476 The Role of Medical Students in an International, Collaborative, Multi-Centre Global Surgery Study

Introduction

The gaps in formal education caused by the pandemic have provided medical students with opportunities to redefine their role in settings across clinical medicine, education and research. This task shifting could provide avenues for students to engage with global surgery, where the cultivation of research skills, networking, and global collaboration amongst students is imperative for sustainable progress.

COVIDPaedsCancer is an international collaborative cohort study assessing the impact of the pandemic on paediatric cancer services. We aimed to trial a student and junior doctor-lead team to perform the day-to-day running of this research.

Method

An operations team of 47 students and junior doctors across 11 countries was assembled. Sub-teams were created for social media, network management, email communications, REDCap, research support and graphics. Together, they ran the study under guidance from the steering committee.

Results

To date, the operations team has coordinated study collaborators in collecting data for 1252 patients from 78 centres across 39 countries. Cooperation between sub-teams enabled the recruitment of collaborators from 558 hospitals in total. They also identified 2 errors in the protocol and resolved them with steering committee input, and continuously managed hospital leadership issues and general queries throughout the course of the study. The team was able to adapt in response to the evolving needs of collaborators and the steering committee.

Conclusions

Medical students were able to aid the delivery of an international, multicentre, collaborative, global surgery research study while benefiting from learning opportunities, networking opportunities, and developing interest and understanding of global surgery.

244 Traumatic Brain Injury Related Paediatric Mortality and Morbidity in Low- And Middle-Income Countries: A Systematic Review and Meta-Analysis

Aim

Three million cases of paediatric traumatic brain injury (pTBI) occur annually, the majority of which occur in low-and-middle-income countries (LMICs). However, there is a paucity of data on the outcomes of pTBI available. We aimed to systematically review and synthesise the reported morbidity and mortality from pTBI in the published literature about LMICs.

Method

A systematic review and meta-analysis were conducted. MEDLINE, EMBASE, Global Health, and Global Index Medicus were searched for relevant articles from January 2000 to May 2020. Observational or experimental studies on pTBI (individuals between the ages of 0 to 16 years) in LMICs were included. Morbidity data were descriptively analysed, and a random-effects model was used to pool mortality rates. PROSPERO ID: CRD42020171276.

Results

We included 145 studies from 38 countries representing 174073 patients with pTBI. Males were twice (95% CI: 1.6 – 2.4) as likely to have a pTBI than females. Where available, mild TBI represented ≥ 60% of all pTBI cases in most reports (n = 24/43, 56%). The commonest cited cause of pTBI was road traffic accidents (n = 16643/43083, 39%), followed by falls (n = 10927/43083, 25%). 4385 patients (n = 4385/18092, 24%) had a reduction from normal function on discharge. On average, there were 6.7 deaths per 100 cases of pTBI.

Conclusions

Only 38 LMICs have published data on the volume and burden of pTBI in their country. Limited data available suggests that young male children are at a high-risk of pTBIs in LMICs, particularly from road traffic accidents.

Investigating Wilms' Tumours Worldwide: A Report of the OxPLORE Collaboration-A Cross-Sectional Observational Study

BACKGROUND

Childhood cancer is neglected within global health. Oxford Pediatrics Linking Oncology Research with Electives describes early outcomes following collaboration between low- and high-income paediatric surgery and oncology centres. The aim of this paper is twofold: to describe the development of a medical student-led research collaboration; and to report on the experience of Wilms' tumour (WT).

METHODS

This cross-sectional observational study is reported as per STROBE guidelines. Collaborating centres included three tertiary hospitals in Tanzania, Rwanda and the UK. Data were submitted by medical students following retrospective patient note review of 2 years using a standardised data collection tool. Primary outcome was survival (point of discharge/death).

RESULTS

There were 104 patients with WT reported across all centres over the study period (Tanzania n = 71, Rwanda n = 26, UK n = 7). Survival was higher in the high-income institution [87% in Tanzania, 92% in Rwanda, 100% in the UK (X² 36.19, p < 0.0001)]. Given the short-term follow-up and retrospective study design, this likely underestimates the true discrepancy. Age at presentation was comparable at the two African sites but lower in the UK (one-way ANOVA, F = 0.2997, p = 0.74). Disease was more advanced in Tanzania at presentation (84% stage III-IV cf. 60% and 57% in Rwanda and UK, respectively, X² 7.57, p = 0.02). All patients had pre-operative chemotherapy, and a majority had nephrectomy. Post-operative morbidity was higher in lower resourced settings (X² 33.72, p < 0.0001). Methodology involving medical students and junior doctors proved time- and cost-effective. This collaboration was a valuable learning experience for students about global research networks.

CONCLUSIONS

This study demonstrates novel research methodology involving medical students collaborating across the global south and global north. The comparison of outcomes advocates, on an institutional level, for development in access to services and multidisciplinary treatment of WT.

Correction to: Development of a new reproductive tissue cryopreservation clinical service for children: the Oxford programme

In the published version, the Acknowledgements section was missing a funding note of co-author Dr C Verrill. The corrected version should read as follows.

Primary paediatric chest wall tumours necessitating surgical management

INTRODUCTION

Limited literature exists on oncological chest wall reconstruction in the paediatric population, with the field still largely undecided on the best surgical reconstructive techniques to employ. The use of biological grafts/meshes is gaining popularity in certain adult surgical procedures but their use in paediatric procedures is rarely reported in the literature. We present the outcomes of our institution's multidisciplinary approach to managing paediatric chest wall tumours as well as our experience with the use of biological grafts for chest wall reconstruction following oncological resections.

METHODS

Data were analysed retrospectively from eight paediatric patients who were treated for primary chest wall tumours between 2010 and 2018.

RESULTS

The tumours comprised two lipoblastomas, three Ewing's sarcomas, an undifferentiated sarcoma with osteosarcomatous differentiation, a high grade undifferentiated sarcoma and a myofibroma. Seven of the eight patients underwent chest wall reconstruction with a biological graft. There were no postoperative mortalities and no evidence of recurrence in any of the patients in the series. No further chest wall operations were required and there were no postoperative infection related complications.

CONCLUSIONS

We support the use of biological grafts for chest wall reconstruction after oncological resections and maintain that a multidisciplinary approach is essential for the management of paediatric chest wall tumours.

Development of a new reproductive tissue cryopreservation clinical service for children: the Oxford programme

PURPOSE

This article describes the development of a new reproductive tissue cryopreservation clinical service for children at high risk of infertility in the NHS during times of severe financial constraints in the health service.

METHOD

A development plan with two phases was drawn up. Phase 1 restricted the service to childhood cancer patients referred to the Oxford Paediatric Oncology and Haematology Principle Treatment Centre. It was estimated that there would be 10 patients/year and used existing staff and facilities from paediatric oncology, surgery, anaesthetics radiology, pathology, psychology, teenage-young adult gynaecology, and an existing Human Tissue Authority tissue bank with a licence for storage of tissue under a Human Sector Licence. Phase 2 extended the service to include children and young adults across England, Wales and Ireland-patients from Scotland having access to a research programme in Edinburgh. The main challenge in phase 2 being resources and the need for patients to be able to be treated as close to home as safely as possible.

RESULTS

The Oxford team developed information resources and eligibility criteria based on published best practice, referral and treatment pathways, multidisciplinary team meetings, a network of third party sites, and a dedicated case management and database. As the programme expanded, the Oxford team was able to justify to management the need for a dedicated theatre list. Patient feedback through questionnaires, qualitative work conducted as part of a Ph.D. thesis as well as direct patient stories and interviews in TV, and radio features underpins the positive impact the programme has on patients and their families.

CONCLUSION

The Oxford Reproductive Cryopreservation programme delivers fertility preservation treatment to children and young adults at high risk of infertility safely, effectively and as close to home as possible. The onward view is to apply for national funding for this programme for recognition and sustainability.

Low-fidelity Paediatric Surgical Simulation: Description of Models in Low-Resource Settings

BACKGROUND

Surgical simulation is an important aspect of competency-based training. Recent trends in paediatric surgical simulations have migrated towards high-fidelity simulation with advanced technology resulting in models which are expensive and largely inaccessible in low- and middle-income countries.

METHODS

This article describes four wet simulation models of common surgical procedures in paediatric population created with animal tissue from local abattoir. The models are designed to provide a framework for others to make the models and benefit from the training opportunity they provide especially in low-middle-income countries.

RESULTS

The models created in the wet laboratory are neonatal bowel anastomosis, duodenoduodenostomy for discrepancy anastomosis, gastrostomy and pyeloplasty. These models are easily reproducible in resource-challenged healthcare setting as they are low cost, utilise locally available resources and require only a basic set of surgical instruments with which to perform the procedures.

CONCLUSION

These models provide locally accessible material for sustainable training programmes which are fundamental in developing safe and affordable surgical care worldwide.

Post-natal outcomes of antenatally diagnosed intra-abdominal cysts: a 22-year single-institution series

PURPOSE

The aim of this study was to establish the post-natal diagnosis and outcome of antenatally diagnosed intra-abdominal cysts between 1991 and 2013 at our institution.

METHODS

All antenatally diagnosed intra-abdominal cysts between 1991 and 2013 were identified using a foetal anomaly database. The cysts were monitored for resolution. In all cases where the cyst had not resolved antenatally, additional post-natal scans were conducted. Antenatal diagnosis, post-natal diagnosis and outcomes were also recorded.

RESULTS

118 cases of antenatal intra-abdominal cysts were identified over the 22-year study period with a 98 % live birth rate. The overall accuracy of an antenatal diagnosis at our institution was 92 %. 26 cases (22 %) resolved spontaneously in utero, the majority of which (77 %) were ovarian in nature. Four tumour cases were identified in the series, which included two neuroblastomas, one yolk sac tumour and one teratoma. 90 cysts persisted post-natally with 52 % requiring surgery. These primarily included choledochal and enteric duplication cysts as well as symptomatic solid organ cysts. Diagnostic revision was limited to 8 % of cases over the study period with an overall improvement over the last decade. Overall, 40 % of all antenatally diagnosed cysts required surgical intervention. In those cysts that persisted post-natally, 52 % required surgery.

CONCLUSIONS

A fifth of prenatally diagnosed intra-abdominal cysts will resolve with most ovarian cysts regressing in utero. Half of all persistent cysts will, however, require surgical intervention. These data are useful for prenatal counselling and demonstrates the important role played by the paediatric surgeon in the overall management of intra-abdominal cysts.

Anorectal atresia with gross terminal colonic distension in Africa

Anorectal malformation (ARM) is a group of significant birth defects with geographic variation in incidence, individual phenotypes and regional geographic subtypes occurring in approximately 1:5,000 live births. Anorectal atresia with gross terminal colonic distension in the presence of an absent anal canal has also been known as 'pouch colon' which is mainly associated with the Indian subcontinent. Its prevalence is unknown but it is rare, possibly representing a fraction of 1 % of ARM. The problem seems to revolve around the gross terminal distension of the distal pouch which remains a significant surgical challenge to surgeons resulting in poorer postoperative continence in many instances.

AIM

This study set out to collate data on ARM patients with gross terminal distension of the distal pouch from Africa to evaluate its epidemiology and outcome in African patients.

METHODS

Fifteen African paediatric surgical centres (7 South African and 8 African centres) were polled on the occurrence of anorectal atresia with gross terminal distension of the terminal bowel, an ARM variant. Data included ethnic group, age, gender as well as the anatomical pathology, classification and presence or absence of associated anomalies.

RESULTS

Of 12 respondents, 8 (67 %) responded and sufficient data to classify and analyse were obtained from six of the eight positive replies (7 new cases). Abdominal X-ray showed a grossly dilated terminal portion of the colon in the presence of an imperforate anus. A colovesical fistula was observed in four (three males and one female cloaca). Three were associated with a colonic atresia, of which two were in the transverse colon and one in the sigmoid colon. Surgical corrective procedures were carried out in six, but one patient, with a cloaca, died prior to surgical correction.

CONCLUSIONS

In this survey of 15 African centres, we have attempted to document the occurrence and presentation of anorectal atresia with gross terminal distension in Africa and report seven additional new cases. A possible association with associated conditions like colonic atresia requires further investigation.

Finding vessels--accuracy of CT for identifying anomalous feeding vessels in patients with congenital cystic lung lesions

INTRODUCTION

Contrast computer tomography (CT) scanning is the investigation of choice for the further assessment of suspected cystic congenital lung lesions (CCLL). Its use to identify the presence of anomalous feeding vessels supplying the lesion is well documented, but data regarding its accuracy is limited. This study compares CT results to operative and pathological findings to determine the accuracy of CT in identifying these anomalous vessels.

METHODS

51 consecutive cases of cystic congenital lung lesions managed in one hospital by a single consultant were reviewed. All cases had contrast CT scans performed preoperatively, as standard practice in this institution. We compared the results of these CT scans to the macroscopic appearance at surgery and histological findings postoperatively. We also compared the results of 2 CT protocols used in our institution between 1999-2007 and 2007-2009, respectively.

RESULTS

Anomalous vessels were reported on CT in 9 cases. All but 1 had concordant operative and pathological findings. In the remaining 42 cases, no anomalous vessels were seen on CT. Of these, 9 cases were found to have an anomalous blood supply at surgery, 6 of which were hybrid lesions and 3 isolated sequestrations. The specificity of CT in identifying feeding vessels in the study was 97% (95% CI: 0.83-0.99) and the sensitivity was 47% (95% CI: 0.23-0.71). The positive predictive value was 89% (95% CI: 0.50-0.99) and negative predictive value 79% (95% CI: 0.62-0.89). The most recent protocol yielded an improved sensitivity of 75% (95% CI: 0.22-0.98) and a specificity of 100% (95% CI: 0.46-1.0) with a 100% (95% CI: 0.31-1.0) positive and 83% (95% CI: 0.36-0.99) negative predictive value.

CONCLUSION

CT is a specific investigation for identifying anomalous vessels in CCLL but lacks sensitivity, leading to a relatively low negative predictive value. This emphasises the need in every case to look for anomalous vessels at surgery to avoid morbidity and potential mortality. An improved protocol for CT scans leads to improved specificity and sensitivity and predictive values.

Rectal biopsy for Hirschsprung's disease--are we performing too many?

BACKGROUND

Rectal biopsy is considered the gold standard for the diagnosis of Hirschsprung's disease. The aim of this study was to evaluate the outcome of rectal biopsies performed in our institution, and to determine whether we are performing an adequate number of biopsies in patients presenting with features suggestive of this disease.

METHODS

A retrospective analysis was conducted of patients who underwent rectal biopsy to exclude Hirschsprung's disease over a seven year period between 2000 and 2006. The histological diagnosis of Hirschsprung's disease was made using haematoxylin and eosin as well as acetylcholinesterase on frozen section. Patients were grouped into three age categories: neonates (group A), infants (group B) and those over 1 year of age (group C). The results of the biopsies were compared between groups.

RESULTS

A total of 668 patients underwent rectal biopsy. 18 samples were insufficient. Based on the histological studies of 650 suitable samples, 73 (11%) were positive and 577 (89%) were negative for Hirschsprung's disease. Of the 73 positive biopsies, 34 (47%) were from group A, 20 (27%) from group B and 19 (26%) from group C. The percentage of positive biopsies was much higher in group A with 29% (34 out of 118) compared to group B with 15% (20 out of 135) and group C with 5% (19 out of 395). Three complications of minor rectal bleeding occurred.

CONCLUSIONS

With 3 complications and 18 insufficient samples out of 668, rectal biopsy is a safe procedure and remains the gold standard for the diagnosis of Hirschsprung's disease, despite the large number of negative biopsies. Contrary to some reports in the literature which question the need for rectal biopsy in those presenting after the neonatal period, 53% of our positive diagnoses were made in children presenting after this period, with 19 positive biopsies out of 395 (5%) performed in children above the age of 1 year.

Duodenal atresia: associated anomalies, prenatal diagnosis and outcome

BACKGROUND

The diagnosis of duodenal atresia is commonly made prenatally, either as an isolated lesion or due to its association with other chromosomal abnormalities (Robertson et al. in Semin Perinatol 18:182-195, 1994; Hemming and Rankin in J Prenat Diagn 27:1205-1211, 2007). The aim of this study was to describe the prevalence of associated anomalies, prenatal diagnostic accuracy and survival of cases of congenital duodenal atresia in our institution.

METHODS

All cases of duodenal atresia registered with our local congenital anomaly register over a 10-year period, 1995-2004 inclusive, were studied, including those resulting in termination of pregnancies, stillbirths, intrauterine deaths and neonatal deaths. To ensure high-case ascertainment, data were cross checked with prenatal ultrasound, cytogenetic laboratory, pathology department and neonatal surgical data base. Data were analysed for associated anomalies, accuracy of prenatal diagnosis and neonatal outcomes.

RESULTS

A total of 65 patients were initially diagnosed as having duodenal atresia, of these 4 were subsequently excluded (1 postnatal normal bowel and 3 high jejunal atresias). In the remaining 61 cases, 35 (57%) had an association with other congenital abnormalities and 26 (43%) were isolated anomalies. Thirty-five were male and 26 female (M:F = 1.4:1). Twenty-one out of 29 (72%) patients prenatally diagnosed, compared with 14 out of 32 (44%) patients diagnosed postnatally had associated anomalies. Duodenal atresia was suspected on routine prenatal ultrasonography at 20-week gestation in 33 cases and confirmed in 29 (48%) cases with 4 false-positive diagnoses (1 normal bowel and 3 high jejunal atresias). No prenatal diagnosis was made in 32 (52%) babies. Of the 61 cases, 53 were live births with 2 early neonatal deaths (1 cardiac and 1 VACTERL), 5 terminations, 2 intrauterine deaths and 1 stillbirth (Fig. 3). Overall neonatal survival was 96% (51 cases). Mortality in the group diagnosed prenatally was 34 % (10 cases).

CONCLUSION

This study shows an overall increased association of duodenal atresia with Down's syndrome. In the group diagnosed prenatally, mortality as well as the association with other congenital anomalies was found to be higher. We have demonstrated a greater prenatal diagnostic accuracy, but confirm postnatal outcomes similar to previous studies.

An unusual cause of caecal perforation in a child

Faecolith impaction leading to caecal perforation is a rare cause of acute abdominal pain in children. We present a case of an 11-year-old boy who was admitted to our department with a perforated caecum caused by faecolith impaction. Histology demonstrated a normal appendix with ganglion cells present. No mechanism of action could be detected for the faecolith impaction. This is a previously unreported cause of caecal perforation in children.

Patent processus vaginalis: a window to the abdomen

A patent processus vaginalis (PPV) allows a communication between the peritoneum and scrotum. Hydrocoele is the usual presentation of a PPV in children. However, with intraabdominal pathology the patent PPV may provide the first clue to the mischief within the abdomen. We present here two unusual cases associated with a PPV and migration of intraabdominal contents from the abdomen to the scrotum.

Management of congenital cystic adenomatous malformations of the lung

Congenital cystic adenomatous malformation of the lung (CCAM) is a rare lung lesion easily diagnosed on prenatal scan. The pathology of fetal lesions differs from postnatal lesion, hence the need for separate classifications during the different stages of development. Fetuses with CCAMs and hydrops have a poor prognosis and may be candidates for prenatal intervention where available. Most prenatally diagnosed CCAMs have a favourable outcome. Early surgery is required for symptomatic babies. Management of prenatally diagnosed asymptomatic lesions remains controversial, with the options of conservative management with CT scan surveillance or surgical excision. Surgical excision is favoured by many centres because of the risk of infection and malignant transformation if the CCAM remains in situ. Surgical outcomes are excellent.

Congenital lung lesions: classification and concordance of radiological appearance and surgical pathology

Congenital lung lesions are diagnosed antenatally in the majority of cases. Postnatal management includes chest radiography and CT-scanning, followed by either surgical resection or CT surveillance. Pre-operatively, lesions are often "labelled" as CCAM (and the Stocker classification incorrectly applied), sequestration, or lobar emphysema, and their frequent "hybrid" nature sometimes missed. The aim of our study was to correlate antenatal and postnatal radiological diagnoses and classification of congenital lung lesions with surgical and pathological outcome. Twenty-six consecutive cases of antenatally-diagnosed cystic lung lesions managed at our centre between January 2003 and April 2007 were reviewed. Diagnoses were: cystic adenomatoid malformations (CCAM) in 13 cases (50.0%), three bronchopulmonary sequestrations (11.5%), "hybrid" lesions in eight cases (30.8%), one isolated lobar emphysema (3.8%) and a normal lung segment with anomalous systemic supply (3.8%). Overall concordance rate between prenatal ultrasound and resection pathology was 61.5%, whereas CT findings correlated with pathology in 65.4% of cases. Incorrect radiological classification resulted in one morbidity, when an attempted thoracoscopic resection of a presumed CCAM had to be converted to an open procedure due to bleeding from an unsuspected anomalous vessel. The common embryological origin of these lesions, and the need for standardisation of reporting is discussed. We propose that lesions should be classified anatomically according to their nature, arterial supply and venous drainage in order to reduce discrepancies between radiological, intra-operative and pathological reporting.

Epidermal growth factor in neonatal saliva

AIMS OF STUDY

Epidermal growth factor (EGF) is an amino acid polypeptide that has been shown to promote mucosal healing and intestinal growth in experimental models and has a potential role in the aetiology and treatment of NEC. The aim of this study was to determine the normal levels of salivary EGF in a cohort of healthy neonatal infants.

MATERIAL AND METHODS

With appropriate ethical approval and informed consent, saliva was collected using a suction catheter from all normal neonatal infants admitted to our unit over a 9-month period. The samples were immediately frozen at - 20 degrees C and analysed using an ELISA assay (R & D Systems, Oxford, UK). Samples taken a week prior to and two weeks following a septic episode (as diagnosed by clinical or biochemical evidence) were excluded. Patients with congenital malformations and chromosomal anomalies were excluded.

RESULTS

A total of 65 samples were collected and analysed from 27 babies. The mean gestation and weight of the patients was 32.2 (+/- 5.50) weeks and 1954.44 (+/- 1045.7) grams, respectively. Five samples from 2 infants were discarded. None of the patients in whom the samples were analysed had clinical or serum markers of sepsis or NEC. All infants were given maternal breast milk starting at the mean age of 5 (+/- 3.47) days. The mean EGF values were 676.95 (+/- 168.47) pg/ml. There was a significant rise in serial salivary EGF values in patients (p = 0.0019). There was no correlation between the EGF values and gestation (R = 0.35, p = 0.08). The birth weight, sex or timing of initiating enteral feeds did not correlate with EGF values.

CONCLUSION

In conclusion, our study shows a rise in salivary EGF values in serial samples in a clearly defined group of healthy infants.

A comparison of neonatal surgical admissions between two linked surgical departments in Africa and Europe

Resources for neonatal surgery vary hugely between the developed countries and Africa. Due to the burden of other childhood diseases, neonatal surgery is of low priority to health-care budget holders in the developing countries. Admissions to two linked neonatal surgical institutions in Africa and Europe are compared to draw attention to the need of newborn care in developing countries. In a 3-year period, there have been 528 neonatal surgical admissions to the Kilimanjaro Christian Medical Centre (KCMC), Tanzania. During the same period, 707 surgical neonates were admitted to the John Radcliffe Hospital, UK (JRH). Conditions more commonly seen in the JRH include necrotising enterocolitis (NEC) (10.2 vs 0%), gastrochisis (5.5 vs 0.9%), congenital diaphragmatic hernia (2.4 vs 0.4%), congenital lung cysts (1.6 vs 0.4%), meconium ileus (2.4 vs 0%), malrotation (2.7 vs 0.6%) and abdominal/pelvic cysts (1.1 vs 0%). Conditions more commonly seen in KCMC include anorectal malformation (9.5 vs 4.7%), sacrococcygeal teratoma (2.3 vs 0.3%), Hirschsprung's disease (10.2 vs 4.5%), branchial fistula (0.9 vs 0%), haemangioma (2.1 vs 0%) and cystic hygroma (2.1 vs 1.0%). The spectrum of neonatal surgical admissions in our two institutions varied. We believe this is attributable to availability of antenatal diagnosis, primary health-care, transport facilities, genetics as well as survival of delayed presentation. This study demonstrates the extent and spectrum of neonatal surgical pathology in this part of Africa and highlights the need for newborn surgical care in developing countries.

Postnatal outcome of antenatally diagnosed intra-abdominal cysts

The aim of this study is to establish the postnatal diagnosis and outcome of all abdominal cystic lesions diagnosed antenatally over a 13-year period. All prenatally suspected and postnatally confirmed intra-abdominal cysts seen and delivered between 1991 and 2004 were identified. Antenatal diagnosis, gestational age at delivery, sex and postnatal diagnosis and outcome were recorded. Fifty-five patients were identified with an antenatal diagnosis of abdominal cystic lesion. There were 53 live births and 2 intrauterine deaths. In 13 cases (24%) the cyst had resolved on a postnatal scan. Sixteen (29%) required surgical intervention postnatally. Twenty-six (47%) were given a "non-specific" diagnosis of abdominal cyst antenatally. Three (11%) of these non-specific cysts had resolved on postnatal scan. A "specific" diagnosis of the abdominal cyst was made antenatally in 29 cases (53%) of which 12 (43%) had the diagnosis confirmed postnatally. In ten (35%) of these there was a normal postnatal scan. Antenatal ultrasound scans may not reliably predict the exact pathological diagnosis of abdominal cystic lesions. However this study provides valuable information on the proportion of correctly diagnosed lesions and those that will persist into the postnatal period allowing more informative counselling for prospective parents.

Multidisciplinary approach to expansion thoracoplasty for congenital spinal deformity: a preliminary report

BACKGROUND

In children with congenital chest wall deformities, the vertical expandable prosthetic titanium Rib (VEPTR) has recently been developed to move the emphasis away from corrective spinal fusion, to expanding the deformed hemithorax. The aim of this paper is to demonstrate the need for paediatric surgeons in what is primarily an orthopaedic procedure.

MATERIALS AND METHODS

All patients less than 5 years old who had primary congenital scoliosis with poor respiratory function and were treated by VEPTR at our institution in conjunction with the spinal orthopaedic surgeons were reviewed.

RESULTS

All 6 cases required rib exposure and thoracostomy by a paediatric surgeon. One required exposure of the ribs only, 3 required an extrapleural thoracotomy and 2 required intrapleural thoracotomy with a patch repair of the rib space. None of the patients required blood transfusion and there were no early complications. All patients showed radiological improvement of their spinal and thoracic deformity as well as improvement in their respiratory function.

CONCLUSION

Paediatric surgeons play an important role in the thoracic exposure required for this orthopaedic procedure. The benefit of a multidisciplinary approach is highlighted in this paper. The VEPTR implant may replace major spinal fusion surgery in this challenging group of patients.

The spectrum of anorectal malformations in Africa

Anorectal malformations (ARM) remain a significant birth defect with geographic variation in incidence, individual phenotypes and regional geographic subtypes. Although early studies indicated a low incidence in Black patients, there is a great paucity of knowledge as to the types, frequency and incidence of ARMs encountered in the African continent and their associated anomalies. Current evidence suggests a significant clinical load. This study set out to evaluate ARM in Southern and other parts of Africa to define the clinical load of ARM. We retrospectively collected data on 1,401 ARM patients from six South African Paediatric Surgical units plus representative samples from five other African countries from West, Central and Southern Africa. Data included ethnic group, age, gender as well as the anatomical pathology, classification and presence or absence of associated anomalies. ARM lesions classified by the Wingspread classification plus an analysis of fistula position was carried out in evaluable cases for purposes of comparison. South African centres reported a higher prevalence of cloacae and vestibular fistulae, whereas rectovaginal, recto prostatic and anorectal malformation without fistula were more prevalent in the Northern African group. 76% of 1,401 patients were ethnically Black African [gender ratio = 2 (vs gender ratio 1.38 overall)] and 49.8% were "low" lesions (Wingspread classification). High or intermediate lesions were mostly males (72%). Anal stenosis was most prevalent in black males and non-Black females. Fistulae were identified in 95% with 682 (52%) being low (perineal/covered anus/vestibular) fistulae. Perineal fistulae had a male predilection (n = 260; 20%), whereas vestibular fistulas (n = 416; 32%) was strikingly frequent in black females (55%). Of the remainder, 15 fistulae were rectovesical (1.2%), 544 recto-urethral or prostatic (42%), 16 recto-vaginal (1.2%). In addition, there were 43 cloacal lesions (3.3%). Isolated rare ARM anomalies included "Pouch" colon (2) and H-type fistula (2). Isolated lesions occurred in 81% but 163 associated anomalies were identified in 114 patients. These included chromosomal lesions (10), genito-urinary anomalies (50), genital (16), cardiac (31), skeletal anomalies (33), gastro-intestinal malformations (28). Other anomalies included CNS anomalies (14), anterior abdominal wall defects (2) and facial (8) abnormalities and neuroblastoma (1). The ARM is not uncommon in Black African populations and constitutes a significant clinical load to surgical practice in Africa. Ethnic differences appear to exist and vestibular fistulae predominate in black females. Cloaca (3.3%) did appear to be more prevalent. Isolated lesions are frequent but the types of associated anomalies appear similar to other series except chromosomal syndromes. This study illustrates the need for more objective data from developing countries to assess geographical differences.

Primary pleural synovial sarcoma presenting as a multiloculated cyst in an adolescent

Primary pleural synovial sarcoma (PPSS) is a rare pleural malignancy with a grave prognosis. Most cases present as a well-circumscribed mass with foci of haemorrhage and necrosis. We present an unusual case in a Nepalese boy that presented as a multiloculated cyst mimicking hydatid disease. The diagnosis was confirmed by histology and cytogenetic analysis.

The scope of emergency paediatric surgery in Tanzania

This article helps to outline the scope of emergency paediatric operations in Tanzania by quantifying the nature of cases seen over a 12 month period in a teaching hospital. Data collected at the Kilimanjaro Christian Medical Centre (KCMC) showed that operative paediatric surgical emergencies represented 4% of all paediatric admissions. Of emergency procedures, 47 (43%) were for congenital abnormalities, 32 (29%) for infections, 19 (17%) for trauma and 12 (11%) for other reasons. Emergency operative mortality was 34%. The challenges to meet patient needs in the African setting include: a scarcity of surgeons with training in paediatric surgery, the variety of conditions which all surgeons must manage, a lack of equipment (e.g., neonatal ventilators) and educational resources. Potential avenues for overcoming these challenges are discussed, including the promotion of paediatric surgery as a profession, by the expansion of existing facilities, promoting African associations of paediatric surgery and highlighting the need for resources and continued education and training. We argue that surgical training in developing countries should include the skills needed to treat those paediatric conditions most likely to require urgent surgical intervention.

Prenatal diagnosis of tracheo-oesophageal fistula and oesophageal atresia

OBJECTIVES

To assess the accuracy of the prenatal ultrasound finding of subjectively small/absent stomach bubble in the prenatal diagnosis of tracheo-oesophageal fistula and oesophageal atresia (TOF/OA).

METHODS

A retrospective study of prenatal ultrasound scans showing small/absent stomach bubble was carried out between 1st January 1994 and 31st December 2003.

RESULTS

There were 62 cases with prenatally suspected (n = 40) and/or post-natally diagnosed (n = 22) TOF/OA. Among the 40 cases of prenatally suspected TOF/OA 15 were thought to be isolated and 25 non-isolated. Of the 15 suspected isolated cases, 7 were normal and 8 had TOF/OA (5 isolated + 3 TOF/OA with another anomaly) at delivery. Among the 25 cases of prenatally suspected non-isolated TOF/OA, there was confirmation in only two cases, in the remaining 23 cases other anomalies were confirmed but TOF/OA was not present.Twenty-two babies with TOF/OA were identified in whom there had been no prenatal ultrasound suspicion on ultrasound scanning. Six had isolated TOF/OA and 16 had non-isolated TOF/OA.

CONCLUSION

Of the 32 cases of confirmed TOF/OA,10 (31%) were suspected prenatally. If the TOF/OA was an isolated anomaly (11 cases), the prenatal detection rate was 45%. Interpretation of ultrasound findings suspicious of TOF/OA requires caution, particularly, when there are associated multiple anomalies on scan.

Rectal adenocarcinoma following cranio-spinal radiotherapy for cerebellar medulloblastoma

The authors present a case of a 16-year-old female diagnosed with rectal adenocarcinoma 10 years after receiving cranio-spinal radiotherapy for a cerebellar medulloblastoma. While the risk of a second malignancy is recognised to be increased in children previously treated with radiotherapy, rectal adenocarcinoma is a rare presentation. A child presenting with symptoms of weight loss and a change in bowel habit in a patient who has previously received radiotherapy should alert practitioners to the possibility of a colorectal malignancy.

Infantile hypertrophic pyloric stenosis: an infectious cause?

The aetiology of infantile hypertrophic pyloric stenosis (IHPS) remains unclear. The aim of this study was to test the hypothesis that a common bacterium, Helicobacter pylori (HP) may be implicated in the pathogenesis of IHPS. Thirty-nine consecutive infants with confirmed IHPS had their stool analysed with an enzyme immunoassay for the presence of HP. An age/sex-matched group of infants with unrelated surgical conditions were also tested. No positive results for the presence of HP stool antigen were obtained in the study nor the control group. The results of this study demonstrate no causative link between HP and IHPS. A genetic basis has been implicated for IHPS. However, evidence does exist that IHPS is a condition acquired after birth and that an infective agent may be involved in the pathogenesis. Further studies are required to elucidate perinatal factors that may induce the expression of this condition in a genetically sensitive individual.

Challenges in developing paediatric surgery in Sub-Saharan Africa

The aim of the present study is to report on the difficulties in developing paediatric surgery in a teaching hospital in Tanzania. The methods are as follows: (1) information on the demography and health services of Tanzania were obtained from the Ministry of Health and the 1998 consensus report; (2) hospital data was obtained from the Medical Director's Office and analysed; (3) the current delivery of surgical services for children at the Tumaini University Hospital and Kilimanjaro Christian Medical Centre (KCMC) is reported; (4) the local, national and international support for the development of surgical services for children is noted; (5) the teaching, training and research programmes are proposed. The results showed that (1) Tanzania has a population of 31 million with a total health expenditure of 10%. There is 1 doctor for 23,000 inhabitants and 1 hospital bed per 940. The infant mortality is 173 per thousand life births. (2) The bed capacity at KCMC is 500 with a staff of 40 consultants, 294 nurses, 246 health attendants and 38 clinical officers. (3) Forty-two percent of admissions to the surgical ward and 50% of surgical outpatients are children. Surgical newborns are cared for in the special care baby unit and there are no neonatal or paediatric ventilators. (4) Support to develop surgical services for children has been pledged for locally, nationally and internationally; however, delivery of the service has not had the equivalent momentum. (5) The proposed teaching and training programme has been approved by the University. There is a need for surgical services for children with encouraging support for this venture; however, the challenges remain in delivering the service.

Outcome of antenatally suspected congenital cystic adenomatoid malformation of the lung: 10 years' experience 1991-2001

OBJECTIVE

To determine the outcome of antenatally suspected congenital cystic adenomatoid malformation of the lung (CCAM) over a 10 year period.

METHODS

This is a retrospective study of all babies diagnosed antenatally in the Prenatal Diagnosis Unit and delivered in Oxford between 1991 and 2001. Data were obtained from the Oxford Congenital Anomaly Register, theatre records, and histopathology reports.

RESULTS

Twenty eight cases of CCAM were diagnosed antenatally. Five pregnancies were terminated. Data are available on all 23 of the pregnancies that continued and resulted in two neonatal deaths and 21 surviving babies. Eleven of the 23 cases (48%) showed some regression of the lesion antenatally, and four of these cases appeared to resolve completely on prenatal ultrasound. Three of the 23 babies (13%) were symptomatic in the early neonatal period, and three developed symptoms shortly afterwards. Seventeen of the 23 babies (74%) were asymptomatic, of whom 12 had abnormalities on chest radiograph or computed tomography scan and had elective surgery. Two babies (8%) had completely normal postnatal imaging, and three had abnormalities which resolved in the first year of life. Seventeen of the 23 babies (74%) had surgery. Histology at surgery was heterogeneous. Of the 23 live births, all 21 survivors (91%) are well at follow up or have been discharged.

CONCLUSIONS

All babies diagnosed antenatally with CCAM require postnatal imaging with computed tomography irrespective of signs of antenatal resolution. In asymptomatic infants, the recommendations are close follow up and elective surgery for persistent lesions within the first year of life. Histology at surgery was heterogeneous, and this should be considered when counselling parents.

Somatostatin for intractable postoperative chylothorax in a premature infant

A premature infant of 31 weeks' gestation underwent repair of an oesophageal atresia, distal tracheo-oesophageal fistula and anal stenosis. A lymphatic leak was noted at the time of surgery. Chylous drainage persisted and an intravenous infusion of somatostatin was begun. The volume of chyle drained fell dramatically within the first 24 h and was negligible by the 5th day of treatment. No reaccumulation of the chylothorax was seen after the cessation of somatostatin. To our knowledge this is the youngest reported child in whom somatostatin has been used successfully in treating a postoperative chylothorax.

Follow-up of children with isolated fetal echogenic bowel with particular reference to bowel-related symptoms

OBJECTIVES

To determine whether there was any evidence of long-term bowel pathology in children, apparently healthy at birth, who had a prenatal second-trimester diagnosis of isolated grade 2 fetal echogenic bowel.

METHODS

This was a retrospective study using data from the Oxford Congenital Anomaly Register. Fetuses with isolated grade 2 fetal echogenic bowel and date of delivery from 1994 to 2000 inclusive were identified. Information about the health of the children, particularly relating to bowel symptoms, was obtained from hospital records and from a questionnaire sent to the general practitioner.

RESULTS

A total of 109 cases were identified, with delivery details available for 108. There was one unexplained intrauterine death, and additional problems were subsequently diagnosed in four cases (cystic fibrosis (2), Down syndrome (1), and VACTERL (1)). Questionnaires were sent to the GPs of the 103 who had no problems identified at the time of discharge from the maternity hospital. Age at follow-up ranged from one to four years. Responses to the questionnaires were received from 83 (81%). Of these, 74 (89%) had not reported bowel symptoms to the GP, 9 (11%) reported symptoms relating to constipation (6), chronic abdominal pain (1), infantile colic with milk intolerance (1) and gastro-oesophageal reflux (1).

CONCLUSION

This small study provides some reassurance that there was no evidence of any serious long-term bowel pathology associated with isolated fetal echogenic bowel.

Anti-reflux surgery for the neonatal intensive care-dependent infant

AIM

The benefit of anti-reflux surgery for gastro-oesophageal reflux (GOR) in early infancy is uncertain. The aim of this study was to assess the value of Nissen fundoplication in a group of infants with severe GOR.

METHODS

10 infants underwent Nissen fundoplication for gastro-oesophageal reflux following a failure of medical management. All had suffered life-threatening respiratory episodes as a consequence of gastro-oesophageal reflux, and were neonatal intensive care-dependent. Median (range) birth weight was 1.26 kg (0.48-3.8 kg), gestation 30 weeks (25-38 weeks); at surgery, weight was 3.25 kg (2.5-6.1 kg) at a corrected age of 11.5 weeks (term-22) weeks. For each infant, the success of enteral feeding and the level of support required pre- and post-operatively was compared, and where appropriate, the facilitation of palliative feeding was assessed. Median follow-up was 14 (3-36) months.

RESULTS

No infant suffered intra-operative morbidity or mortality. One infant died within 1 month of surgery from a collapse unrelated to surgery. Eight of nine surviving infants were discharged from intensive care following extubation and the establishment of enteral feeding. One patient died of severe bronchopulmonary dysplasia 3 months post-surgery. One infant developed a gastrostomy site infection, and two required gastrostomy tube replacement within 6 months of surgery. All were thriving at follow-up. Two infants with a congenital myopathy died as a result of their muscle disease at 9 and 11 months post-operatively.

CONCLUSIONS

Nissen fundoplication is a feasible, effective and safe operation in severe gastro-oesophageal reflux unresponsive to medical treatment in term and pre-term infants. It has an additional important role in facilitating safe palliative enteral feeding in infants with a diagnosis incompatible with survival into adulthood.

Intralobar pulmonary sequestration with congenital cystic adematous malformation and rhabdomyomatous dysplasia

Pulmonary sequestration and congenital cystic adenomatous malformations (CCAM) are well known but still uncommon anomalies of the lung. Extralobar sequestrations are well described in association with CCAM, but fewer intralobar lesions are found with this association. The existence of striated muscle within CCAM is described, and we have evidence of dysplastic changes within the various cellular components occurring, with rhabdomyomatous dysplasia being one of these. A literature review shows no previous evidence of a reported intralobar sequestration associated with CCAM and rhabdomyomatous dysplastic changes.

Spontaneous intestinal perforation and Candida peritonitis presenting as extensive necrotizing enterocolitis

Spontaneous intestinal perforation (SIP) has been increasingly reported in very-low-birthweight (VLBW) infants, although it is still less common than necrotizing enterocolitis (NEC). In around one-third of cases, SIP is associated with systemic candidiasis. We describe a case of SIP and Candida peritonitis in a VLBW infant, which was mistakenly diagnosed as NEC during the infant's short life. At laparotomy, the bowel surface was black and thought to be necrotic. As the infant was thought to have whole-bowel necrosis due to NEC, her condition was deemed incompatible with survival. At postmortem, however, the bowel wall was found to be healthy apart from a very localized patch of necrosis associated with a single perforation. The bowel was covered by a thick, black, serosal exudate consisting of fungal elements from Candida albicans.

CONCLUSION

This case reinforces the fact that a markedly discoloured bowel is not necessarily necrotic and that the discoloration can potentially recover.

Immunoreactive epidermal growth factor receptors are present in gastrointestinal epithelial cells of preterm infants with necrotising enterocolitis

INTRODUCTION

Epidermal growth factor (EGF) affects epithelial cell proliferation, differentiation and migration in the gastrointestinal tract of experimental animals, and increases proliferation when given intravenously to children with congenital microvillous atrophy or necrotising enteritis. The aim of the present study is to determine whether EGF receptors (EGFR) are present in the gut epithelium of preterm infants, and to discover whether neonatal necrotising enterocolitis (NEC) is associated with the absence of EGFR from mucosal cells.

METHODS

Tissues were taken from involved colon and small intestine of four preterm infants with NEC, and control tissues were taken from four other neonates who had laparatomies for congenital malformations. Sections of the tissues were examined histopathologically after treatment with a monoclonal antibody against the external domain of the EGFR (Zymed Laboratories, San Francisco, CA, USA).

RESULTS

Histopathological examination confirmed diagnosis of NEC in the involved bowel and controls showed appearance within normal limit. Immunoreactive EGFR were present on the epithelial cells of both the colon and small intestine, localised on the basolateral membrane of the cells of both subject and the controls. There was no apparent reduction in expression compared with controls.

CONCLUSION

NEC in preterm infants is not associated with absence of EGFR. The presence of EGFR in gut epithelial cells raises the possibility of using EGF for prophylaxis or treatment of NEC.

Potency and stability of C terminal truncated human epidermal growth factor

INTRODUCTION

Epidermal growth factor (EGF) is normally present as EGF(1-53). A variety of C terminal truncated forms have been used in preliminary trials for treating gastrointestinal injury but their relative potency and stability when used in a clinical setting are unclear. Therefore, we compared the biological activity of recombinant EGF(1-53), EGF(1-52), EGF(1-51), and the C terminal peptides EGF(44-53) and EGF(49-53).

METHODS

Purity of forms was confirmed by mass spectrometry. Bioactivity of the different EGF forms was determined using [methyl-(3)H] thymidine incorporation into primary rat hepatocytes and their ability to reduce indomethacin (20 mg/kg subcutaneously)/restraint induced gastric injury in rats. Stability of EGF peptides was determined by serial sampling from a syringe driver system containing EGF/4% albumin in saline.

RESULTS

Biological activity assays of EGF(1-53), EGF(1-52), and EGF(1-51) gave almost identical thymidine uptake dose-response curves (maximal responses increasing baseline uptake from 4400 (600) cpm (mean (SEM)) to about 22 000 (2000) cpm when EGF was added at 1. 6 nM). EGF(44-53) and EGF(49-53) did not stimulate (3)H thymidine uptake. Control rats had 47 (4) mm(2) damage/stomach, EGF(1-51), EGF(1-52), and EGF(1-53) at 0.16 and 0.80 nmol/kg/h each reduced gastric injury by about 50% and 80%, respectively (both doses p<0.01 compared with control but no significant difference between the different forms). EGF was stable at room temperature for seven days but biological activity decreased by 35% and 40% at two and three weeks, respectively (both p<0.01). Exposure to light did not affect bioactivity.

CONCLUSION

EGF(1-51) and EGF(1-52) are as biologically active as full length EGF(1-53) but the C terminal penta- and decapeptides are ineffective. Clinical trials of EGF can probably use infusion systems for at least 48 hours at room temperature and with exposure to light, without reducing biological efficacy.

Magnetic resonance imaging of intestinal necrosis in preterm infants

BACKGROUND AND OBJECTIVE

Noninvasive diagnosis of intestinal necrosis is important in planning surgery in preterm infants with necrotizing enterocolitis (NEC). We aimed to assess the potential of magnetic resonance imaging (MRI) for the diagnosis of intestinal necrosis.

STUDY PARTICIPANTS AND METHODS

Abdominal MRI scans were performed in a group of preterm infants with suspected NEC and compared with surgical findings and to MRI results in a group of control infants. In addition, MRI was performed in 2 preterm infants with suspected NEC who did not require surgery.

RESULTS

Six infants with a median birth weight of 1220 g (range, 760-1770 g) and median gestational age at birth of 30 weeks (range, 28-34 weeks) were studied at a median postnatal age of 10 days (range, 4-19 days). Four infants had a bubble-like appearance in part of the intestinal wall, intramural gas, and an abnormal fluid level within bowel lumen. At surgery, NEC was found in 5 infants and sigmoid volvulus in 1. The site of the bubble-like appearance corresponded to the site of intestinal necrosis at surgery. Four control infants with a median birth weight of 1500 g (range, 730-2130 g) and a median gestational age of 31 weeks (range, 26-36 weeks) had abdominal MRI at a median postnatal age of 8 days (range, 4-70 days). None of the above findings were seen in any control infant. The bubble-like appearance was not seen in the 2 infants with suspected NEC who did not require surgery.

CONCLUSION

Abdominal MRI allows the noninvasive diagnosis of bowel necrosis. This may aid the timing of surgical intervention in preterm infants with a clinical diagnosis of NEC.gangrene, ischemia, MRI, necrotizing enterocolitis.

Thymectomy in black children with juvenile myasthenia gravis

Fifteen black children with juvenile myasthenia gravis presented to our institution over a 10-year period at ages ranging from 18 months to 7 years, 4 males and 11 females. Twelve presented with progressive, generalised weakness and 3 had bulbar manifestations. Ocular signs were absent in 2 patients. All 15 patients were placed on pyridostigmine bromide (Mestinon) and 1 also required steroids and plasmapheresis. Medical therapy only was instituted in 5 patients, of whom 2 came to surgery, 2 died, and 1 was lost to follow-up. Thymectomy was performed in 12 children (including the 2 with failed medical therapy) via a median sternotomy with no mortality or morbidity related to the operation. The timing of surgery was less than 3 months in 75% of the children. Thymic hyperplasia was noted in 10 glands and 2 were reported as normal. Of the children in the operative group, 83% are on minimal medication or in total remission. Better results were noted in young patients with early thymectomy and diseased glands.

Failure of pre-natal ultrasonography to prevent urinary infection associated with underlying urological abnormalities

OBJECTIVES

To analyse the reasons underlying the failure of routine pre-natal ultrasonography to prevent the subsequent development of urinary tract infection (UTI) in children with predisposing urological abnormalities.

PATIENTS AND METHODS

This retrospective study comprised 39 children (22 females and 17 males) who had at least one documented UTI, the presence of an anatomical anomaly of the urinary tract recognized as predisposing to UTI and had undergone ultrasonography of the urinary tract undertaken in fetal life as part of routine maternal ante-natal ultrasonography. Four categories of patients were defined: Group A, those with normal findings on pre-natal ultrasonography and no urological abnormality detected; Group B, those with a urological abnormality detected but where there was a subsequent failure of communication among clinicians; Group C, those with a urological abnormality but who received inappropriate or sub-optimal post-natal management and; Group D, those with a urological abnormality but who had a UTI despite appropriate post-natal management. In each case, the most severe documented episode of UTI was categorized as: Grade I, asymptomatic bacteriuria; Grade II, mild/moderate symptomatic UTI and; Grade III, severe symptomatic UTI necessitating hospital admission.

RESULTS

Group A comprised 22 (56%), Group B three (9%), Group C two (5%) and Group D 12 children (31%). Of the 22 children in Group A, nine experienced a UTI of sufficient severity to necessitate hospital admission. Of the 12 children in Group D only one required hospital admission.

CONCLUSIONS

The failure of pre-natal ultrasonography to identify the underlying predisposing urological abnormality was the most important factor contributing to subsequent UTI in post-natal life. Failure of communication and inappropriate post-natal management were numerically unimportant. In some children, UTI occurred despite pre-natal detection of their underlying anomaly and appropriate post-natal management. However, in this group the UTI was less severe than in those children whose urological anomalies had not been detected by pre-natal ultrasonography.

Is inguinal exploration for the impalpable testis an outdated operation?

OBJECTIVE

To evaluate the reliability of open inguinal exploration for the investigation of the impalpable testis by reviewing laparoscopic findings after previous negative inguinal exploration.

PATIENTS AND METHODS

Laparoscopy was performed in 18 boys (with a total of 22 impalpable testes) in whom previous inguinal exploration in their referring hospitals had yielded negative or inconclusive findings. Subsequent management of the impalpable testes was based on laparoscopic findings.

RESULTS

Despite previous negative surgical findings at inguinal exploration, laparoscopy revealed that 13 of the 22 impalpable testes (59%) were present, 12 within the abdomen and one in the inguinal canal. Absence of the remaining nine testes was positively confirmed by visualizing confluent blind ending vas and vessels.

CONCLUSION

Inguinal exploration is an unreliable method of investigating the impalpable testis, with an unacceptably high incidence of false-negative or inconclusive findings. Laparoscopy should be undertaken as the initial diagnostic manoeuvre of choice.

Left-sided liver abscess in childhood

Abscesses occur less frequently on the left side of the liver than on the right, and are implicated in a higher incidence of complications. Of a total of 124 children with liver abscesses seen at Red Cross War Memorial Children's Hospital from 1974 to 1990, 26 had left-sided and 98 right-sided lesions. A similar spectrum of organisms was cultured, and 20 (77%) of the left-sided abscesses were found to be caused by pyogenic organisms as opposed to 78 (79%) of those on the right. The remainder were of amoebic origin. In 5 patients with multiple abscesses involving predominantly the left side of the liver, the right side was also involved. These were excluded from further comparison of left and right liver abscesses. Of the remainder, 16 (62%) left-sided and 77 (83%) right-sided abscesses were solitary. Clinical features were similar in both groups but epigastric mass was more frequent in left-sided lesions. After an initially conservative management policy, surgical drainage was necessary in 87.5% of solitary left-sided liver abscesses as opposed to 64% of solitary right-sided abscesses. No intrapericardial ruptures were noted, but 2 pericardial effusions required drainage. There was no mortality but 3 patients with solitary left-sided abscesses ruptured. The important role of ultrasound in the diagnosis and follow-up period is stressed. Patients with solitary left-sided abscesses are identified as being at risk. Abscess drainage is recommended in this group.

Mediastinal teratomas: review of 15 pediatric cases

One hundred fifty-three children with a teratoma presented to one hospital between 1970 and March 1992. The clinical and pathological features of 15 patients with mediastinal teratomas are reviewed; six were newborn and nine aged from infancy to 13 years. Thirteen patients including the six newborns presented with respiratory distress and all 15 patients had a mass on chest radiograph. A definite diagnosis of teratoma was not made preoperatively in any of these patients. At operation, a median sternotomy was used to approach seven anterior tumors and a lateral thoracotomy performed in the other eight patients. Histologically two were mature, 10 had immature elements, and three were malignant teratomas. The patients with malignant tumors were all over 12 years of age and died within 6 months of treatment. All six neonates had immature teratomas. Raised serum alpha-fetoprotein levels provided useful markers in two patients with recurrent tumors. Three conclusions can be drawn: (1) mediastinal teratomas are rare in children and frequently are not diagnosed before operation; (2) in newborns these tumors may be immature and present with respiratory distress; and (3) a median sternotomy gives excellent exposure for anterior mediastinal tumors.

Bowel stomas in infants and children. A 5-year audit of 203 patients

A 5-year audit of the formation, management and closure of small-bowel stomas and colostomies at Red Cross War Memorial Children's Hospital, Cape Town, is described. Of the 203 patients, 128 (63%) required the stroma in the neonatal period. Anorectal malformations (80), Hirschsprung's disease (65), necrotising enterocolitis (33), trauma (11) and neoplasm (5) comprised most of the indications. One hundred and thirty large-bowel stomas were sited in the proximal sigmoid and 37 in the transverse colon, all but 11 being divided with each end brought out through a short muscle cutting incision or through the laparotomy wound. Thirty-six ileostomies were performed and in 30 of these the stoma was sited in the wound. Complications, which included necrosis, bleeding, prolapse and wound sepsis, occurred in 31%. The colostomies sited in the transverse colon had the highest incidence of prolapse (38%). Neonatal stomas brought out in the wound had an acceptably low incidence of complications. Most stomas were temporary in nature. One hundred and eighty-eight were closed, all with excision and end-to-end intraperitoneal anastomosis. There was a 4% incidence of complications (5 would sepsis, 2 leaks, 1 stenosis). The formation, management and closure of bowel stomas represents a considerable section of the work of the paediatric surgeon. Correct meticulous technique is essential in keeping complications to a minimum.

Galactocele in a male infant: case report and review of literature

An 11-month-old male developed painless enlargement of the left breast over 1 month. The lesion was mobile, fluctuant, and nontender. Surgical excision was performed and histological examination revealed a galactocele. A galactocele is a very rare cause of breast enlargement in male infants and children.

Gastric acid secretion and gastrin release in the baboon

Significant species differences have been demonstrated in gastric physiology, a factor that limits extrapolation of animal data to man. Primate physiology is thought to be similar to that of man; however, gastric function has not been adequately documented in the primate. In the present study six baboons (body weight 25.5 +/- 1.8 kg) were trained to sit in a chair and gastric acid secretion and gastrin release was studied in conscious animals. Mean basal acid secretion was 1.3 +/- 0.1 mmol (H+)/hr. Maximum output after pentagastrin (12 micrograms/kg/hr) was 9.5 +/- 0.9 mmol (H+)/hr and 11.0 +/- 0.4 mmol (H+)/hr after histamine (40 micrograms/kg/hr). A statistically significant (by cosinor analysis) circadian rhythm was demonstrated for intragastric pH over 24 hr in fasted baboons (P less than 0.001). Mean basal serum gastrin level was 37.7 +/- 8.3 pg/ml. The integrated gastrin response after administration of a protein rich meal was 2.52 +/- 0.07 ng x min/ml and this increased to 5.17 +/- 0.18 ng x min/ml (P less than 0.05) following simultaneous administration of a meal with atropine (0.2 mg/kg) (P less than 0.05). Our results suggest that there is significant basal and stimulated acid secretion in the baboon; the amount of acid secreted is similar to that reported in man. Gastric pH demonstrated a circadian rhythm. Postprandial gastrin release was significantly enhanced by cotreatment with atropine. As the present findings are similar to those previously reported in man, the baboon may be a useful model for further studies in gastric physiology and experimental peptic ulceration.

Blunt splenic trauma in children

Splenic trauma in 96 patients over an 11-year period is reviewed. Almost 80% of injuries resulted from motor vehicle accidents in which the patients was a pedestrian, and over 80% of patients sustained multiple injuries. Splenic injury was confirmed by isotope scanning at laparotomy. Non-operative management was feasible in 87.5% of the children, with no mortality or morbidity. In patients requiring surgery, splenic salvage was possible in 75%.