystatin cream and, in each case, Candida was successfully cleared within 5 days (mean, 2.8 days). Only three wounds were clinically healed within the trial period, however. The remaining seven wounds showed evidence of improved, but ongoing excoriated dermatitis and a heavy growth of polymicrobial organisms. n nConclusions Both agents eradicated Candida, the major difference being the marked response of the diaper dermatitis to mupirocin. Mupirocin should be applied topically 3–4 times daily or with each diaper change and is an excellent antifungal agent.Objective To assess the efficacy and clinical outcome of 2% mupirocin in a polyethylene glycol base and nystatin cream as treatment regimens in diaper candidosis.