Association Between Administration of Antacid Medication and Anastomotic Stricture Formation After Repair of Esophageal Atresia

BACKGROUND

Anastomotic stricture is a significant cause of morbidity after repair of esophageal atresia (EA). Exposure to gastric acid has been postulated to contribute to stricture development and severity leading to prophylactic antacid use by some surgeons. We investigated the association between administration of antacid medication and the development of anastomotic strictures.

METHODS

Retrospective case-note review of consecutive infants undergoing repair of EA with distal tracheoesophageal fistula (type C) between January 1994 and December 2014. Only infants who underwent primary esophageal anastomosis at initial surgical procedure were included. Stricture-related outcomes were compared initially for infants who received prophylactic antacid medication (PAAM) versus no prophylaxis, and the role of PAAM in stricture prevention was explored in a multivariate model. Outcomes were also compared for infants grouped by antacid use at any stage.

RESULTS

One hundred fourteen infants were included. Sixteen infants received PAAM at surgeon preference. Of the remaining 98 infants, 44 subsequently received antacid as treatment for gastroesophageal reflux (GER) and 54 never received antacid medication. There was no statistically significant association between incidence of stricture in the first year (10 of 16 versus 41 of 98; P = 0.18) nor time to first stricture (median, 57 d [41-268] versus 102 d [43-320]; P = 0.89) and administration of PAAM. Similarly, there were no statistically significant associations between incidence of stricture, age at first stricture and number of dilatations, and administration of antacid medication either as prophylaxis nor when given as treatment for symptoms or signs of GER.

CONCLUSIONS

These data do not support the hypothesis that PAAM reduces the incidence or severity of anastomotic stricture after repair of EA. Treatment with antacids may be best reserved for those with symptoms or signs of GER. Further prospective investigation of the role of antacid prophylaxis on stricture formation after EA repair is warranted.

Growth pattern of infants with gastroschisis in the neonatal period

BACKGROUND/AIM

Early postnatal growth patterns may have significant long term health effects. Although preterm infants on parenteral nutrition (PN) exhibit poor growth, growth pattern of term or near-term infants requiring PN is not well reported. We aimed to investigate this in infants born with gastroschisis.

METHODS

Retrospective review of all infants with gastroschisis requiring PN treated at a single centre over a 4 year period. Growth and clinical data were retrieved, and weight SDS scores for corrected gestational age calculated. Weight SDS (mean ± SD) were compared at clinically relevant timepoints and multi-level regression used to model growth trends over time.

MAIN RESULTS

During the study period 61 infants with gastroschisis were treated; all were included. Infants were small for gestational age at birth for weight (SDS score -0.87 ± 0.85). Weight SDS decreased significantly during the first 10 days of age (mean decrease 0.81 ± 0.56; p < 0.0001) and between birth and discharge (mean decrease 0.81 ± 0.56; p < 0.0001). Despite tolerating full enteral feeds, weight SDS velocity was negative around the time of transition from parenteral to enteral feed. There was evidence of 'catch up' growth between 3 and 6 months of age.

CONCLUSION

Despite nutritional support with PN, infants with gastroschisis demonstrate significant growth failure during the newborn period. Further efforts are required to understand the underlying mechanisms, improve nutritional support and to evaluate the long term consequences of postnatal growth failure in this population.

Esophageal replacement by gastric transposition: A single surgeon's experience from a tertiary pediatric surgical center

BACKGROUND

Many pediatric surgeons have limited experience of esophageal replacement. This study reports outcomes of esophageal replacement by gastric transposition performed by a single UK-based pediatric surgeon.

METHODS

Consecutive patients were identified who underwent esophageal replacement by gastric transposition over a 28 year period. Clinical and demographic data were collected. Weight-for-age Z-scores were calculated for esophageal atresia patients.

RESULTS

Nineteen patients were identified. Indication in the majority was long-gap esophageal atresia (n = 17; 10 with tracheoesophageal fistula). At surgery, median age was 8.5 months (range 2-55); median weight was 7.4 kg (range 4.0-17.4 kg). A right-sided thoracotomy or transhiatal approach was used. Median postoperative length of stay was 17.5 days (range 7-130); median intensive care stay was three days (range 1-63). There were no deaths. Anastomotic leak rate at 30 days was 10.5% (n = 2). One patient required early stricture dilatation. Median weight-for-age Z-score increased from -2.17 at one year of age to -1.86, -1.70 and -1.93 at 5, 10 and 15 years.

CONCLUSIONS

Esophageal replacement by gastric transposition offers a potentially life-changing treatment; however, it is associated with significant morbidity. The majority of patients eventually achieve full oral feeding and maintenance of weight gain trajectory. A right-sided approach to the esophagus is feasible.

TYPE OF STUDY

Treatment Study.

LEVEL OF EVIDENCE

IV.

Oesophageal atresia with no distal tracheoesophageal fistula: Management and outcomes from a population-based cohort

PURPOSE

To describe the incidence and outcomes to one-year in infants born with oesophageal atresia (OA) with no distal tracheoesophageal fistula within a population cohort.

METHODS

A subgroup analysis of a prospective multicentre population cohort study was undertaken describing the outcomes of infants with OA and no tracheoesophageal fistula, (type A) and those with only an upper pouch fistula, (type B).

MAIN RESULTS

Twenty-one of 151 infants in the whole cohort were diagnosed with type A or B oesophageal atresia (14%). Fifteen were type A (71%) and six type B (29%). Infants with type B had a shorter gap length than those with type A: 2.5 vertebral bodies (2-3) vs. 5 (4-6) (p=0.008). All infants with type B OA underwent oesophageal anastomosis, 83% (n=5) as the primary procedure. All infants with type A, underwent staged management. Six (40%) had delayed primary anastomosis and eight required oesophageal replacement (53%). One infant died prior to reconstruction. The median time to delayed primary anastomosis in infants with type A or B OA was 82days (75-89days) (n=7). The median time to oesophageal replacement was 94days (89-147days) (n=8). Median length of stay for infants with type A or B OA from first operation to first discharge was 101days (31-123days).

CONCLUSIONS

Infants with type B OA had a shorter gap length and all were managed with oesophageal anastomosis. OA with no distal tracheoesophageal fistula is uncommon at a population level and frequently has a complex course.

LEVEL OF EVIDENCE

Rating: II.

The management of bilious vomiting in the neonate

Bilious vomiting is synonymous with intestinal obstruction, be it functional or anatomical. In the neonate it may be due to congenital malformations of the gastrointestinal tract or develop due to acquired conditions, particularly intestinal complications associated with prematurity. This review considers the congenital malformations that may present with bilious vomiting and explores the diagnostic dilemmas faced in the preterm infant. The difficult issue of the need to exclude malrotation in term infants with bilious vomiting and the consequences of time-critical transfer is discussed.

Antenatally diagnosed right-sided stomach (dextrogastria): A rare rotational anomaly

AIM

Antenatal detection of right-sided stomach (dextrogastria) is rare, and its significance in regards to intestinal rotation is unclear. We aimed to review all cases of antenatally-diagnosed dextrogastria in our regional fetal medicine unit over 10years.

METHODS

A retrospective case-note review of patients identified from a prospectively-maintained database was performed.

RESULTS

Twenty cases of antenatally-diagnosed dextrogastria were identified from 2004 to 2014. There were 8 terminations and 1 intra-uterine death. One patient has no post-natal information obtainable. Ten infants were live-born, and 2 died secondary to cardiac disease in the neonatal period. All had significant cardiac/vascular anomaly on postnatal assessment, including the 3 neonates in whom dextrogastria was the only antenatal finding. Two neonates developed bilious vomiting and underwent Ladd's procedure. Operative findings were dextrogastria/malrotation in both. A third child had gastro-oesophageal reflux, and contrast demonstrated stable duodenal/midgut position. This child has not developed symptoms attributable to malrotation and not undergone surgery. All 3 of these infants had asplenia or polysplenia and were managed with antibiotic prophylaxis/immunisation. Five children in the series were not investigated for malrotation and have not come to surgical attention (one is known to be asplenic).

CONCLUSION

Antenatally-detected dextrogastria, even if apparently isolated, was always associated with postnatal significant cardiovascular anomaly, splenic abnormality or situs inversus. This may be important for antenatal counselling. We currently recommend postnatal echocardiography and splenic assessment, but reserve GI investigation/intervention for symptomatic malrotation owing to potential significant cardiac comorbidity.

Conservative management of antenatally diagnosed cystic lung malformations

AIM

To review the outcome of all antenatally diagnosed conservatively managed congenital lung malformations (CLMs) managed at our centre.

METHODS

All patients diagnosed antenatally with cystic lung malformations from 2001 to 2011, at a tertiary referral paediatric surgical centre practising a policy of conservative management of asymptomatic cases, were retrospectively reviewed. Data were collected from medical case notes and radiology reports. Ethical approval was obtained from our institutional research and development department.

RESULTS

The complete records of 74 fetuses antenatally diagnosed with CLM were reviewed. There were 72 live births, at a median gestation of 39.6 weeks. Emergency lobectomy was performed in one symptomatic neonate. Elective lobectomies were performed at parental request in three asymptomatic infants, one of whom had a family history of synovial sarcoma. Two patients developed pneumonia in the affected lobe during early childhood and proceeded to lobectomy at the age of 3 years. One patient with a bronchopulmonary sequestration required embolisation for cyanotic episodes. The remaining 65 patients have been conservatively managed to date, and none have required hospital admission. Less than a quarter report mild respiratory symptoms such as cough or wheeze. Median follow-up is 5 years.

CONCLUSIONS

This retrospective cohort study of 74 consecutive CLMs diagnosed antenatally over a 10-year period demonstrates that most of these lesions will remain asymptomatic throughout childhood. Although the natural history of CLMs in later years remains to be elucidated, we hope that this report on medium-term outcomes will be useful to clinicians who undertake antenatal counselling and may inform the discussion on how best to manage these children.

Operative intercostal chest drain is not required following extrapleural or transpleural esophageal atresia repair

BACKGROUND

Approximately half of the United Kingdom patients undergoing esophageal atresia (OA) repair have an operative intercostal chest drain (ICD) placed (2008 British Association of Pediatric Surgeons Congenital Anomalies Surveillance Study data). We reviewed our experience of OA repairs to evaluate if an ICD placement is necessary.

METHODS

Patients with OA/distal tracheoesophageal fistula (TOF), treated between January 1990 and January 2010, were identified by retrospective review of a prospectively maintained electronic database and patient case notes.

MAIN RESULTS

A total of 112 consecutive patients were identified, of whom 107 were included (73 male). Five were excluded as no case notes were available. Median birth weight was 2,597 g (range 924 to 4,245 g) and median gestational age was 38 weeks (27 to 41 weeks). Median age at discharge was 22 days (3 to 440 days) and median follow-up was 3.5 years (0 to 18 years). Patients were analyzed in two groups-group 1 (n = 73) had an extrapleural (EP) repair, of which 23 had a pleural breach and group 2 (n = 34) had a purposeful transpleural (TP) approach (surgeon preference). Eleven patients (10%) had an operative ICD, of which six patients were in group 1 and five in group 2. These 11 patients had an uncomplicated postoperative course and all operative ICD were removed within 48 hours of surgery. Of the 96 patients that did not have an operative ICD, only 2 (2%) required postoperative intervention. One patient, in group 2, had a postoperative ICD inserted for a simple pneumothorax at 12 hours and removed at 48 hours. The other patient, in group 1, had a clinically detected anastomotic leak after 48 hours and required operative repair.

CONCLUSION

An operative ICD is not required following OA/distal TOF repair, whether the approach is EP or TP. ICD that were electively placed (in 10%) served no clinical purpose.

Congenital lung malformations: an ongoing controversy

INTRODUCTION

Congenital lung malformations are rare lesions that are most commonly diagnosed antenatally. Management of such lesions, particularly those that are asymptomatic, remains controversial. We undertook a survey to ascertain current practice of surgeons in the UK and Ireland.

METHODS

All consultant members of the British Association of Paediatric Surgeons were asked to complete a survey on congenital lung malformations with respect to antenatal management, symptomatic and asymptomatic lesions, and operative techniques.

RESULTS

Responses were received from 20 paediatric surgical centres and highlighted the ongoing variability in management of such lesions, particularly those that are asymptomatic. Twenty per cent of surgeons never resect an asymptomatic lesion and twenty-four per cent always do. The remainder intervene selectively, with size being the most commonly stated indication. Most resections are undertaken via thoracotomy although 35% of surgeons use thoracoscopy for some procedures.

CONCLUSIONS

National data based on congenital anomaly registers are needed to determine the natural history of these malformations and to guide future management.

Contemporary management and outcomes for infants born with oesophageal atresia

Background

Reports on the management and outcome of rare conditions, such as oesophageal atresia, are frequently limited to case series reporting single-centre experience over many years. The aim of this study was to identify all infants born with oesophageal atresia in the UK and Ireland to describe current clinical practice and outcomes.

Methods

This was a prospective multicentre cohort study of all infants born with oesophageal atresia and/or tracheo-oesophageal fistula in 2008–2009 in the UK and Ireland to record current clinical management and early outcomes.

Results

A total of 151 infants admitted to 28 paediatric surgical units were identified. Some aspects of perioperative management were universal, including oesophageal decompression, operative technique and the use of transanastomotic tubes. However, there were a number of areas where clinical practice varied considerably, including the routine use of perioperative chest drains, postoperative contrast studies and antireflux medication, with each of these being employed in 30–50 per cent of patients. There was a trend towards routine postoperative ventilation.

Conclusion

The prospective methodology used in this study can help identify practices that all surgeons employ and also those that few surgeons use. Areas of clinical equipoise can be recognized and avenues for further research identified.

Scope and feasibility of operating on the neonatal intensive care unit: 312 cases in 10 years

PURPOSE

To report the scope, feasibility and learning experience of operating on neonates on the neonatal intensive care unit (NICU).

METHODS

(1) Review of all NICU operations performed by general neonatal surgeons over 10 years; (2) 6-month prospective comparison of procedures performed in NICU or operating room; (3) structured interviews with five surgeons with 1-13 years experience of operating on NICU.

RESULTS

312 operations were performed in 249 infants. Median birth weight was 1,494 g (range 415-4,365), gestational age 29 weeks (22-42), and age at operation 25 days (0-163). Nearly half (147) were laparotomy for acute abdominal pathology in preterm, very low birth-weight infants There were no surgical adverse events related to location of surgery. Surgeon satisfaction with operating on NICU for this population was high (5/5). Several factors contribute to making this process a success.

CONCLUSIONS

This is the largest reported series of general neonatal surgical procedures performed on NICU. Operating on NICU is feasible and safe, and a full range of neonatal operations can be performed. It removes risks associated with neonatal transfer and is likely to reduce physiological instability. We recommend this approach for all ventilated neonates and urge neonatal surgeons to operate at the cotside of unstable infants.

Ten-year experience of home parenteral nutrition in a single centre

AIM

Recent data are scarce on the provision of home parenteral nutrition (HPN) in children from the UK but would help to commission intestinal failure services. Our aim was to describe 10 years of HPN experience in our centre, which serves a population of 650,000 children.

METHODS

Outcome and complication data were collected retrospectively from hospital records of children receiving HPN from April 2001. Data from other centres were used to compare complications and outcomes in the provision of HPN.

RESULTS

Nineteen children (12 females) received 10,213 days (28 years) of HPN. In this group, incidence of blood culture positive sepsis was four episodes/1000 days PN. Two children had early intestinal failure-associated liver disease. Of the 19, seven still receive HPN at our centre, six survived PN, three were transferred to other services while still on HPN and three died.

CONCLUSION

Outcome and complication data for HPN from a single UK regional paediatric centre are similar to larger centres. These data provide recent evidence of the disease burden of HPN, which are important for the commissioning of intestinal failure services.

Workload and costs associated with providing a neonatal surgery service

AIM

To identify the workload related to provision of a neonatal surgical service in a UK neonatal network in order to inform local and national service commissioning.

METHOD

Data relating to neonatal surgical admissions to a level 3 perinatal centre serving a network with 36,000 births per year collected prospectively over a 5-year period were analysed to identify annual activity. Daily dependency was assessed prospectively over a 6-month period and service costs calculated using existing local tariffs. Admissions from outside the network were excluded from analysis, and allowance was made for refused network admissions.

RESULTS

On average 140 admissions required 2137 cot-days per year. At 80% occupancy, the service requires seven neonatal cots suggesting that there is a national requirement for one neonatal surgical cot per 5000 births. Intensive care, high care (HC) and special care accounted for 37%, 46% and 17% of cot-days, respectively. This equates to an annual service cost of £2m, about £250,000 per 5000 births.

CONCLUSIONS

This assessment of the facilities and costs required to provide a neonatal surgical service in a level 3 perinatal centre in the UK may be used to inform network and national commissioning.

The use of mouth brushings for screening girls who present with inguinal hernia for complete androgen insensitivity syndrome

INTRODUCTION

Published guidance recommends that all girls with inguinal hernia should be screened for complete androgen insensitivity syndrome (CAIS). We report a novel, noninvasive screening technique.

METHODS

Retrospective review of all girls undergoing inguinal herniotomy from April 2009 to October 2010. Those screened using the novel technique of extraction of Y chromosome specific DNA from a buccal mucosal sample obtained by mouth brushing are reported.

RESULTS

A total of 29 girls were screened by mouth brushing at median age 2.9 years (range 29 days to 9.3 years). Of the 29 samples, 25 were adequate for DNA extraction; 4 were inadequate and screening was repeated (3 repeat mouth brushing, 1 perioperative blood test). Mouth brushing was well tolerated by children and acceptable to parents. A preoperative blood test was avoided in all girls who had a mouth brushing. None of the girls in this study had CAIS. Turn-around time for mouth brushing was mean 4.9 days compared with a minimum of 10 days for a karyotype. This technique is cheaper than a karyotype (£ 87 vs. £ 205).

CONCLUSION

Extraction of Y chromosome specific DNA from a mouth brushing sample is effective for screening girls with inguinal hernia for CAIS. It is acceptable, cheaper, and quicker than alternatives.

Meconium obstruction of prematurity

Meconium obstruction of prematurity is an entity primarily affecting very low birthweight or extremely low birthweight babies causing low intestinal obstruction. Its presence may at best delay establishment of enteral feeding and compromise nutrition and at worst lead to mechanical obstruction requiring surgery or to intestinal perforation. There are considerable challenges in the recognition, diagnosis and management of this condition. Awareness of the disease and understanding of its pathogenesis may lead to early detection of affected babies and allow proactive measures to decrease the associated morbidity and mortality.

Trans-anastomotic tubes reduce the need for central venous access and parenteral nutrition in infants with congenital duodenal obstruction

PURPOSE

To determine the effect of trans-anastomotic tube (TAT) feeding on outcome following repair of congenital duodenal obstruction (CDO).

METHODS

Retrospective comparative study of all infants with CDO over 10 years. Data are median (range). Mann-Whitney U test and Fisher's exact test were used.

RESULTS

Of 55 infants with CDO (48 atresia, 7 stenosis), 17 were managed with a TAT, 38 without. Enteral feeds were commenced earlier in infants with a TAT compared to those without (TAT 2 days post-repair [1-4] vs. no-TAT 3 days post-repair [1-7]; p = 0.006). Infants with a TAT achieved full enteral feeds significantly sooner than those without (TAT 6 days post-repair [2-12] vs. no-TAT 9 days post-repair [3-36]; p = 0.005). Significantly fewer infants in the TAT group required central venous catheter (CVC) placement and parenteral nutrition (PN) than in the no-TAT group (TAT 2/17 vs. no-TAT 28/38, p < 0.0001). There were six CVC-related complications (5 infections, 1 PN extravasation) and four TATs became displaced and were removed before achieving full enteral feeds. One infant with a TAT with trisomy 21 and undiagnosed Hirschsprung disease developed an anastomotic leak and jejunal perforation requiring re-operation.

CONCLUSIONS

A TAT significantly shortens time to full enteral feeds in infants with CDO significantly reducing the need for central venous access and PN.

Late-onset volvulus without malrotation in preterm infants

PURPOSE

The aim of the study was to report a new observation of late-onset volvulus without malrotation (VWM) in preterm infants.

METHODS

The study used medical note review of infants with VWM identified at a single regional centre between 1996 and 2007.

RESULTS

Ten patients were identified. Group 1 includes 4 patients (gestation, 28-38 weeks; median, 32) who presented within 4 days of age (range, 1-4; median, 3). Group 2 includes 6 patients (gestation, 25-33 weeks; median, 27), who presented later (range, 22-57 days; median, 45). Characteristics of group 2 patients included recurrent episodes of abdominal distension and bile vomiting (6/6), long-term continuous positive airway pressure requirement (5/6), and sudden, severe deterioration with acute abdominal signs (6/6). Small bowel volvulus was found at laparotomy requiring resection (30%-70% of total small bowel) and either primary anastomosis (4) or stoma formation (2). All babies survived.

CONCLUSIONS

There appear to be 2 clinical groups with VWM-one presenting within the first few days of life and the other presenting after the first month of life associated with a specific clinical history. This latter group has not been described before.

Gastroschisis: the cost of an epidemic

BACKGROUND

The rising incidence of gastroschisis has been highlighted by the Department of Health as a growing concern. As well as the health implications for the increasing number of affected infants, this increase in incidence will have an impact of the costs of health care. This study was undertaken to estimate the financial cost of treating this condition in one tertiary neonatal surgical center.

METHODS

A retrospective analysis was performed of all patients admitted to a tertiary neonatal surgical center with gastroschisis from January 1996 to December 2005. The main outcome measures were incidence, length of hospital stay, and total cost for all patients each year.

RESULTS

The incidence of gastroschisis has risen 3-fold in 10 years. The median cost per patient is relatively constant. A few patients with severe intestinal dysmotility require prolonged hospital stay. As the condition becomes more common, there are an increasing number of complex patients and thus an increase in annual costs, which is disproportionate to the increase in numbers of cases. We estimate that the annual cost to the National Health Service (NHS) of this condition in England and Wales has risen from pound3.6 million in 1996 to in excess of pound15 million in 2005.

CONCLUSIONS

Urgent research is required into the etiology of gastroschisis and into the severe intestinal dysmotility that occurs in some complex patients.

Recurrent neonatal gastro-intestinal problems after spontaneous intestinal perforation

To identify intestinal complications during the neonatal period following spontaneous isolated intestinal perforation (SIP). A retrospective case notes review was undertaken of all patients with a diagnosis of SIP, confirmed at laparotomy or post-mortem, admitted between January 2000 and January 2005. Patients with confirmed gastric perforation were excluded as were patients with proven necrotising enterocolitis (NEC) or suspected, but not confirmed, SIP. Seventeen patients, median gestation 27 weeks and median birth weight 780 g, were treated by drain alone (1), drain and later laparotomy (4) or primary laparotomy (12). Eight patients required enterostomy formation at primary laparotomy (1 jejunostomy, 1 colostomy and 6 ileostomy). Five babies died in the neonatal period and three later in the first year. Nine patients (53%) had ten subsequent episodes of intestinal pathology requiring surgical intervention between 5 and 136 days later comprising early recurrent isolated perforation (2), NEC (3), milk curd obstruction with or without perforation (3) and adhesion obstruction (2). Secondary surgery involved laparotomy in eight patients, five of whom required formation or re-formation of a stoma, and palliative drain insertion in one patient. Recurrent intestinal pathology requiring surgical intervention during the neonatal period occurred in 53% of babies with SIP. Surgeons and neonatologists should be aware that this group of patients are prone to further intestinal pathology.

A technique to demonstrate external haemorrhoids

Although uncommon in children, haemorrhoids are one of the causes of a protruding anal lesion and may be confused with rectal prolapse or prolapse of a rectal polyp. The lesions may not be obvious when the child is anaesthetised because of lack of straining. This may prevent accurate diagnosis and impede identification of the lesion if surgery is being attempted. The authors report 3 cases where a 20 F Foley catheter with 30 ml balloon was inserted rectally and gentle traction applied to reproduce the raised venous pressure generated during straining. On each occasion external haemorrhoids could be demonstrated as the underlying pathology.

The effect of antenatal diagnosis on the management of small bowel atresia

The aim of this study was to determine whether babies with small bowel atresia (SBA) diagnosed antenatally followed a different course from those diagnosed postnatally. We reviewed the records of neonates admitted to a single institution between 1985 and 2000 with a diagnosis of SBA. Thirty-nine neonates presented with SBA, with antenatal diagnosis (AND) being made in 12 (31%). There was no difference between the AND and postnatal diagnosis (PND) groups in terms of gestational age at birth, but the AND group had a lower mean birth weight. The babies in the AND group were operated on more quickly than those in the PND group. Ten out of 12 (83%) AND patients required parenteral nutrition compared with 12 out of 27 (44%) in the PND group, and the AND group had a significantly longer mean length of stay and spent a longer time on parenteral nutrition than the PND group.

Operating and anaesthetic time required for inguinal hernia repair in the neonate

Inguinal hernia repair in neonates can be a challenging operation and anaesthetic. However, there is no information on how much anaesthetic and operating time is required for such surgery. Planning operating time and resources requires this knowledge. This study looked at 94 neonatal hernia repairs and compared anaesthetic and operating times for these patients with 297 day-case hernia repairs. The median anaesthetic and operating times for neonates with unilateral repair were 20 and 45 min compared with 13 and 30 min for day-cases. However, the ranges for anaesthetic time (10-185 min) and operating time (20-170 min) were considerably in excess of those for day-cases (0-54 and 15-80 min) respectively. Neonatal hernia operations accounted for a total of one theatre list per month in our centre.

Exclusion of androgen insensitivity syndrome in girls with inguinal hernias: current surgical practice

To review the current approach of paediatric surgeons to the exclusion of androgen insensitivity syndrome (CAIS) in girls with inguinal hernias (IH), a questionnaire was sent to all specialist paediatric surgeons in the United Kingdom and Ireland asking if they exclude CAIS, how they exclude it, and what they say to parents preoperatively. In all, 32 surgeons responded (29%); 41% made no attempt to exclude CAIS because they thought the incidence was too low to justify exclusion; 19(59%) excluded CAIS at the time of surgery by assessment of the internal genitalia. Only 1 performed karyotyping primarily, and then only for bilateral IH. Although most would proceed to karyotyping if the primary assessment suggested CAIS, some would not. Of those who exclude CAIS, only 1 mentions CAIS preoperatively, 6 others mention gonadal inspection, and 12/19 (63%) make no comment. Thirty-one surgeons agreed to take part in a prospective study to define the incidence of CAIS in girls with IH. It is concluded that surgeons who exclude CAIS in girls with IH adopt different assessment methods, some of which may be unreliable. However, many do not attempt to exclude CAIS, believing the incidence to be too low. As the health and medicolegal consequences of failing to exclude CAIS may be considerable, surgeons should consider changing their practice. A prospective study should be undertaken to determine the incidence of CAIS in girls with IH.

The ascending testis: is late orchidopexy due to failure of screening or late ascent?

It is widely recommended that infant boys with undescended testes (UDT) should be referred for surgical opinion before the age of 18 months. To attempt to identify the reasons why the mean age at orchidopexy in our institution was as high as 5.5 years, a retrospective review of the screening history, examinations, and management of boys over the age of 3 years at the time of orchidopexy was undertaken by reference to community, general practitioner, and hospital records. In 36 children where hospital and community records giving information prior to referral were available, the UDT had previously been documented on at least one occasion as descended in 24 children or retractile in 10. In 1 child there was delayed referral, and in another, there was operative delay. It is concluded that there is either frequent failure of the Child Health Surveillance screening programme, or that late ascent of a testis previously sited in the scrotum is a common occurrence. We recommend further prospective studies to clarify this latter phenomenon.

Gastric tube graft interposition as an oesophageal substitute

BACKGROUND

Use and techniques of oesophageal replacement for long gap oesophageal atresia are still evolving. Gastric tube graft interposition as an oesophageal substitute was evaluated on an animal model.

METHODS

Twenty-three postweaned, 28-day-old-piglets were used as the experimental animals. Isoperistaltic gastric tube interposition based on the right gastroepiploic vessels was performed at 28 days of life. Postoperative evaluation included weekly measurement of weight, clinical assessment for gastrointestinal and respiratory complications and deglutition difficulties. Haemoglobin, serum ferritin, albumin, globulins, total proteins and red cell folate were assayed. Pigs were killed and analysed histopathologically following a maximum observation period of 149 days.

RESULTS

Growth of the pigs was normal. Deglutition was not impaired in 16 pigs (89%). Minor leak was diagnosed in three pigs (17%), which was successfully managed conservatively. Anastomotic stricture was seen in two pigs (11%). Graft necrosis was not seen. Gross histology showed the absence of hypertrophy, redundancy and kinking of the interposed gastric tube graft. Microscopically non-erosive oesophagitis was seen in three pigs (17%), ulcerative oesophagitis was seen in two pigs (11%) and submucosal fibrosis was seen in seven pigs (39%). Dysplasia or Barrett's oesophagitis was not observed at the end of animal growth.

CONCLUSIONS

Gastric tube graft interposition is an immediate ideal oesophageal substitute due to fewer complications, probable absence of gastro-oesophageal reflux in the majority by histology, and absence of dilatation and redundancy of the interpose tube. The oesophageal substitute adequately met the nutritional needs for growth and development in the animal model.

Thoracic wall lipoblastoma: a case report and review of histopathology and cytogenetics

A rare case of a successfully excised intra- and extrathoracic lipoblastoma of the anterior chest wall in a 13-month-old female infant is reported. Histopathology and cytogenetical analysis established the diagnosis of a lipoblastoma. The differential diagnosis, histology and cytogenetical evaluation of lipomatous neoplasms are discussed. Karyotypic analysis may be of use in diagnostically difficult cases owing to the characteristic alterations in 18q11-13. A complete resection of lipoblastomas is feasible and advantageous with no need for a mutilating radical excision.

Management of antenatally diagnosed pulmonary sequestration associated with congenital cystic adenomatoid malformation

BACKGROUND

Sequestration with associated cystic adenomatoid malformation is rare. A study was undertaken to determine whether pulmonary sequestration associated with congenital cystic adenomatoid malformation has a more favourable natural history than that of sequestration without associated cystic adenomatoid malformation.

METHODS

An outline of the postnatal work up leading to the management of extralobar or intralobar pulmonary sequestration with congenital cystic adenomatoid malformation diagnosed antenatally as pulmonary malformation is presented and the indications for surgical intervention are discussed.

RESULTS

In five infants in whom an antenatal ultrasound scan had detected a congenital lung malformation at 18-19 weeks gestation a final diagnosis of extralobar or intralobar pulmonary sequestration with congenital cystic adenomatoid malformation was made postnatally. Postnatal ultrasound and computerised axial tomographic scans confirmed the diagnosis of sequestration by delineating anomalous vascular supply. Cystic changes were also observed in the basal area of the sequestration in all patients. Four children remained asymptomatic and one infant presented at 10 months of age with pneumonia. The mean age at surgical resection was 6.8 months (range 2-10). Histopathological examination confirmed intralobar pulmonary sequestration with associated Stocker type 2 congenital cystic adenomatoid malformation in two patients and extralobar pulmonary sequestration with associated Stocker type 2 congenital cystic adenomatoid malformation in three patients. The mean period of follow up was four years (range 1-8). The children remain well and are developing normally.

CONCLUSIONS

The importance of seeking an anomalous blood supply in children with congenital lung lesions is emphasised. Pulmonary sequestration and congenital cystic adenomatoid malformation probably share a common embryogenesis despite diverse morphology. The natural history of antenatally diagnosed lung masses is variable. Early postnatal surgical resection of pulmonary sequestration with cystic adenomatoid malformation is recommended. Surgical excision should be conservative, sparing the normal lung parenchyma.

Gastric tube interposition as an esophageal substitute: comparative evaluation with gastric tube in continuity and gastric transposition

BACKGROUND/PURPOSE

The aim of this study was to evaluate growth, hematologic and biochemical parameters, and histopathology after gastric tube interposition, gastric tube in continuity with or without posterior fundoplication, and gastric transposition in an experimental model.

METHODS

Twenty-two postweaned, 28-day-old piglets were divided randomly into four groups: group 1 (n = 9) gastric tube interposition, group 2 (n = 4) gastric tube in continuity, group 3 (n = 5) gastric tube in continuity with posterior fundoplication, and group (n = 4) gastric transposition. The postoperative assessment included weekly measurement of weight, documentation of clinical symptoms, and deglutition difficulties. Hemoglobin, serum ferritin, albumin, globulins, total proteins, and red cell folate were measured. The pigs were killed and histopathologic assessment was made following a maximum observation period of 149 days.

RESULTS

The four pigs with gastric transposition died within 96 hours postoperatively of respiratory embarrassment. The salient clinical features and histology are summarised. The salient clinical complications observed in the four groups were as follows. Group 1: vomiting (11%), minor leak (22%), and stricture (11%). There was no impairment of deglutition and the growth was normal. Group 2: vomiting (100%), excessive salivation (100%), and episodes of cyanosis (100%). Growth was impaired but there was no impairment of deglutition. Group 3: vomiting (80%), excessive salivation (80%), and episodes of cyanosis (20%). There was no impairment in deglutition or growth. Group 4: vomiting (100%), episodes of cyanosis (100%), and respiratory embarrassment (100%). Pigs in group 4 had to be sacrificed on day 3 or 4 postoperatively because of severe respiratory embarrassment, cyanosis, and presumed gastroesophageal reflux. At autopsy the anastomoses were intact, with no evidence of leak. The stomach and esophagus had good vascularity. Histopathology demonstrated esophagitis in 11% of the specimens in group 1, 100% of those in group 2, and 60% of those in group 3. Submucosal fibrosis was seen in 56% of group 1, 100% of group 2, and 80% of group 3. Hyperkeratosis was observed in 75% of group 2 and 40% of group 3 specimens.

CONCLUSIONS

Gastric tube interposition in this animal model was associated with improved growth, fewer clinical complications, and fewer histopathologic changes than gastric tube in continuity with or without posterior fundoplication or gastric transposition.

Quantitative assessment of intracranial pressure by the tympanic membrane displacement audiometric technique in children with shunted hydrocephalus

The objective of this prospective study was to compare the clinical features at presentation, tympanic membrane displacement test results and direct intracranial pressure measurements in children with shunted hydrocephalus to procure a quantitative measure of the intracranial pressure by tympanic membrane displacement test. A prospective comparative evaluation of 61 clinical episodes of shunt malfunction was assessed by volume displacement of the tympanic membrane and direct intracranial pressure measurements in 40 patients with shunted hydrocephalus between January 1995 and June 1996. The volume displacement of the tympanic membrane (Vm) on stapedial contraction was inward for raised intracranial pressure in 27 episodes and ranged from -120 nl to -506 nl (mean = -250 nl). This was confirmed by direct intracranial pressure monitoring, which ranged from 23 to 40 mm Hg (mean = 29 mm Hg). The tympanic membrane displacement test measurement in 30 episodes of low intracranial pressure ranged from +263 nl to +810 nl (mean = +530 nl), and this was corroborated by direct intracranial pressure measurement ranging from 1 to 6 mm Hg (mean = 3.8 mm Hg). The normal baseline Vm values obtained when the subjects were asymptomatic ranged from +58 nl to +175 nl (mean = +115 nl). The tympanic membrane displacement test as a non-invasive diagnostic tool in predicting changes in intracranial pressure had a sensitivity of 93% and specificity of 100%. The predictive value of the test was 100%, and the negative predictive value was 73%. The kappa statistical analysis was used to measure the agreements between the groups. The strength of the agreement was very good, kappa = 0.88 and the P value was < 0.001. The objective measure of intracranial pressure by tympanic membrane displacement test with the Vm value of -200 nl and more negative was indicative of raised intracranial pressure and a Vm value of +200 nl and greater, for low intracranial pressure. The intracranial pressure measurements made on an individual subject basis were reliable and accurate. The test can therefore be used for regular assessment of shunted hydrocephalics to enable correlation of intracranial pressure with symptoms in individual patients.

Tympanic membrane displacement testing in regular assessment of intracranial pressure in eight children with shunted hydrocephalus

OBJECT

The authors assessed the accuracy and repeatability of the tympanic membrane displacement (TMD) test, an audiometric technique that is used to evaluate changes in intracranial pressure (ICP) in children with shunted hydrocephalus.

METHODS

A prospective comparative evaluation of 31 clinical episodes of shunt malfunction was made by using the serial TMD test and direct ICP measurement in eight children with shunted hydrocephalus between January 1995 and February 1996. The volume displacement of the tympanic membrane (Vm) on stapedial contraction was inward for raised ICP in 11 instances and ranged from -120 to -539 nl (mean -263.5 nl). This was confirmed by direct ICP monitoring, which showed values ranging from 20 to 30 mm Hg (mean 26 mm Hg). The TMD test measurement (Vm) in 18 instances of low ICP ranged from 263 to 717 nl (mean 431.3 nl); this was corroborated by direct ICP measurement, which ranged from 3 to 7 mm Hg (mean 4.2 mm Hg). The normal baseline Vm values obtained when patients were asymptomatic ranged from 98 to 197 nl (mean 110 nl). As a noninvasive diagnostic tool used in predicting changes in ICP, the TMD test had a sensitivity of 83% and specificity of 100%. The positive predictive value of the test was 100% and the negative predictive value was 29%.

CONCLUSIONS

The TMD test can be used on a regular basis as a reproducible investigative tool in the assessment of ICP in children with shunted hydrocephalus, thereby reducing the need for invasive ICP monitoring. The equipment necessary to perform this testing is mobile. It will provide a useful serial guide to ICP abnormalities in children with shunted hydrocephalus.

Prenatal diagnosis of laryngotracheoesophageal clefts

Seven infants with laryngotracheoesophageal (LTE) clefts who had abnormal prenatal fetal sonographs were reviewed retrospectively to evaluate the antenatal scan characteristics, clinical features at presentation and associated malformations. The prenatal scans demonstrated polyhydramnios, lung cysts and an absent stomach in all. The mode of delivery was by emergency lower segment cesarean section for fetal distress, in all 7 babies. The mean gestational age at delivery was 36 weeks (range 33-38) and intrauterine growth retardation was seen in 4 neonates. A combination of endoscopy, surgery and autopsy confirmed LTE cleft type 4 in 5 patients, type 3 and type 2 in a patient each. Esophageal atresia and lower pouch tracheoesophageal fistula was present in all. Agastria was seen in 4 and microgastria in 3 children. Lung abnormalities were seen in all 7 infants and they included congenital lung cysts (4 patients), absent lung lobulation (3 patients), bronchogenic cysts (2 patients), cystic adenomatoid malformation (1 patient) and bronchoesophageal fistula (1 patient). The mortality was 86% and the sole survivor had a LTE cleft type 2 which was successfully repaired. The diagnosis of LTE cleft must be considered if a prenatal scan demonstrates the triad of: (1) polyhydramnios; (2) absent stomach, and (3) presence of lung cyst. This should lead to a detailed postnatal evaluation and early diagnosis of this uncommon anomaly resulting in early counseling and suitable management.

Adverse outcome after prenatal diagnosis of gastroschisis: the role of fetal monitoring

Fifty-seven fetuses with gastroschisis presented between 1982 and 1995 were studied by retrospective review of medical records. There were three late intrauterine deaths (IUD). Fetal distress, as determined by reduced fetal movements or abnormal cardiotopograph (CTG), was encountered in 23 of the 54 liveborn infants (43%), all of whom had delivery expedited either by emergency caesarean section (n = 19) or induction (n = 4). Six infants had abnormal neurological outcome: two died in the neonatal period of severe perinatal brain injury, neonatal fits were observed in four, two of whom developed cerebral palsy, and one died at the age of 7 years. All six of these infants had suffered fetal distress. If the three intrauterine deaths are included, 16% of all cases were associated with abnormal neurological outcome. The introduction of regular CTG monitoring from 32 weeks' gestation in 1990 increased the ability to detect fetal distress twofold. This resulted in a similar increase in obstetric intervention and an associated reduction in adverse neurological outcome. Pregnancies associated with gastroschisis should be considered at significant risk of fetal distress, which itself may culminate in late intrauterine death, neonatal death, or adverse neurological outcome. Careful, repeated fetal monitoring in the third trimester is indicated.

Pneumonia presenting with acute abdominal pain in children

Abdominal pain is a common cause of emergency admission in children. Although often due to appendicitis and other intra-abdominal causes, extra-abdominal conditions, especially pneumonia, can simulate an acute abdominal catastrophe. Accurate and prompt diagnosis is essential, not only to avoid general anaesthesia and a negative laparotomy in the presence of pneumonia but also to start antibiotic therapy early so as to prevent the complications of pneumonia.

Extra-lobar intra-abdominal pulmonary sequestration

An ultrasonography scan detected a left upper quadrant abdominal mass in a fetus of 20 weeks gestation. The mass was confirmed by a postnatal ultrasonography scan, computerized tomography and magnetic resonance imaging prior to surgery. The sonographic characteristic of this lesion was that of a homogenous echogenic mass embedded in the left diaphragmatic crus, which moved with respiration. Histopathological evaluation of the mass demonstrated alveolar and bronchial tissue, with its own visceral pleural covering corroborating the diagnosis of extra-lobar intra-abdominal pulmonary sequestration. Surgical excision is a valid recommendation because of the uncertainty of preoperative diagnosis of this uncommon malformation.

Gastroschisis bowel in an intact exomphalos: implications for etiology and possible prevention

The etiology of changes in the bowel in gastroschisis is unknown. A case of exomphalos is described, in which the bowel had a gastroschisis-like appearance. The possibility of a vascular mechanism as the cause is discussed.

Opsite skin closure in day case paediatric surgery: is a subcuticular suture necessary?

Opsite skin closure without skin suture was compared with subcuticular Vicryl in a randomized trial in children undergoing day-case surgery for hernia, hydrocele or undescended testis. Ninety-nine groin closures were randomized, 47 to Opsite and 52 to subcuticular Vicryl. There was no difference in the duration of operation or in the cosmetic appearance of the wounds. Complications were all minor and similar in both groups. Opsite alone is suitable as a skin closure for the groin wounds in children.

Gastric volvulus and associated gastro-oesophageal reflux

Between 1984 and 1994, 10 neurologically normal children between 2 and 24 months were diagnosed as having gastric volvulus with associated gastro-oesophageal reflux (GOR). The common features at presentation were episodic colicky abdominal pain, non-bilious vomiting, upper abdominal distension, haematemesis, and failure to thrive. Anterior gastropexy and conservative management of GOR was curative.

Renal agenesis: an acquired condition?

Renal agenesis is a relatively common congenital anomaly, although its etiology is unknown. It is clear that some solitary kidneys are the result of postnatal involution of multicystic dysplastic kidneys. The authors present a series of nine neonates with abnormal prenatal renal ultrasound findings; subsequent postnatal investigations showed an absent kidney. Five children had a prenatal diagnosis of multicystic dysplastic kidney (MDK) and two of hydronephrosis. In five cases (56%) there was a contralateral renal unit anomaly. It appears that MDK, and occasionally hydronephrosis, can involute prenatally, producing the postnatal appearance of renal agenesis.

Vitamin K coagulation status in surgical newborns and the risk of bleeding

The vitamin K coagulation status in surgical newborns, who may be at increased risk of developing hypocoagulability and hemorrhage, has not previously been studied. Therefore, we measured the combined activity of the plasma vitamin K-dependent coagulation factors (Thrombotest), total prothrombin, PIVKA II, plasma vitamin K1, fibrinogen, D-Dimer, and platelets in 49 newborns admitted to a neonatal surgical intensive care unit. All infants had significant pathology, and treatment involved surgery in all but two. Twenty-three infants (47%) underwent surgery on two or more occasions. Intravenous or oral antibiotics were used in all patients and many received more than one course. All infants had vitamin K1 prophylaxis at birth. At day 0 (date of birth), the mean Thrombotest and total prothrombin levels were 51% (range, 20% to 100%) and 40% (range, 24% to 59%), respectively. Coagulation activity decreased on day 1 (P > .1) and was followed by a graduate increase in clotting activity, reaching normal adult levels (> 60%) at day 5 for Thrombotest and day 24 for total prothrombin. Only three infants had a Thrombotest less than 20%. PIVKA II was detected in 20 cases (41%). However, levels were within normal limits (< 0.9%) in 17 of these, and between 1.0 and 4.8% in the remaining three infants. There was no relationship between elevated PIVKA levels and coagulation activity in these patients. Plasma vitamin K1 was very high, particularly in the first days of life.(ABSTRACT TRUNCATED AT 250 WORDS)

Exclusion criteria and outcome in pressure reduction of intussusception

Experience of 53 episodes of intussusception was examined to compare the observed success rate of pressure reduction with potential outcome had stricter exclusion criteria been applied (history > 24 hours, presence of rectal bleeding, radiological signs of intestinal obstruction). With stricter criteria 25 avoidable laparotomies would have been performed. Most infants can be cured of intussusception by pressure reduction and though some must be excluded this decision should be based on clinical assessment by those experienced in its management. Pressure reduction should not be attempted in the absence of a surgeon with regular experience of intussusception.

Fetal vesicoureteral reflux: outcome following conservative postnatal management

Of 222 infants with a urinary tract abnormality detected antenatally 30 male and 9 female patients (64 renal units) were found to have primary vesicoureteral reflux. Grade of reflux was predominantly severe, with grade III or higher noted in 83% of the patients. Prenatal and postnatal ultrasound failed to detect any abnormality in 29 refluxing units (45%) discovered contralateral to the known abnormal system, although 19 had grade III or higher reflux. Of the 64 refluxing units 8 underwent primary ureteral reimplantation, 12 were lost to followup and 44 were managed conservatively for a mean of 3.3 years. Reflux ceased in 61% of the cases, improved in 14% and remained unchanged in 23%. In only 1 unit did the grade of reflux increase. Documented urinary tract infection occurred in 6 of the 39 reflux patients. Dimercaptosuccinic acid renography performed in 21 infection-free patients demonstrated global reduction in renal parenchyma in 4 units, focal parenchymal defects in 3 and normal function in 14. Conservative postnatal management of fetal vesicoureteral reflux is justified. Global and focal parenchymal changes can occur in the kidneys of infants with reflux despite the absence of urinary tract infection.

Long-term assessment of intracranial pressure using the tympanic membrane displacement measurement technique

The tympanic intracranial pressure (ICP) measurement technique was used to assess intracranial pressure over several months in two patient populations. In the first study, 43 shunted hydrocephalic children, aged 4-17 years, were tested over a period of 18 months when clinically well. Of these 11 (26%) were later admitted with symptoms suggesting acute shunt blockage. The tympanic ICP measurement correlated with clinical and/or operative findings in 10 cases. In the second study, illustrated by a case report, repeated testing over a period of 5 months in children with chronic symptoms suggestive of periods of increased ICP, demonstrated a correlation between symptoms and ICP and helped influence management decisions. Tympanic ICP measurement in shunted children is a valuable tool in the assessment of acute and chronic shunt malfunction. Serial testing was shown to be clinically useful in the long-term management of these patients as a diagnostic indicator of pressure variation and shunt dysfunction.