S. Cywes

Radiation enteritis in children

Six children with intestinal radiation injury following cancer therapy are presented. The radiation dose varied from 3500 rads to 6600 rads. Symptoms of radiation enteritis took from 3 weeks to 3 years to develop. All patients received concomitant chemotherapy. Incomplete bowel obstruction was the most common presenting feature (four cases); five came to laparotomy. Simple adhesiolysis was successful in two cases; two children required more extensive surgical manoeuvres (small-bowel bypass and bowel resections). All are alive and well 4 to 13 years following therapy although five have other radiation effects. Radiation injury to the bowel and its management are discussed.

Intestinal atresia and Hirschsprung's disease

Intestinal atresia associated with Hirschsprungs disease has been reported in only 26 cases (20 of small bowel and 6 of colon). Three additional patients are reported, two with associated myelomenigocoele. The significance of the myelomeningocoele and possible aetiological mechanisms of these associations are discussed with particular reference to the role of a vascular accident or the embryological failure of migration of nerve cells. The most likely cause is a volvulus proximal to the aganglionic bowel resulting in the associated atresia.

The deadly vomit: malrotation and midgut volvulus

Abstract137 cases of malrotation and midgut volvulus seen over a 28-year period are reviewed to emphasize the patterns of clinical presentation. Although 62% presented as neonates, 20% were over 1 year of age. Vomiting was the sympton of paramount importance in 97% but was not initially bile-stained in 20%. Sixteen percent had diarrhea as a major symptom. Abdominal pain occurred in 96% of patients over 1 year of age. Clinical signs were not apparent in most cases until gut infarction had occurred. Radiographic examination of the abdomen was considered normal in more than 20%. Barium meal was the contrast examination with most accuracy and should be diagnostic if correctly interpreted. The significant mortality (19%) in all age groups was invariably related to delay in presentation or diagnosis.

Circumcision in South Africa

Still remains the commonest reason. The arguments for requesting circumcision by the mother are the same as outlined by King and coauthors. In this country most circumcisions are performed privately. In our public hospitals, circumcision are supposed to be performed only for medical reasons. The following are the statistics from the Red Cross War Memorial Childrens Hospital and the Mowbray Maternity Hospital in Cape Town, both teaching hospitals of the University of Cape Town. During a 4-year period 1985-1988, 276 circumcisions were performed at the Red Cross Childrens Hospital. The ages ranged from 3 months to l0 years none in the neonatal period. The reasons for circumcision and the complications are shown in Table 1. Despite the policy in our public hospitals of performing circumcisions for medical reasons only, the most common reason was request by mother and several were for Muslim ritual reasons. There were 30 referrals for complications following a circumcision performed elsewhere. There were 40 complications, as shown in Table 1, for which 32 revision circumcisions were

Pharmacologic control of gastro-esophageal reflux in infants with cisapride

Autonomic receptors in the upper gastro-intestinal tract permit pharmacologic manipulation of esophageal and gastric function. A new non-anti-dopaminergic, non-cholinergic, prokinetic agent, cisapride, was evaluated to determine its efficacy in controlling gastro-esophageal reflux (GER) in infancy. Forty infants, mean age 6.5 months, were studied and their response to therapy determined by continuous measurement of lower esophageal pH over a 36-hour period. Five parameters were assessed in the erect, supine, and prone positions, both before and during short-term cisapride therapy. The drug was effective in reducing GER in 86% of the infants studied. Those infants who had a poor overall response to therapy could be identified retrospectively by the lack of improvement in esophageal acid clearance and frequency of reflux episodes; anatomic abnormalities were present in the majority of this subgroup. Cisapride is considered to be effective in the short-term treatment of primary GER of infancy, and a more prolonged assessment is indicated.

Cloacal exstrophy: a long-term follow-up with faecal continence

Of 24 infants with cloacal exstrophy admitted to the Red Cross Childrens Hospital in Cape Town since 1956, 8 underwent surgery. Six died after the first phase of surgical repair, and only 2 have survived long-term. A 19-year follow-up of these 2 patients is described. One of them has had a remarkable end-result, with complete faecal continence and a palpable sphincter. She had an exstrophied colonic field, in contrast to the caecal plate found in the majority of cases. Although she had vertebral and sacral abnormalities, there was no evidence of myelomeningocoele. An ileal urinary conduit was performed after excision of the exstrophied half of the bladder. She has developed fully as a female and has not required genital re-construction. Our second patient followed the usual pattern in that she has severe neurological deficits due to the myelomeningocoele, a urinary conduit, and a colostomy. She has been reared as a female after removal of intra-abdominal testes. Although she is on replacement oestrogen therapy, she has not has genital reconstruction as yet. Some of the theories on aetiology are mentioned and the operative procedures are outlined.

Peripheral gangrene in children

The case histories of 36 patients treated for peripheral gangrene between 1973 and 1987 were reviewed. The commonest causes of gangrene were disseminated intravascular coagulation due to bacterial septicaemia (15 patients) and dehydration due to gastro-intestinal fluid loss (8 patients). In only 2 patients was gangrene of truly iatrogenic origin; in 4 no apparent cause could be found. Secondary or contributing factors were recognisable in the majority. The overall mortality was 30%. Major lower limb amputation was necessary in 5 patients (bilateral in 3). The aetiology of peripheral gangrene was therefore multifactorial in most patients and idiopathic in only a small number. Delay before amputation allows both adequate stabilisation of severely ill patients and clear demarcation of gangrenous tissue.

A comparison between scintigraphy and computed abdominal tomography in blunt liver and spleen injuries in children

Fifty consecutive paediatric patients with objective clinical signs of blunt abdominal trauma underwent both computed abdominal tomography (CT) and liver-spleen scintigraphy (LSS). All were managed non-operatively with no morbidity or mortality. Five splenic and 13 liver injuries were visualised on CT while LSS revealed 9 splenic and 29 liver injuries. Where injury to either organ was detected by both modalities, there was good correlation anatomically and also as to the extent of injury. LSS demonstrated injuries not shown on CT, which appeared to detect only more extensive injuries. We conclude that scintigraphy may be the more sensitive and therefore more appropriate method when blunt injury to the liver and spleen alone is clinically suspected. Abdominal CT remains the early investigation of choice in patients with clinical evidence of haemoperitoneum associated with shock or multiple injuries, particularly when injury to the kidneys as well as to the liver and spleen is suspected or when a concomitant brain scan is indicated.

Pelvic rhabdomyosarcoma in children

From 1961 to 1986, 29 patients with pelvic rhabdomyosarcoma (including pelvic retroperitoneal rhabdomyosarcoma) were admitted to the paediatric surgical service at the Red Cross Childrens Hospital, Cape Town. During the period 1961–1970, the mainstay of treatment was radical surgery with or without subsquent chemotheraphy and radiotherapy. Of the 13 patients, only 2 have survived long-term (15%). From 1971 a new management policy of pre-treatment with chemotherapy and in some instances radiotherapy followed by conservative limited surgery was commenced. Twelve of the 16 patients have survived (75%). One patient with stage III prostatic tumour had treatment with only chemotherapy and radiotherapy and is surviving 8 years after diagnosis; another with a vaginal tumour, also stage III, whose parents refused surgery is alive tumour-free 4 years after similar treatment. Chemotherapy has not only significantly improved survival in pelvic rhabdomyosarcoma but has permitted limited surgery and in some instances has resulted in survival without surgical excision.

Selective bronchial intubation for acute post-operative atelectasis in neonates and infants

Selective bronchial intubation and lavage under fluoroscopic control was performed in 10 surgical neonates and infants to clear lobar atelectasis, after standard physiotherapeutic techniques had failed. Full re-expansion of the lung was obtained in all cases. The indications and techniques of selective bronchial intubation and lavage are described. This manoeuvre can be recommended in early postoperative atelectasis in neonates and infants if non-invasive measures have failed.