Outcomes after surgery for children in Africa (ASOS-Paeds): a 14-day prospective observational cohort study

BACKGROUND

Safe anaesthesia and surgery are a public health imperative. There are few data describing outcomes for children undergoing anaesthesia and surgery in Africa. We aimed to get robust epidemiological data to describe patient care and outcomes for children undergoing anaesthesia and surgery in hospitals in Africa.

METHODS

This study was a 14-day, international, prospective, observational cohort study of children (aged <18 years) undergoing surgery in Africa. We recruited as many hospitals as possible across all levels of care (first, second, and third) providing surgical treatment. Each hospital recruited all eligible children for a 14-day period commencing on the date chosen by each participating hospital within the study recruitment period from Jan 15 to Dec 23, 2022. Data were collected prospectively for consecutive patients on paper case record forms. The primary outcome was in-hospital postoperative complications within 30 days of surgery and the secondary outcome was in-hospital mortality within 30 days after surgery. We also collected hospital-level data describing equipment, facilities, and protocols available. This study is registered with ClinicalTrials.gov, NCT05061407.

FINDINGS

We recruited 8625 children from 249 hospitals in 31 African countries. The mean age was 6·1 (SD 4·9) years, with 5675 (66·0%) of 8600 children being male. Most children (6110 [71·2%] of 8579 patients) were from category 1 of the American Society of Anesthesiologists Physical Status score undergoing elective surgery (5325 [61·9%] of 8604 patients). Postoperative complications occurred in 1532 (18·0%) of 8515 children, predominated by infections (971 [11·4%] of 8538 children). Deaths occurred in 199 (2·3%) of 8596 patients, 169 (84·9%) of 199 patients following emergency surgeries. Deaths following postoperative complications occurred in 166 (10·8%) of 1530 complications. Operating rooms were reported as safe for anaesthesia and surgery for neonates (121 [54·3%] of 223 hospitals), infants (147 [65·9%] of 223 hospitals), and children younger than 6 years (188 [84·3%] of 223 hospitals).

INTERPRETATION

Outcomes following anaesthesia and surgery for children in Africa are poor, with complication rates up to four-fold higher (18% vs 4·4-14%) and mortality rates 11-fold higher than high-income countries in a crude, unadjusted comparison (23·15 deaths vs 2·18 deaths per 1000 children). To improve surgical outcomes for children in Africa, we need health system strengthening, provision of safe environments for anaesthesia and surgery, and strategies to address the high rate of failure to rescue.

FUNDING

Jan Pretorius Research Fund of the South African Society of Anaesthesiologists and Association of Anesthesiologists of Uganda.

Outcome of Transanal Endorectal Pull-Through in Patients with Hirschsprung's Disease

BACKGROUND

Transanal endorectal pull-through (TERPT) has become one of the preferred treatments for Hirschsprung's disease (HD) in our setting. This report aims to evaluate the current outcome of TERPT in the setting.

MATERIALS AND METHODS

A retrospective review of 71 children who had TERPT for histologically-confirmed HD in 11 years (2006-2017) in Nigeria.

RESULTS

There were 48 boys and 23 girls; aged 3 days-12 years at initial presentation (median = 10 months). Three (4.2%) patients had associated anomalies (duodenal atresia; anorectal malformation and sensorineural deafness with hypopigmented skin patches each). Age at TERPT was 2 months to 15 years (median = 3 years), with surgery waiting time of 1 month-14.9 years (median = 18 months). Sixty-six (93.0%) patients had rectosigmoid, four (5.6%) patients had long segment and one (1.4%) had total colonic disease. Five (7.0%) patients with large megacolon and one (1.4%) with the total colonic disease had assisted abdominal resection of the colon at TERPT. Seventeen (23.9%) patients had post-operative complications, including post-operative enterocolitis 8 (11.3%); anastomotic dehiscence 3 (4.2%); retained aganglionic segment 2 (2.8%); anastomotic stenosis 2 (2.8%), resulting in prolonged hospital stay (P = 0.0001; range = 1-30 days; median = 5 days). The mortality rate was 4.2% (3) from malignant hyperthermia in one patient and in 2 patients, the cause of mortality was unclear. Patients were followed up for 3-6 years (median = 3.5 years). Bowel movement stabilised to 2-4 times daily by 6 weeks after surgery.

CONCLUSION

TERPT is a safe treatment for HD in this setting with good short-term outcomes. Longer follow-up is necessary to further evaluate the long-term bowel movement outcomes.!

A Modified Rectal Mucosal Biopsy for the Diagnosis of Hirschsprung's Disease: Zaria Experience

Background

Full-thickness rectal biopsy is often used for the diagnosis of Hirschsprung's disease (where a suction biopsy kit is not available). This is associated with some challenges such as limited theatre space and the need for general anaesthesia. We aim to highlight the usefulness and sensitivity of a modification of the rectal mucosal biopsy without general anaesthesia in the diagnosis of Hirschsprung's disease.

Materials and Methods

This is a retrospective analysis of children with Hirschsprung's disease who had rectal mucosal biopsy over a 16-year period (January 2004-December 2019). Research was approved with institutional number ABUTHZ/HREC/H22/2022. The patients had the biopsy with small, curved artery forceps, surgical blade, and dissecting scissors. Histological analyses of tissue were done. Clinical data and results were recorded on a structured pro forma, and the data were analysed.

Results

There were 263 boys and 97 girls with a median age of 10.5 months. Only 37 (10.3%) of the rectal biopsies were done by consultants. Hirschsprung's disease was confirmed in 279 (75.5%) of the partial-thickness biopsies, whereas 52 (14.4%) biopsies were inadequate specimens. Resident doctors were responsible for 92.2% (47) of inadequate biopsies (P = 0.63), although they did 89.7% of all biopsies. In one (0.3%) patient, the procedure ended as a full-thickness biopsy leading to a significant haemorrhage that required blood transfusion.

Conclusions

The modified rectal mucosal biopsy is a simple, safe, and effective method for making the diagnosis of Hirschsprung's disease. This is performed without general anaesthesia and is useful where a suction biopsy kit is unavailable.

Duodenal obstruction due to missed pre-duodenal portal vein in a patient with intestinal malrotation

Pre-duodenal portal vein (PDPV) is a rare anomaly and a rare cause of duodenal obstruction (DO), with only a few cases reported in the literature. We present an infant whose bilious vomiting persisted despite having Ladd's procedure for intestinal malrotation due to a missed diagnosis of DO from PDPV that was found at re-exploration. The patient was diagnosed with malrotation and had Ladd's procedure at 12 weeks of age, but bilious vomiting persisted post-operatively. The patient presented to us after 4 weeks, was clinically malnourished and dehydrated, resuscitation was done and re-exploratory laparotomy performed, where an obstructing PDPV was found and a duodeno-duodenostomy was performed anterior to PDPV. However, the patient died on post-operative day 7 probably from severe malnutrition due to delayed diagnosis and absence of parenteral nutrition. We conclude that PDPV may be a cause of DO in infants with malrotation and should be properly sought for during Ladd's procedure for possible bypass surgery if found.

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

BACKGROUND

Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality.

METHODS

We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung's disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis.

FINDINGS

We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung's disease) from 264 hospitals (89 in high-income countries, 166 in middle-income countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36-39) and median bodyweight at presentation was 2·8 kg (2·3-3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in low-income countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88-4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59-2·79], p<0·0001), sepsis at presentation (1·20 [1·04-1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4-5 vs ASA 1-2, 1·82 [1·40-2·35], p<0·0001; ASA 3 vs ASA 1-2, 1·58, [1·30-1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02-1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41-2·71], p=0·0001; parenteral nutrition 1·35, [1·05-1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47-0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50-0·86], p=0·0024) or percutaneous central line (0·69 [0·48-1·00], p=0·049) were associated with lower mortality.

INTERPRETATION

Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between low-income, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030.

FUNDING

Wellcome Trust.

Accuracy of ultrasonography in the evaluation of abdominal masses in children in Nigeria

INTRODUCTION

Abdominal masses in children constitute a spectrum of lesions of diverse origin, nature and significance. In a low-income setting with limited investigative facilities, accurate diagnosis of abdominal masses can be very challenging. However, ultrasound has been used preferentially as a diagnostic tool in evaluating abdominal masses in children. This study aimed to determine the accuracy of ultrasound evaluation of abdominal masses in children.

MATERIALS AND METHODS

This was a prospective descriptive study of 135 consecutive children presenting with palpable and/or suspected abdominal masses over a 1-year period at a tertiary hospital. Data analyses were done using SPSS version 17 software and level of significance was set at P < 0.05.

RESULTS

Abdominal mass was located in the kidney in 40 (32.3%) patients. Definitive diagnoses of abdominal masses were confirmed intraoperatively in 33 (24.4%) and by histopathological examination in 102 (75.6%) cases. Abdominal masses were detected in 124/135 (91.9%) of the participants. Ultrasound (US) correctly identified 109/124 (87.9%) of the pathologies. The sensitivity and specificity of USS were 87.9% and 81.8%, respectively. Positive predictive value (PPV) and negative predictive value (NPV) were 97.2%-98.2% and 37.5%-45.7%, respectively. The overall US diagnostic accuracy was 87.4%. The predictive value of US for intussusceptions, Wilms' tumour and hydronephrosis was high (sensitivity was 92.0%, 95.8% and 81.1% and PPV was 90.0%, 83.0% and 93.8%, respectively). On the other hand, the sensitivity indices for appendiceal mass/abscess, lymphoma and neuroblastoma were low (28.6%, 66.7% and 57.1%, respectively), while their PPV was low too (66.7%, 42.9% and 77.7%, respectively). The PPV was especially poor for lymphoma. The specificity and NPV indices for these six disease conditions were good.

CONCLUSION

Ultrasound is a reliable tool in the evaluation of abdominal masses in children in this setting.

Presentation and outcome of treatment of jejunoileal atresia in Nigeria

BACKGROUND

Intestinal atresia is a common cause of neonatal intestinal obstruction. Previous reports from Nigeria have indicated a high mortality rate. This is a report of current outcome review from one tertiary center.

PATIENTS AND METHODS

A retrospective analysis of infants managed for jejunoileal atresia in 10 years (2005-2014). The information retrieved from patients' records was analyzed using SPSS 17.

RESULTS

There were 38 patients (19 boys and 19 girls) aged 1-28 days (median 4 days). Twenty-four patients (63.2%) presented after 48 h of life. Twenty-five (65.8%) had jejunal atresia and 13 (34.2%) had ileal atresia. Six patients had associated anomalies. The most common atresia was type III (39.5%, 15 patients). Twenty-eight (73.7%) patients had a resection of the atresia and anastomosis and others had enterostomies. Total parenteral nutrition and neonatal intensive care support were not available during the period of the study. Bowel function was established within 1 week and 27 (71.1%) patients commenced oral feeding. Twenty-six (68.4%) patients had postoperative complications resulting in prolonged hospital stay of 2-44 days (median = 13). Mortality was 34.2% (13 patients). Factors that significantly affected mortality were intestinal necrosis at presentation, postoperative complications, and severe malnutrition.

CONCLUSION

Intestinal atresia is still associated with unacceptably high morbidity and mortality, due to late presentation, and lack neonatal intensive care services and parenteral nutritional support. Efforts need to be intensified to address these factors to improve outcome.

Role of vesicostomy in the management of posterior urethral valve in Sub-Saharan Africa

OBJECTIVE

To review the role of vesicostomy in the management of posterior urethral valve (PUV), in neonates and infants, given the limitations for endoscopic treatment in this setting.

METHODS

A review of 35 patients who presented with posterior urethral valve over a 10-year period. Demographic and clinical information were prospectively recorded on a structured pro forma, and the data extracted analysed using SPSS 11.0.

RESULTS

The 35 boys were aged 3 days to 10 years (median 3 weeks). Twenty-three (65.7%) had a vesicostomy (age range 3 days-3 years, median 3 weeks). The mode of presentation was poor urinary stream 15 (65.2%), urinary retention 4 (17.4%), and renal failure 6 (26.1%). Main findings were palpable bladder 23 (100%), hydronephrosis 4 (17.4%). Abdominal ultrasound confirmed hydronephrosis and thickened bladder wall, and voiding/expressive cystourethrogram confirmed dilated posterior urethra and vesicoureteric reflux in all 23 patients. Complications following vesicostomy were stoma stenosis 1 (4.3%), bladder mucosal prolapse 1 (4.3%), perivesicostomy abscess 1 (4.3%); there was no mortality. Following vesicostomy, 10 (43.5%) patients had excision of the valves and vesicostomy closure at age 2-8 years (median 4 years). They are well, with normal renal ultrasonographic findings, bladder capacity range 115-280 ml, and normal urea, serum electrolytes, creatinine, at 3 years of follow up. Thirteen (56.5%) are still awaiting valvotomy but have remained well and with normal ultrasonographic renal findings.

CONCLUSION

Vesicostomy is a useful temporising mode of urinary diversion in neonates and infants with posterior urethral valve (in the absence of unobstructed upper tracts) when facilities for endoscopic valve ablation are not readily available.

Persistent umbilical discharge in infants and children

BACKGROUND

Umbilical discharge is not an unusual presentation in infants and children. However, the evaluation and management are rarely discussed.

METHOD

A retrospective review of 18 patients presenting with persistent umbilical discharge over a period of 22 years, excluding neonates with omphalitis.

RESULTS

The patients' ages ranged between 11 days and 9 years. Presentation was usually discharge of clear, serous or purulent fluid or faecal matter from the umbilicus, sometimes dating back to the neonatal period. Evaluation consisted of bacteriology, fistulogram (one patient) and histopathology. The cause of discharge was patent vitello-intestinal duct in 11 patients, umbilical granuloma in three, umbilical sinus in two and patent urachus and osteomyelitis of the ischium in one each. Definitive treatment was exploration and complete excision of the lesion and antibiotics. Two patients with patent vitello-intestinal duct died, one before surgery from hypokalaemia and sepsis, and the other from anaesthetic complications.

CONCLUSION

There is a need for early referral and treatment in patients with persistent umbilical discharge. Conservative treatment is usually not successful as the common causes would normally require complete excision.

Management of biliary atresia in Nigeria: the ongoing challenge

BACKGROUND

In developed countries, the outlook for patients with biliary atresia has improved remarkably owing to early referral, good diagnostic facilities and the availability of liver transplantation. In Nigeria and most of sub-Saharan Africa, there is little information on the current outlook for these children.

METHODS

A retrospective review of 14 patients with biliary atresia managed from 1991 to 2004 at Ahmadu Bello University Hospital, Zaria.

RESULTS

Six girls and eight boys presented at between 6 and 24 weeks of age (median 16). Seven presented to another hospital with persistent jaundice in the neonatal period. Eleven at presentation already had liver cirrhosis and deranged coagulation and could not have corrective surgery. Three patients aged 8, 10 and 16 weeks had Kasai's porto-enterostomy. Facilities for diagnosis were limited. Ten patients were lost to follow-up and their outcome is unknown. Of the three patients who had porto-enterostomy, one died at 2 years from gastro-enteritis, one from cholangitis after 8 weeks, and one did not recover from anaesthesia. One patient who had a laparotomy and liver biopsy died from peritonitis.

CONCLUSION

Owing to late presentation, delayed referral and difficulties in diagnosis, the outlook for infants with biliary atresia in this environment is poor. A concerted effort to encourage primary practitioners to detect and refer these infants at an earlier age is critical to outcome.

Dicephalus dipus tetrabrachius conjoined twins of Zaria: case report and literature review

One of the most interesting congenital malformations to manage is a conjoined twin. Conjoined twins are rare occurrences in obstetric/pediatric practice. More commonly known as Siamese twins, this phenomenon is shrouded in mystery and considered a curiosity by general public. Current technology is lending a helping hand in the early diagnosis of these conditions. Frequently, the twins are born dead, but there are few cases in which the twins survive. We presented a case of dicephalus dipud conjoined twins; a rare type of conjoined twins.

Management of anorectal malformation: Changing trend over two decades in Zaria, Nigeria

BACKGROUND

Anorectal malformation is a common congenital defect and its management has evolved over the years. This is a review of the trend in the management of this condition in a major paediatric surgical centre in Nigeria over two decades.

MATERIALS AND METHODS

A retrospective analysis of 295 patients with anorectal malformations managed from January 1988 to December 2007 was carried out.

RESULTS

There were 188 boys and 107 girls aged 1 day-9 years (median 8 years) at presentation. There were 73 (54.5%) and 106 (65.8%) emergency operations in groups A and B, respectively. There were 61 (45.5%) and 55 (34.2%) elective operations in groups A and B, respectively. Regarding treatment, in group A, patients requiring colostomy had transverse loop colostomy, while in group B, sigmoid (usually divided) colostomy was preferred. The definitive surgery done during the two periods were: group A: cutback anoplasty 29 (47.5%), anal transplant 5 (8.2%), sacroabdominoperineal pull through (Stephen's operation) 6 (9.5%) and others 21 (34.4%). In group B, posterior sagittal anorectoplasty (PSARP) 46 (83.7%), anal transplant 1 (1.8%), posterior sagittal anorectovaginourethroplasty (PSARVUP) 2 (3.6%) and anal dilatation 6 (10.9%) were done. Early colostomy-related complication rates were similar in the two groups (P > 0.05). The overall late complication rate was 65.5% in group A and 16.4% in group B (P < 0.05). The mortality was 25 (18.6%) in group A compared to 17 (10.6%) in group B (P < 0.05).

CONCLUSION

There have been significant changes in the management of anorectal malformations in this centre in the last two decades, resulting in improved outcomes.

Transanal protrusion of intussusception in infants is associated with high morbidity and mortality

BACKGROUND

Although anal protrusion of intussusception in infants is well recognised, it is rarely reported and confusion with rectal prolapse often results in delayed diagnosis and treatment. This report highlights the problems of diagnosis and the morbidity and mortality associated with this condition.

METHOD

A retrospective case series of five infants presenting to Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, Nigeria with anal protrusion of intussusception over a period of 5 years. During that time, 17 children were treated for intussusception at ABUTH.

RESULTS

The anal protrusion rate of intussusception was 29%. The five infants were three girls and two boys aged 4-18 months (median 8). The duration of symptoms was between 6 and 28 days (median 21). The features were mainly protruding anal mass, diarrhoea and vomiting. Abdominal pain and passage of bloody stools occurred late. There was delay in referral and treatment owing to misdiagnosis as rectal prolapse. The intussusception was ileocolic in four patients and in one the type could not be ascertained before death. Two patients had perforation of the involved intestine and another had gangrene of the intestine, necessitating intestinal resection. In one patient, there was no bowel compromise and only open reduction was necessary. Two patients died from overwhelming infection, one before surgery and another after surgery.

CONCLUSION

The risk of morbidity and mortality in anal protruding intussusception is high. As early features might not be typical of intussusception, a high index of suspicion is necessary to avoid confusion with rectal prolapse so as not to delay diagnosis and treatment.

Challenges of managing paediatric abdominal trauma in a Nigerian setting

BACKGROUND

The management of abdominal trauma (particularly blunt trauma) has undergone tremendous revolution in the last 30 years with significant reduction in morbidity and mortality in developed countries. The aim of this report is to highlight the challenges of managing abdominal trauma in children in Nigeria based on our experience in Zaria, northern Nigeria.

METHOD

This is a retrospective review of 82 children managed for abdominal trauma from 1991 2002 at the Ahmadu Bello University Teaching Hospital, Zaria, Nigeria. Information regarding demographics, mechanism of injury, haemodynamic status at presentation, clinical and radiologic evaluation, management, intraoperative findings and outcome, were extracted from case notes, operation notes and discharge summary notes.

RESULTS

Fifty seven (69.5%) children had blunt trauma, mostly from traffic accidents (32, 57%) and falls (20, 36%), and 25 (30.5%) penetrating trauma mainly from falls onto sharp objects (7 of 18 patients) and animal-related injuries (5 of 18 patients). In the management of those with blunt trauma, advanced imaging modalities were usually not available and this resulted in an unnecessary laparotomy rate of 51% (laparotomy considered unnecessary because the patients remained haemodynamically stable after resuscitation and any intraperitoneal bleeding had stopped by the time oflaparotomy and no active operative measure was required to control bleeding). The management of penetrating trauma was more straightforward as this was guided by evidence of peritoneal penetration. Mortality from blunt trauma was 14.5% (8 of 55 patients) from exsanguinations before surgery 2, gastric perforation 3, hepatic laceration 2 and splenic injury one. Mortality from penetrating trauma was 12% (3 of 25 patients) from tetanus, overwhelming infection and haemorrhage respectively. The overall mortality from abdominal injury was 13.8% (11 of 80 patients) and were mostly avoidable if the patients presented early, and received some resuscitation before arrival at our hospital.

CONCLUSION

The management of blunt abdominal trauma in children in Nigeria is faced with several challenges, which are mainly absence of an organised trauma system and lack of appropriate facilities. These need to be addressed in order to improve the care of these injuries.

Lingual harmatoma in an infant

Lingual tumours are uncommon in infants and harmatomas are rarely reported. A 5-month-old boy presented with a growth on the dorsum of the tongue which had been present from birth. The growth produced no respiratory or feeding difficulties. It was confirmed to be a harmatoma after complete excision. There has been no recurrence.

Necrotizing fasciitis of the external genitalia following traditional circumcision

BACKGROUND

Necrotizing fasciitis of the external genitalia is not common in children, and is particularly unusual after circumcision.

METHOD

A case report of necrotizing fasciitis of the external genitalia in a one month old boy with discussion of relevant literature.

RESULT

A one-month-old boy presented with necrotizing fasciitis of the external genitalia following traditional circumcision. Treatment consisted of early administration of intravenous broad-spectrum antibiotics and debridement. Skin grafting was not necessary as the wound contracted and healed by secondary intention with minimal scarring.

CONCLUSION

Early institution of appropriate antibiotics and debridement should prevent morbidity and mortality from this uncommon condition.

Osteomyelitis of the ischium: unusual presentation

A 7-year-old boy presented with urinary symptoms and umbilical discharge. A perivesical abscess was drained from which Staphylococcus aureus was cultured. He responded to antibiotics. Subsequently, he developed a discharging sinus in the gluteal region. A plain radiograph, which had previously been normal, confirmed osteomyelitis of the ischial bone.

Fournier's gangrene in neonates and infants

BACKGROUND

Fournier's gangrene is uncommon in childhood and little is known about the disease in this age group.

METHOD

A retrospective review was carried out of neonates and infants treated for Fournier's gangrene over a period of 16 years.

RESULTS

Twelve neonates and infants aged 5 days-3 months (median 3 weeks) were treated in our hospital. The precipitating cause was omphalitis in 7 babies, strangulated inguinal hernia in 2 and in 3 babies there was no identifiable cause. Gram-negative bacteria were cultured in 3 patients, but in most the culture was sterile. Treatment consisted of debridement of devitalised tissue and administration of broad-spectrum antibiotics. Primary closure was achieved in 1 baby and secondary closure in 2 others. In 7 babies the wound contracted rapidly and healed. There was no mortality.

CONCLUSION

Fournier's gangrene in neonates and infants in our environment is largely preventable. Early debridement and appropriate antibiotics give good results.

A rare left-sided abdominal wall defect

A 4-hour-old boy is presented here, who was born with a large abdominal wall defect situated in the left flank. Silo closure was necessary due to the large size of the defect. A Medline search up to December 2002 revealed only 2 other left-sided abdominal wall defects distant from the umbilicus. The possible embryology of this anomaly is discussed.