Nick Lansdale

Staged reduction of gastroschisis using preformed silos: practicalities and problems

PURPOSE Previous single-center studies have reported favorable outcomes when preformed silos (PFS) are used for the staged reduction of gastroschisis. The aim of this study was to assess the frequency and nature of complications associated with PFS in a large population and provide an insight into the practicalities of their routine use. METHODS A retrospective review was carried out of all cases of gastroschisis managed with PFS in 4 UK neonatal surgical units for a 6-year period. RESULTS One hundred fifty infants were included, and 139 (92.7%) silos were applied at cot side (no sedation, n = 93). Median silo size was 4 cm, and time of application was 2.5 hours. Enlarging the defect by incision of fascia was required in 17 (11%). Defect closure was performed at a median of 4 days (0-47) with 93 (62%) being at cot side. Methods of closure were adhesive strips/dressings (n = 94), sutures (n = 48), and patch (n = 8). Discoloration of the viscera occurred in 16 (11%), managed successfully by simple methods (change of PFS, aspirating the stomach, or incision of the defect fascia) (n = 8), conversion to operative silo (n = 3), and operative reduction (n = 1). Four required bowel resection. Other complications included missed atresia (n = 5; 3.3%) and nectrotizing enterocolitis (n = 11; 7%). There were 5 deaths in the series (3.3%). CONCLUSIONS Staged reduction of gastroschisis with PFS is simple, convenient, and safe. The low rates of associated complications and mortality appear favorable when compared to infants managed with more traditional techniques. We recommend that PFS should be used for the routine management of gastroschisis.

Factors affecting the outcome of foreskin reconstruction in hypospadias surgery

OBJECTIVE Despite ongoing refinement of numerous techniques, the incidence of complications following hypospadias repair is still significant. The aim of this study is to evaluate the factors that affect the success in childhood of foreskin reconstruction with hypospadias repair. MATERIALS AND METHODS A retrospective study was carried out of all primary hypospadias repairs with foreskin reconstruction (n=408) over the last 23 years. The hypospadias was coronal in 160 (39%), glanular in 114 (28%), subcoronal in 78 (19%) and distal penile in 56 (14%) cases. Foreskin reconstruction was included in 362 cases suitable for a meatal advancement (191) or distal urethral tubularization (171), and 46 cases for a flip-flap procedure (37 Mathieu, nine Barcat). Outcome analysis was of foreskin-related complications post surgery. RESULTS Foreskin repair was successful in 333 cases (92%) that underwent meatal advancement/distal urethral tubularization, and 33 (72%) that underwent a flip-flap operation. Complications related to the foreskin occurred in 10% of the whole group with a urethral fistula rate of 8%. The median age at surgery was 13 months (2-120 months), and the median follow-up period was 11 months (1-100 months). CONCLUSIONS A good cosmetic and functional outcome can be achieved with foreskin reconstruction combined with a variety of hypospadias repairs. The outcome in this series was better in cases of distal hypospadias using interrupted polyglactin sutures.

Population-level surgical outcomes for infantile hypertrophic pyloric stenosis

OBJECTIVES Determine national outcomes for pyloromyotomy; how these are affected by: (i) surgical approach (open/laparoscopic), or (ii) centre type/volume and establish potential benchmarks of quality. METHODS Hospital Episode Statistics data were analysed for admissions 2002-2011. Data presented as median (IQR). RESULTS 9686 infants underwent pyloromyotomy (83% male). Surgery was performed in 22 specialist (SpCen) and 39 nonspecialist centres (NonSpCen). The proportion treated in SpCen increased linearly by 0.4%/year (r=0.76, p=0.01). Annual case volume in SpCen vs. NonSpCen was 40 (24-53) vs. 1 (0-3). Time to surgery was shorter in SpCen (1day [1, 2] vs. 2 [1-3]), but total stay equal (4days [3-6]). 137 (1.4%) had complications requiring reoperation (wound problem 0.6%; repeat pyloromyotomy 0.5% and perforation, bleeding or obstruction 0.2%): pooled rates were similar between SpCen and NonSpCen (1.4% vs. 1.6%, p=0.52). Three NonSpCen had >5% reoperations (within 99.8% C.I. as small denominators). There was no relationship between reoperation and centre volume. Laparoscopic pyloromyotomy had increased risk of repeat pyloromyotomy (OR 2.28 [1.14-4.57], p=0.029). CONCLUSIONS Pyloric stenosis surgery shifted from centres local to patients, but outcomes were unaffected by centre type/volume. Modest reported benefits of laparoscopy appear offset by increased reoperations. Quality benchmarks could be set for reoperation <4%. TYPE OF STUDY Treatment Study. LEVEL OF EVIDENCE Level III.

Stress-related mucosal disease in childhood appendicitis.

Stress-related mucosal disease (SRMD) is known to occur in critically ill patients both in the adult and paediatric population. Acute appendicitis is the most common surgical emergency in childhood and can precipitate SRMD. This possibility should be kept in mind, particularly in prolonged, complicated episodes. Although clinical complications of SRMD are rare, they may be highly significant in terms of haemorrhage or perforation and result in considerable morbidity or mortality. We provide a thorough review of the incidence, aetiology, role of Helicobacter pylori, risk factors, prophylaxis and management of this condition and describe a series of three cases of ulcerative SRMD in children with complicated appendicitis.

PO-0912 Short Bowel State: Does Autologous Gastrointestinal Reconstruction Reduce Catheter-related Blood Stream Infections?

Background and aims Catheter-related blood stream infections (CRBSI) occur frequently in Short Bowel Syndrome (SBS) children on parenteral nutrition (PN). Central venous catheter (CVC) complication and complete loss of central venous access are indication for intestinal transplantation. Autologous gastrointestinal reconstruction surgery (AGIR) is mandatory in any chronically PN-dependent patient when there is substantial bowel dilation to reduce bacterial translocation. We reviewed patients who underwent lengthening surgery and calculated the rate of CRBSI pre and post surgery. Methods PN dependent children with SBS were identified. Inclusion criteria were CVC for PN administration pre and post-operatively, CVC removed after weaned off PN and having gained enteral autonomy. CRBSI episodes were defined as temperature above 38.0 °C, along with positive blood culture microbiological infection from the CVC. Results Nineteen patients were identified (male n = 13). Median gestation was 35 (33.5–36.5) completed weeks and birth weight 2080 g (1725–2374). Ten patients underwent tapering enteroplasty, eight Longitudinal Intestinal Lengthening and Tailoring (LILT) procedure, and one Serial Transverse Enteroplasty (STEP) procedure. Median duration of PN was 5.3 months (2.9–6.6) pre and 9.0 months (4.2–10.9) post surgery. A total of 115 septic episodes were confirmed (70 prior to surgery and 45 post surgery). The total rate of catheter related sepsis was significantly lower after AGIR compared to before it (p = 0.016). Conclusions CRBSI frequency in PN dependent patients with dilated bowel reduces after AGIR. AGIR appears associated with significantly reduced frequency of CRBSI in PN dependent children with bowel dilatation. These findings warrant further exploration in larger, preferably controlled studies.

An ovarian tumour with a potential appendiceal origin

A 14-year-old girl underwent left oopherectomy for a multicystic ovarian mass. Histology revealed this to be an intestinal type mucinous borderline tumour (IMBT). In view of this, a semi-urgent laparoscopic appendicectomy was carried out. The appendix was histologically normal. IMBT of the ovary is a mucinous tumour with atypical proliferation of the goblet cell containing epithelium. It is known to occur simultaneously with tumours of the appendix. Paediatric surgeons need to be aware of this rare tumour and when operating on any ovarian pathology should always inspect the peritoneal cavity for mucinous deposits and examine the appendix.