R. R. Turnock

Double blind randomised controlled trial of topical glyceryl trinitrate in anal fissure

AIMS To determine the effectiveness and safety of topical glyceryl trinitrate (GTN) in the management of acute anal fissure in children. METHODS Individual children were randomised to receive GTN paste or placebo for six weeks in addition to oral senna and lactulose. Patients took laxatives alone for a further 10 weeks. Each week a research nurse telephoned families to assess pain scores and give advice. Main outcome measures were validated standardised pain scores and time to painless defaecation. RESULTS Forty subjects were recruited from 46 eligible children; 31 children completed the trial (13 in the GTN group and 18 in the placebo group). No differences in the proportion of those achieving pain free defaecation with relation to time were seen between the two groups. Similarly, there were no significant differences in pain scores between the two groups over the 16 week study period. However, in both groups pain scores had decreased significantly. There were no differences in the incidence of rectal bleeding, faecal soiling, presence of visible fissure, skin tag, or faecal loading at outpatient review at the time of recruitment, or at 6 weeks and 16 weeks. No serious adverse effects were observed. CONCLUSIONS This study suggests that 0.2% GTN paste is ineffective in the treatment of acute anal fissures in childhood. However the overall fissure healing rate is high (84%) with associated reduction in pain scores, suggesting that a nurse based treatment programme can achieve a high rate of fissure healing.

Wandering calcified ovary in children

A case of a mobile, calcified, intrapelvic mass representing an autoamputated ovary in an asymptomatic girl is presented. There was no previous history of acute abdominal pain indicating possible torsion of the adnexa. The diagnosis should be suspected when radiological investigations show a freely mobile, calcified intraperitoneal mass incidentally in young females with absent adnexa. The diagnostic and therapeutic role of laparoscopy in this case is emphasised.

The impact of an operative note proforma at a paediatric surgical centre

Rationale, aims and objectives With expectations for standardization and evidence-based practice, the Royal College of Surgeons (RCS) published the ‘Good Surgical Practice’ in 2008. The document sets standards for operative records anticipating improved documentation, audits, medico-legal review and quality and safety of handover. We evaluated (1) documentation against RCS standards; (2) whether RCS standards are applicable to and adequate for paediatric surgery; and (3) the impact of a standardized operative proforma. Methods All general surgery and urology admissions during July 2011 and August 2012 were retrospectively reviewed using 23 set criteria. An operative note proforma was introduced in February 2012. Results were compared and statistically analysed using two-tailed Fishers exact test, with Bonferroni correction where appropriate (SPSS 20.0, IBM SPSS Statistics, Armonk, NY, USA). Results There were 345 children admitted; 63.2% underwent an operation (119 in 2011 versus 99 in 2012); 55% of operations were day cases. The initial audit noted poor documentation in 7 of 23 criteria. Following introduction of the operative note proforma, documentation improved significantly: patient identifiers by 12.3%, procedure time 43.3%, assistants name 31.9%, procedure type 21.4%, closure 6.2%, anaesthetists name 15.9%, anaesthetic type 56.8% and surgeons grade 65.8% (P < 0.05). Subgroup analysis in the latter cohort shows most of these effects to be related to the use of the proforma rather than education alone (P < 0.05). Quality of documentation was better by consultants versus trainees in 2 of 23 criteria (P < 0.05). Conclusion We have demonstrated a simple and cost-effective way of improving the quality of operative documentation, in line with guidelines set out by the RCS, in a climate of increasing economic austerity.