R. Wiersma

Oesophageal atresia: caudo-thoracic epidural anaesthesia reduces the need for post-operative ventilatory support

The mortality of neonates with oesophageal atresia in the Third World remains high because of delays in presentation and diagnosis. Lack of appropriate intensive care facilities is a further contributing factor. Caudothoracic epidural anaesthesia was used during surgical repair of oesophageal atresia in 35 patients in an attempt to minimise the need for post-operative ventionally support. This group was compared with 36 patients whose surgery was performed under general anaesthesia. The age at the time of referral, sex ratio, and weight were comparable in both groups. Using the Waterson classification, a greater number of poorer prognostic patients were seen in the epidural group (P <0.02). In all Waterson risk categories fewer patients required ventionally support post-operatively, which was statistically significant (P <0.01) when all categories were combined. We are encouraged by our results and believe this technique has a rôle in the management of neonates undergoing major surgery, both where neonatal intensive care exist or is deficient as in many parts of the Third World.

True hermaphroditism in southern Africa: the clinical picture

This is an 18-year (1985–2001) retrospective review of 85 patients with true hermaphroditism, with the aim of facilitating early recognition of this condition. Presentation of neonates and infants 6 months or younger, constituting 54% of this cohort, were different from the older children. The presentation, clinical features and investigative results of all patients diagnosed with true hermaphroditism at a single South African paediatric surgical unit were reviewed. This paper highlights the previously reported high incidence (51%) of this condition, as well as some of the unusual features of true hermaphroditism in this region. Diagnosis of true hermaphroditism requires a high index of suspicion for subtle anomalies of the genitalia. Although there were no pathognomonic clinical features, the true hermaphrodite presents as a patient of either gender with a congenital anomaly of the genitalia. The child is likely to have a normal male phallus, bifid labio-scrotal folds, a perineal hypospadias and in 53% of patients there was a palpable gonad. The method of investigation, together with the results and some of the management dilemmas associated with true hermaphroditism in a Third World population are presented.

Intralingual cysts of foregut origin

Intralingual cysts lined by epithelium of foregut origin are rarely reported. We present 16 patients seen over an 8-year period (1983 to 1990) with such lesions. Respiratory and squamous epithelium were the most commonly encountered. These unusual cysts generally presented in the neonatal period with feeding difficulty. Two children had multiple cysts. Histological varieties of epithelia are described and the clinical features are discussed. From our experience we conclude that these cysts are adequately treated by complete surgical excision through a sagittal glossal split. This can be safely done electively in the neonatal period. Cyst aspiration was found to be inadequate definitive treatment.

Minimizing surgery in complicated intussusceptions in the Third World

When presentation is delayed, intussusceptions may be difficult to reduce using standard enema regimens. Our endeavour to minimize the need for surgery in an environment where failed reductions are common has led to the development of an aggressive, non-operative method of reducing intussusceptions. One hundred and six patients with intussusception were reviewed with the aim of evaluating a new method of reducing intussusceptions suited to our Third World environment. In our cohort, delayed presentation was common, with 32% of patients presenting more than 48 h after the onset of the intussusception. On clinical grounds alone, 41% of patients required a primary laparotomy. Standard barium and air reductions for intussusception were rarely successful under these conditions i.e. 13% and 22%, respectively. By using an air enema under general anaesthesia in the operating theatre, the reduction rate has improved to 53%. This approach is suggested as a last attempt at reducing an intussusception prior to laparotomy following failed standard enema reduction, and as the first line of management in the attempted reduction in the patient with delayed presentation without symptoms of peritonitis.

Gastrointestinal tract perforation in neonates

Gastrointestinal tract perforation in neonates is a serious problem associated with high morbidity and mortality. Co-morbid factors, particularly prematurity and low birth weight, impact negatively on the outcome. This article highlights issues related to diagnosis and treatment with a view to improving the poor prognosis found in this condition.

Membranous atresia of the body of the stomach

Pyloric and prepyloric webs and atresias have long been recognized and frequently reported; however, membranous atresia of the body of the stomach has not been reported previously. The authors report such a case.

Amoebiasis in children : pathology, diagnosis, and treatment

Experience with 56 children with amoebiasis referred for surgical management is presented. Twenty-four patients had predominantly colitic disease and 32 hepatic; 3 of the 56 had both organs affected. Based on this experience an attempt is made to define therapeutic options in children. The relative roles of colonic resection and peroperative prograde colonic irrigation in the treatment of colitis and the indications for aspiration of hepatic abscesses are discussed. The pathology is outlined.

Extraluminal oesophageal foreign body

Migration of a foreign body through the oesophageal wall is a rare and serious complication of foreign-body ingestion. We report a well 4-year-old child with such an extra-luminal oesophageal foreign body lying wholly within the mediastinum. The importance of detailed pre-operative assessment is emphasised.