Ingo Jester

Surgical management of bronchopleural fistula in pediatric empyema and necrotizing pneumonia: efficacy of the serratus anterior muscle digitation flap

PURPOSE Surgical management of bronchopleural (B-P) fistula associated with thoracic empyema and necrotizing pneumonia is challenging. We evaluated the treatment and outcome of early surgical intervention with limited decortication and insertion of a serratus anterior muscle digitation flap. METHODS A retrospective review during a 10-year period of children with empyema and B-P fistula secondary to necrotizing pneumonia was performed. During this period, 335 children with empyema were admitted, of which 20 developed a B-P fistula. All underwent a thoracotomy with insertion of a serratus anterior muscle digitation flap. RESULTS Prethoracotomy chest computed tomographic scan was performed to define the pathologic characteristic. Streptococcus pneumoniae was identified by pus culture (n = 6) and by polymerase chain reaction (n = 4). The median postoperative time with pyrexia after surgical intervention was 2 days (range, 1-3 days). The median period of thoracostomy drain was 7 days (range, 5-15 days). Length of hospital stay was 21 days (range, 7-43 days). This parenchyma-preserving technique was able to control the B-P fistula successfully in all cases. No reintervention was necessary in any case. Respiratory symptoms and radiology improved in all children on follow-up, except for 3 who required oral antibiotics for subsequent chest infections. CONCLUSION Early surgical intervention with insertion of a serratus anterior muscle digitation flap is effective and safe and avoids morbidity associated with conservative management and necrotic lung resection surgery.

Laparoscopic management of colonic complications in Ehlers-Danlos syndrome type IV

Ehlers-Danlos syndrome type IV, also known as the vascular type, is the most severe form of the disease. It may cause spontaneous bowel perforation and rupture of major arteries. The treatment of bowel perforation in this population remains controversial because they are at risk for major wound complications owing to poor healing. We report the first use of laparoscopy in children with Ehlers-Danlos syndrome.

Congenital Diaphragmatic Hernia

Congenital diaphragmatic hernia (CDH) encountered in the neonates is generally diagnosed antenatally and tends to cause significant postnatal management challenges. In this context surgery is only one of the minor challenges. The procedure involves the gentle reposition of the herniated abdominal viscera back into abdomen and repairing the defect either by primary approximation of the defect or by using a patch to separate the abdomen and thoracic cavity. The morbidity in survivals is mainly related to persistence of pulmonary hypertension, gastro-oesophageal reflux with feeding intolerance and recurrence of hernia. The significant mortality associated with CDH is related to severity of pulmonary hypertension, associated cardiac and chromosomal anomalies. The chapter will deal with both open and minimally invasive method of the repair. The management of pulmonary hypertension is outside the scope of this chapter.

Streptococcus anginosus is associated with postoperative intraabdominal collections in appendicitis

AIM OF STUDY Streptococcus anginosus group (SA) (formerly Streptococcus milleri) are pathogens recognised to have a high risk of postoperative collection in appendicitis, although little data exist specifically in children. We performed a retrospective review of all microbiological data from appendicectomies to assess whether there was an association in children. METHODS A retrospective case note review of patients admitted to a paediatric tertiary centre coded for appendicitis from January 2015 to October 2016 was completed. Initial length of stay (LOS), cumulative hospital days, histology, microbiology, and radiology reports were recorded. The postoperative antibiotic regimen was based on surgeons choice and not standardised. MAIN RESULTS 231 children were identified, and 18 were excluded. In the remainder, 169 (78.9%) had positive microbiology cultures, and of these 45 were positive for SA (26.6%). There was no significant variation in monthly incidence (P=0.58). Patients with SA+ve cultures were associated with complicated appendicitis on histology (P=0.01), longer LOS and cumulative hospital days (P=0.001), and increased likelihood of developing postoperative collections (P=0.001). The relative risk of developing a postoperative collection with SA+ve cultures was 2.40. There was no difference in time to presentation, histology, or intervention between SA and non-SA patients who developed collections. All SA cultures were sensitive to penicillin and erythromycin. CONCLUSION SA cultured from intraoperative serial swabs is associated with an increased risk of developing postoperative collection (2.40). Using this information with standardisation of antimicrobial management may reduce the rate of postoperative complications in paediatric appendicitis. LEVEL OF EVIDENCE Level II prognosis study.

An unusual case of abdominal distension with constipation

A previously healthy 3-year-old boy was referred by his general practitioner to the paediatric outpatient clinic because of a 6-month history of moderate to severe constipation. It was associated with mild central abdominal pain and slight weight loss. He had been treated with Movicol, with minimal effect. There …

Paediatric penetrating thoraco-abdominal injury: Role of minimallly invasive surgery

We report two cases of penetrating thoraco-abdominal injuries who presented to our trauma centre. One with stab to lower left chest and the other one had pallet injury to right upper abdomen. The clinical presentation, radiological investigations and operative intervention are reviewed.