Ian Gollow

The incidence and investigation of acute scrotal problems in children.

Abstract.The true incidence of the various causes of acute scrotum in children is unclear; epididymo-orchitis (EO) is thought to be uncommon. Investigation for underlying urological abnormality in children with EO is recommended. To determine the incidence of the various pathologies in boys presenting to the emergency department with an acute scrotal condition and assess the value of further investigation of the urinary tract in a subgroup of boys with EO, a retrospective review of 100 consecutive patients admitted with a diagnosis of testicular pain was performed. Seventy had torsion of an appendix testis (TAT) and 12 had torsion of the testicle (TT). Ten boys were admitted with 11 episodes of EO; 7 had other pathologies including incarcerated hernia, varicocoele, and idiopathic scrotal oedema. The diagnosis of EO was made at operation in all 11 episodes. Escherichia coli was cultured in 4 patients; none were found to have underlying urinary tract abnormality. TAT was thus commonest causes of the acute scrotum. EO is not rare in infants, the incidence in this study being equal to the of TT. Subsequent urological investigation did not disclose any underlying abnormality. However, based on the current published literature futher investigation is recommended in selected cases.

Gastroschisis: early enteral feeds may improve outcome.

Objective: Population‐based retrospective review of gastroschisis from 1986 to 1996.

Ward reduction of gastroschisis in a single stage without general anaesthesia may increase the risk of short‐term morbidities: Results of a retrospective audit

Background:  Ward reduction of gastroschisis in a single stage without the need for general inhalational anaesthesia (ward reduction) has been reported by some authors to be effective and safe. We introduced this practice to our neonatal unit 2 years ago.

Peritoneal drainage versus laparotomy for perforated necrotising enterocolitis or spontaneous intestinal perforation: a retrospective cohort study.

Aim:  Perforated necrotising enterocolitis (NEC) and spontaneous intestinal perforation (SIP) in preterm infants are associated with high morbidity and mortality. The optimum surgical management during the acute stage remains unclear. The aim of the study was to compare the outcomes of preterm infants (gestational age at birth <30 weeks) with perforated NEC or SIP undergoing primary peritoneal drainage (PD) versus laparotomy.

Single or double bubble: Sign of trouble! Congenital pyloric atresia: Report of two cases and review of literature

Abstract:  Congenital pyloric atresia is a very rare anomaly. It can occur as an isolated anomaly and can be associated with other conditions such as aplasia cutis congenital/epidermolysis bullosa or multiple intestinal atresias. We present two cases of congenital pyloric atresia, solitary air bubble on X‐ray abdomen being pathognomonic sign of pyloric atresia. However, it might present with an intermittent double bubble sign.

Survival of patient after aorto‐oesophageal fistula following button battery ingestion

Clinical history taking is a fundamental building block in the diagnostic process. While structured formats exist for many of the common clinical specialties, bariatric surgery is a relatively new concept. As such, it can be unclear to both surgeons and trainees exposed to these patients how such a history should be approached. This is important, as subtleties within the history can direct the surgeon towards choosing a specific operative procedure. In many bariatric units worldwide, patients are required to complete a questionnaire prior to clinic attendance assessing their eating habits, weight loss attempts and exercise routine, in addition to their pre-existing co-morbidity. This often includes an assessment of their psychosocial background to identify additional risk factors such as eating disorders, smoking, and alcohol or drug misuse. There are currently no clear guidelines regarding which surgical procedure patients should receive and thus it is largely guided by individual surgeons’ experience or preferences. Despite this, a clearly structured clinical history, incorporating the points previously raised, remains a key component in decisionmaking. We have found the following ‘ABC DEEP’ model to be a useful mnemonic to not only ensure that key points in the clinical history are recorded, but also to provide a framework for letter dictation. A series of selective questions within each category is required to provide a complete clinical assessment. A Age of patient B Body mass index C Co-morbidities D Drug history E Eating habits E Exercise habits P Psychosocial history

Low risk, but not no risk, of umbilical hernia complications requiring acute surgery in childhood

Umbilical hernias are a common finding in the paediatric community, with a preponderance to affect Afro‐Caribbean and premature children. The rate of incarceration varies greatly between populations. Therefore, it is valuable to obtain some Australian data on this topic.

Review of the radiation exposure during screening of surgically implanted central venous access devices.

PURPOSE Ionizing radiation is used for the insertion of surgically implanted venous access devices (SIVADs) with children at the highest risk of cumulative radiation effects from these procedures. This study examines the radiation dose in a pediatric population during intraoperative radiological screening. METHODS A retrospective study looked at all pediatric patients in a tertiary hospital between January 2008 and January 2014 who had a surgically implanted venous access device inserted using intraoperative fluoroscopy. Patient demographics, reason for SIVAD insertion, the type and method of insertion, fluoroscopy time and radiation dose area product were determined. RESULTS A total of 505 patients had 682 SIVADs inserted, with 123 patients receiving multiple SIVAD over the six year period. There were two types of SIVAD inserted, 492 were totally implanted venous access devices (TIVAD) and 190 were tunneled central venous catheters (cuffed central line). Five hundred seven of the SIVAD inserted recorded the dose area product and fluoroscopy time. The median time for screening was 5seconds (range 1 to 275seconds) and the median dose area product was 0.00352mGym(2) (range 0.000001mGym(2) to 0.28mGym(2)). Of the 507 SIVAD that recorded the radiation data, 479 were open surgical cut-down insertion and 27 were percutaneous insertion. Percutaneously inserted surgically implanted venous access devices (mean 0.0060mGym(2)) had a longer dose area product than open insertion (mean 0.0034mGym(2); p=0.05). CONCLUSION Screening of SIVAD involves low levels of radiation exposure and is comparable to a chest x-ray or a transatlantic flight. The excess lifetime cancer risk to patients is estimated to be very low and is considered to be outweighed by the benefits of insertion. Open surgical cut-down insertion has a significantly reduced radiation exposure compared to percutaneous techniques. Although radiation dose is higher with percutaneous procedures, the clinical effects are considered minimal, and the resultant radiation risk is estimated to be very low. Radiation dose should not determine technique of insertion of SIVAD.

Early Commencement of Enteral Feeds in Gastroschisis: A Systematic Review of Literature.

Introduction There are no evidence‐based strategies to improve feed tolerance in gastroschisis. Early commencement of enteral feeds (CEF) is known to improve feed tolerance in preterm infants. It is possible that infants with gastroschisis may also benefit from early CEF. Objective To conduct a systematic review to evaluate the relationship between time of CEF, and time to reach full enteral feeds (FEF), duration of parenteral nutrition (PN), and duration of hospital stay (HS). Methods PubMed, EMBASE, Cochrane CENTRAL, and relevant conference abstracts were searched in December 2015. Studies of any design reporting on time to CEF and one or more of the outcomes of interest were included. Meta‐regression analysis was conducted to find the association between time to CEF and the outcomes of interest. Results There were no randomized controlled trials (RCTs) comparing early (≤7 days from birth) versus delayed (>7 days) CEF. Forty‐two observational studies on gastroschisis (4,835 infants) where feed‐related information was available were included. Meta‐regression results indicated that each day delay in CEF was associated with a delay of an additional 1.4 days (95% confidence interval [CI]: 0.95, 1.85) to FEF, 2.05 days (95% CI: 1.50, 2.59) to the duration of PN, and 1.91 days (95% CI: 1.37, 2.45) to the duration of HS. Sensitivity analysis after excluding studies that provided information exclusively on complex gastroschisis continued to show beneficial effects of early CEF. Conclusion Early CEF may be associated with early attainment of FEF in gastroschisis. RCTs comparing early versus delayed CEF are needed urgently.

Does continuous positive airway pressure for extubation in congenital tracheoesophageal fistula increase the risk of anastomotic leak? A retrospective cohort study

Immediate post‐operative care of tracheoesophageal fistula (TEF) and oesophageal atresia (EA) requires mechanical ventilation. Early extubation is preferred, but subsequent respiratory distress may warrant re‐intubation. Continuous positive airway pressure (CPAP) is a well‐established modality to prevent extubation failures in preterm infants. However, it is not favoured in TEF/EA, because of the theoretical risk of oesophageal anastomotic leak (AL). The aim of this study was to find out if post‐extubation CPAP is associated with increased risk of AL.