Comparative Study between Acacia Nilotica versus Povidone Iodine in Topical Treatment of Omphalocele Major.

Well established and common practice in conservative management of omphalocele major is escharotics therapy with different topical agents. Among them mercurochrome, alcohol, silver salts, povidone iodine, acacia nilotca paste are commonly used. It is a comparative study between application of acacia nilotica paste and povidone iodine solution as a primary non surgical treatment of omphalocele major regarding efficacy and safety of these two topical agents. A double blind randomized controlled study was conducted at the department of Paediatric Surgery, Mymensingh Medical College Hospital, Mymensingh, Bangladesh from July 2016 to June 2019. In this study 20 cases of omphalocele major and randomly divided into two equal groups. Group A and Group B treated with acacia nilotica paste and povidone iodine solution respectively. Gastroschisis, ruptured-omphalocele major or omphalocele minor excluded in this study. The size of the fascial defect in cm, time required for full oral feeding tolerance and duration of hospital stay were evaluating parameters. Patients with Group A tolerated full oral feeding earlier, shorter total hospital stay duration and low mortality rate than those from Group B. Application of acacia nilotica is a safe and effective treatment of omphalocele major regarding rapid full oral feeding tolerance, shorter hospital stay and low mortality rate.

The analgesic efficacy of transversus abdominis plane block vs. wound infiltration after inguinal and infra-umbilical hernia repairs: A systematic review and meta-analysis with trial sequential analysis.

BACKGROUND: Both transversus abdominis plane (TAP) block and wound infiltration with local anaesthetic have been used to relieve pain after inguinal or infra-umbilical hernia repair. OBJECTIVES: To determine whether TAP block or local anaesthetic infiltration is the best analgesic option after inguinal or infra-umbilical hernia repair. DESIGN: Systematic review and meta-analysis with trial sequential analysis. DATA SOURCES: MEDLINE, Embase, Cochrane Central Register of Controlled Clinical Trials, Web of Science, up to June, 2020. ELIGIBILITY CRITERIA: We retrieved randomised controlled trials comparing TAP block with wound infiltration after inguinal or infra-umbilical hernia repair. Primary outcome was rest pain score (analogue scale 0 to 10) at 2 postoperative hours. Secondary pain-related outcomes included rest pain score at 12 and 24 h, and intravenous morphine consumption at 2, 12 and 24 h. Other secondary outcomes sought were block-related complications such as rates of postoperative infection, haematoma, visceral injury and systemic toxicity of local anaesthetic. RESULTS: Seven trials including 420 patients were identified. There was a significant difference in rest pain score at 2 postoperative hours in favour of TAP block compared with wound infiltration, with a mean (95% confidence interval) difference of -0.8 (-1.3 to -0.2); I2  = 85%; P   =  0.01. Most secondary pain-related outcomes were also significantly improved following TAP block. No complication was reported. The overall quality of evidence was moderate. CONCLUSION: There is moderate level evidence that TAP block provides superior analgesia compared with wound infiltration following inguinal or infra-umbilical hernia repair. TRIAL REGISTRY NUMBER: PROSPERO CRD42020208053.

Successful treatment of hepatic and mesh Aspergillosis in a neonate with giant omphalocele.

Aspergillosis is a rare and life-threatening fungal infection in immunocompetent children, particularly in infants. We present a case of invasive Aspergillosis (IA) that developed hepatic and mesh infection due to Aspergillus flavus following the rupture of a giant omphalocele. A male baby was born at 37 weeks of gestation with a giant omphalocele. No other congenital abnormalities were found. In the pediatric surgery operation room, the amniotic membrane seemed to be ruptured in some parts, which had been repaired within a few hours of birth. No further intervention to reduce the volume of visceral organs could be performed due to the tiny abdominal cavity. Postoperatively piperacillin-tazobactam and fluconazole were empirically initiated. Abdominal defects had been covered with polypropylene polylactic acid synthetic Mesh on postnatal day 11 to protect the organs and prevent abdominal infections. Fungal hepatic lesions were observed during surgery, and black necrotic lesions were also observed on the mesh on day 12. On the 16th postnatal day, Aspergillus flavus grew in the wound, graft, hepatic biopsy cultures. Serum galactomannan (GM) assay test was positive (GM:2.9), and voriconazole was initiated. All necrotic lesions resolved with liposomal amphotericin B (L-AmB) and voriconazole treatment, and antifungal therapy was discontinued after 134 days. Eye examination for the retinopathy didn't show any abnormalities. The patient was discharged with full recovery on day 155. In conclusion, IA is a rare and life-threatening infection in the neonatal period. To the best of our knowledge, this is the first case of hepatic and mesh infection caused by Aspergillus flavus that was successfully treated with voriconazole and l-AmB.

[Conservative treatment of giant omphaloceles with dissodic 2% aqueous eosin: a case serie]. / Traitement conservateur des omphalocèles géantes par l'éosine aqueuse disodique 2%: une série des cas.

Primary surgical closure for the treatment of giant omphalocele is punctuated by the onset of unpleasant complications. Conservative treatment is an option in low-income countries where neonatal resuscitation is associated with high mortality rates. We conducted a prospective study of patients admitted to the University Clinics of Lubumbashi between January and April 2020 and receiving conservative treatment based on dissodic 2% aqueous eosin according to a defined protocol. Three patients were included in our series. The mean age was 24 hours (1 - 48); they were all full term newborns (38 - 39 SA), born vaginally and with no prenatal diagnosis. Mean birth weight was 2,800 grams (2,400 - 3,000). Mean amniotic sac diameter was 13.7 cm (11 - 15 cm); it contained the liver in all cases. The median time to enteral feed was 4.3 days (4 - 5 days), to granulation was 31.7 days (30 - 33 days) and to epithelialization was 71.7 days (60 - 90 days). No death was reported. These preliminary results encourage the use of disodium aqueous eosin for the conservative treatment of unbroken giant omphaloceles.

La hernia umbilical en el paciente cirrótico: ¿tratamiento conservador o cirugía? / Umbilical hernia in cirrhotic patients: conservative treatment or surgery?

RESUMEN Antecedentes: la ascitis es una complicación de frecuente aparición en el paciente cirrótico que al producir un aumento de la presión intraabdominal puede originar una hernia de la pared abdominal; el defecto umbilical latente es su localización más habitual. Objetivo: presentar la incidencia y los beneficios que ofrece la resolución electiva de la patología um bilical en estos pacientes. Material y método: se presentan 15 pacientes, todos masculinos, que fueron intervenidos por hernia umbilical sintomática en forma electiva en el medio hospitalario. El período comprende desde enero del año 2015 a enero de 2019. El 100% de los enfermos cursa un cuadro de cirrosis hepática, con antecedentes de etilismo crónico. Se efectuó la reparación de la hernia con cierre del defecto y malla supraaponeurótica de polipropileno en la mayoría de los casos. Resultados: los pacientes fueron evaluados desde el punto de vista clínico con la escala (score) de Child en el preoperatorio. Se procedió a la evacuación de la ascitis en todos los casos y el control posoperatorio se efectuó cada 30 días los primeros 6 meses. Luego dos veces al año. No se evidenció recidiva. Dos pacientes no volvieron al control luego del año de la cirugía y 1 paciente falleció por la enfermedad de base a los 6 meses de la cirugía. Conclusiones: los enfermos con cirrosis hepática y hernia umbilical deben ser intervenidos quirúrgica mente en forma electiva. La observación y abstención quirúrgica conllevan el riesgo de rotura del saco herniario con alta morbimortalidad.

ABSTRACT Background: Background: Ascites is a common complication in patients with cirrhosis, and elevated intraabdominal pressure can lead to the development of abdominal wall hernias, particularly in patients with latent umbilical defects. Objectives: The aim of this study was to report the incidence and benefits of elective surgery for the management of umbilical hernias in cirrhotic patients with ascites. Material and methods: Between January 2015 and January 2019 15 patients with symptomatic umbi lical hernia underwent elective surgery in a public hospital; 100% were men with a history of alcoho lism and were hospitalized due to liver cirrhosis. The defect was closed, and a polypropylene mesh was placed in the supra-aponeurotic plane in most cases. Results: The preoperative risk was estimated using the Child-Pugh score. Ascites was evacuated in all the cases. Patients were followed-up every 30 days during the first 6 months and then twice a year. There were no hernia recurrences. Two patients were lost to follow-up 12 months after surgery and 1 patient died 9 months after the procedure due to progression of cirrhosis. Conclusions: Patients with liver cirrhosis and umbilical hernia should undergo elective surgery. Wat chful waiting is associated with higher risk of hernia rupture and high morbidity and mortality.

Abordagem cirúrgica em bezerros com onfalite / Surgical approach in calves with omphalitis

Pathological changes in the umbilical region are common in calves. Among such alterations, omphalitis is included. This term is used to define inflammation and infection of the external structures of the umbilicus. According to the affected structures, it can be subclassified into omphalophlebitis, omphaloarteritis, omphalourachitis and panvasculitis. These inflammations are usually associated with bacterial infections. There are predisposing conditions that include inadequate handling such as poor hygiene and neglect of primary care. Omphalitis can affect the animal in a multisystemic way, compromising its well-being and bringing economic losses. In treatment, the use of antimicrobials does not always solve the problem. Thus, surgical treatment can be used, which has good results and should be the choice in the disease. The objective of this work is to report 30 cases of omphalitis in calves, submitted to surgical or conservative treatment. Thirty cases of omphalitis in calves treated in the routine of the Veterinary Hospital of the Paranaense University was analyzed. On physical examination, the animals presented fever, apathy, hyporexia or anorexia and increase of umbilical volume, usually with purulent secretion. Some animals had sepsis and arthritis. In animals with sepsis, hyperemia of the episcleral vessels, dehydration and severe apathy were observed. In calves with arthritis, increased joint volume, pain on palpation and lameness were observed. In animals where the owners did not authorize the surgery, treatment was instituted with sulfadoxine and flunixim meglumine. In dehydrated calves, fluid therapy was used. Animals that were surgically treated received the same clinical treatment protocol as non-operated animals. The surgical procedure was performed under general anesthesia and consisted of resection of the affected umbilical structures. Omphalophlebitis was the most common illness. The most frequent complication was sepsis. Calves treated surgically had a higher survival rate (86.66%) than those treated clinically (46.67%). The clinical signs presented by all animals converged with the literature, allowing for clinical diagnosis. Clinical examination is essential for diagnosis in omphalitis cases. Complementary methods include ultrasound, thermography and laparoscopy, which are important to identify changes in intra-abdominal umbilical structures. Accurate diagnosis of the involved structures was only possible in animals surgically, as well as alterations in organs such as the liver and bladder. There is great variability related to the umbilical structures involved, according to initial care, breeds, seasonality or even the method of conception. Unlike what is observed in the literature, in the present study, there was a higher prevalence of omphalophlebitis, demonstrating variability in relation to the umbilical structures involved. Sepsis, observed in 16.7% of cases, results from bacterial ascension of the umbilical structures. Lameness due to polyarthritis was found in 10% of animals. Meningoencephalitis was observed in 3.3%. Hepatic and retroperitoneal abscedation were observed in 6.7% and 3.3% of cases, respectively. Conservative treatment with antibiotics and local antiseptics has a limited effect on this type of condition, which was proven in the present study, since the survival rate was statistically higher in animals surgically treated.(AU)

Ventral hernia secondary to giant omphalocele in a child: combined approach of botulinum toxin and preoperative progressive pneumoperitoneum.

Omphalocele is a congenital abdominal wall defect that occurs approximately 1 in 4000-6000 live births. The abdominal-visceral disproportion, large diameter of the defect, volume of liver in the sac along with high incidence of associated anomalies make the surgical management a real challenge. Currently, there are two strategies for managing giant omphaloceles, staged surgical closure and nonoperative delayed closure. The combined treatment with PPP and BoNT/A injection has recently been described in adults. There is strong evidence on safety and efficacy of the use of BoNT/As in other areas of pediatrics and no recent reports of PPP use in children. Also, there are no data available about the combination of both techniques in pediatric population. The purpose of this manuscript is to report a case of a 7-year-old female child that was referred to our institution with a large ventral hernia secondary to omphalocele. We opted for a combined approach with BoNT/A injection and PPP before the definitive surgery. The surgical result was great with midline closure with no tension and no need for prosthetic substitution or component separation needed. To our knowledge, this is the first case report of BoNT/A injection and PPP for large ventral hernias in children. BoNT/A application was safe and the PPP technique was also proved to be applicable on children. We believe that the combination of BoNT/A and PPP presented to be a safe approach with an excellent result, particularly for not needing abdominal wall prosthetic substitution.

Topical treatment of major omphalocoele: Acacia nilotica versus povidone-iodine: A randomised controlled study.

BACKGROUND: Conservative management for major omphalocoele with topical agents as escharotics therapy is well established in practice. Different agents have been used in the past, including mercurochrome and alcohol, proved later to be unsafe. The aim of this study is to evaluate the efficacy and safety of the application of Acacia nilotica paste compared to povidone-iodine solution as a primary non-surgical treatment of major omphalocoele. PATIENTS AND METHODS: A double-blind, randomised study was conducted on 24 cases of major omphalocoele where they were randomly divided into two equal groups; Group A treated with topical application of A. nilotica paste and Group B treated with topical application of povidone-iodine solution. Cases with gastroschisis, ruptured major omphalocoele or minor omphalocoele were excluded from the study. The evaluating parameters were size of the fascial defect in cm, period of mechanical ventilation if needed, time required for full oral feeding tolerance, duration of hospital stay and any short- or long-term complications. RESULTS: There was no statistical significant difference between both groups regarding their gestational or post-natal age, weight and the mean umbilical port defect. Patients from Group A tolerated full oral feeding earlier and had shorter total hospital stay duration than those from Group B, but without a statistical significant difference (P = 0.347 and 0.242, respectively). The overall mortality rate was 33.3% without a statistical significant difference between both groups (P = 0.667). CONCLUSIONS: Application of A. nilotica is a safe and effective treatment of major omphalocoele as it was associated with rapid full enteral feeding tolerance, short duration of hospital stay and low mortality rate.

Outcomes of conservative treatment of giant omphaloceles with dissodic 2% aqueous eosin: 15 years' experience.

BACKGROUND: The surgical management of giant omphalocele is a surgical challenge with high mortality and morbidity in our country due to the absence of neonatal resuscitation. This study evaluates conservative management of giant omphalocele with dissodic 2% aqueous eosin. MATERIALS AND METHODS: In the period from January 1997 to December 2012, giant omphaloceles were treated with dissodic 2% aqueous eosin. The procedure consisted of twice a day application of dissodic 2% aqueous eosin (sterile solution for topical application) on the omphalocele sac. The procedure was taught to the mother to continue at home with an outpatient follow-up to assess epithelialization. We studied the duration of the hospital stay, the learning curve of the procedure by the mother, the complications, the duration and the percentage of complete epithelialization and the mortality. RESULTS: A total of 173 giant omphaloceles had a conservative treatment with dissodic 2% aqueous eosin. The average hospital stay was 21 ± 6 days. The learning curve by the mother of the procedure was 10 ± 3 days. Complications of treatment were intestinal functional occlusion 22% and omphalocele sac infection 18%. The complete epithelialization of the omphaloceles sac after application of dissodic 2% aqueous eosin was 68.5%. Mortality was observed in 25.5%. CONCLUSION: Conservative treatment of giant omphaloceles by dissodic 2% aqueous eosin is a simple, efficient and a good alternative to surgery. The mother can easily learn its procedure which reduces the duration of hospital stay.

Medicated Manuka honey in conservative management of exomphalos major.

PURPOSE: The aim of this study was to assess the effectiveness of Manuka honey ointment and dressings in the conservative management of exomphalos major (EM). METHODS: A retrospective review of five patients with EM who underwent non-operative management with Manuka honey ointments and dressings was carried out to assess the time to complete epithelialisation, time to full feeds, hospital stay, adverse effects, complications and outcome. RESULTS: The skin epithelialisation over the EM sac was achieved in a median of 63 days (48-119). The median time to full enteral feed was 13 days (3-29). The median hospital stay was 66 days (21-121). No adverse effects were noted related to Manuka honey. Three patients had pulmonary hypoplasia requiring prolonged hospitalization; one of those died with respiratory complications at home after achieving complete epithelialisation. The follow-up was a median 16 months (6-22). Two patients did not require repair of the ventral hernia. One patient had ventral hernia repair at 16 months with excellent cosmesis. The remaining patient is awaiting repair. CONCLUSION: This is the first description of the use of medicated Manuka honey ointment and impregnated dressings in the conservative management of EM. This treatment is safe, efficacious and promotes wound healing with favorable outcome.

Delayed management of giant omphalocele using silver sulfadiazine cream: an 18-year experience.

BACKGROUND/PURPOSE: To assess the value of topical silver sulfadiazine (SSD) cream in the treatment of babies with a giant omphalocele. METHODS: From 1991 to 2008 inclusive, 20 infants with giant omphalocele (defined as >10 cm diameter) were treated with SSD, leaving a large ventral hernia to be repaired at a later date. RESULTS: There were 12 boys and 8 girls. Thirteen had prenatal ultrasound diagnosis at a mean gestational age of 23 weeks. The mean gestational age at delivery was 37 weeks, and mean birth weight was 2.5 kg. Nineteen had other anomalies and/or medical problems, 18 of them multiple. The most common was pulmonary hypoplasia (70%). Mechanical ventilation and/or oxygen treatment was required in 15 (75%) for a mean of 10 weeks. SSD was used as primary sac treatment in 5 and secondary treatment in 15 (after Silon pouch 11, Op-site 3, povidone-iodine 1). Six omphalocele sacs were ruptured within the first 5 days of life. SSD was used for a mean of 6 months at a cost of $1 per day. Complications included 2 instances of staphylococcal sepsis and 1 jejunal perforation inside a Silon pouch. Six (30%) died from pulmonary hypoplasia at a mean age of 18 weeks. There were 14 (70%) survivors who went home after a mean of 14 weeks. Of the 14 survivors, 12 had ventral hernias repaired (18 operations with 2 recurrences), and 2 remain with their original ventral hernia. CONCLUSIONS: Initial topical coverage with SSD is associated with excellent outcomes for infants with giant omphalocele who cannot undergo immediate closure.

Conservative management of giant omphalocele with topical povidone-iodine and its effect on thyroid function.

PURPOSE: The aim of the study was to evaluate topical povidone-iodine as a bridge to delayed fascial closure of giant omphaloceles with emphasis on its effect on thyroid function. METHODS: Newborns from a single institution with giant omphaloceles treated with topical povidone-iodine for a 10-year period were reviewed. Recorded data included sex, associated anomalies, length of stay, frequency of povidone-iodine application, thyroid function tests, frequency of laboratory draws, and thyroid supplementation administration. RESULTS: Six neonates with giant omphaloceles were treated with povidone-iodine. Thyroid function testing occurred weekly as inpatients and monthly as outpatients, with abnormal values normalized by the subsequent laboratory draw. One patient demonstrated persistent hypothyroidism and subsequently died secondary to cardiac complications, but this infant's newborn thyroid screening suggested congenital hypothyroidism. Five patients remained euthyroid and ultimately achieved fascial closure without the need for a prosthetic implant. None of these patients had abnormal outpatient thyroid tests nor did they require thyroid hormone supplementation. CONCLUSION: Topical povidone-iodine promotes escharification and epithelialization of the omphalocele sac. Because transient hypothyroidism may occur, thyroid function studies may guide inpatient therapy. After sac desiccation, systemic effects of iodine are minimal and thyroid supplementation is not necessary. Topical povidone-iodine is an effective initial strategy for giant omphaloceles and does not produce clinically significant hypothyroidism.

Management of ventral hernia after giant exomphalos with external pressure compression using helmet device.

PURPOSE: The aim of this study was to evaluate an alternative technique of reducing a ventral hernia that follows the primary conservative treatment of a giant omphalocoele. METHODS: The patient is a full-term male neonate with a giant exomphalos. Initially triple dye was applied as an eschar-inducing agent. This resulted in a ventral hernia after 1 month. It was decided to achieve expansion of the abdominal cavity based on the principle of external pressure compression using a sphygmomanometer cuff over the hernia. The cuff was worn continuously, and manual pressure was applied daily. Care was taken to avoid intraabdominal hypertension using the reading of the manometer that was attached. The external pressure was corroborated with observations of respiration and circulation. RESULTS: The child did not show any ill effects of raised intraabdominal pressure. Throughout the treatment, the child was on full oral feedings and did not require any ventilator support. Reduction of the ventral hernia was achieved in 9 months. Surgical repair of the residual hernia defect was carried out by double breasting of the fascia. CONCLUSIONS: The application of controlled external pressure using a specially constructed device is a safe, noninvasive, and effective method of achieving reduction of a ventral hernia after primary conservative treatment of a giant omphalocoele.

A novel technique to treat ruptured umbilical hernias in patients with liver cirrhosis and severe ascites.

The full-thickness skin erosion (rupture) of an umbilical hernia in a patient with end-stage liver disease can lead to significant morbidity and mortality. Here, we present a case report of the use of a novel technique to treat a patient with this condition. The use of a fibrin-based tissue adhesive provides a means of managing such patients medically.

Spontaneous rupture of infantile umbilical hernia: report of three cases.

Three Nigerian infants with spontaneous rupture of an umbilical hernia are described. In two, hernias developed in the neonatal period following umbilical sepsis. Rupture occurred at the ages of 2 and 3 months, respectively, and was probably precipitated by raised intra-abdominal pressure resulting from excessive crying. The third child had a large, ulcerated umbilical hernia which ruptured at 10 months and was precipitated by damage to the overlying skin. The children were treated successfully.

PIP: Umbilical hernia is common in African children and accounts for 8.7% of pediatric external abdominal hernias in the Department of Surgery at Ahmadu Bello University Teaching Hospital, Zaria, Nigeria. The condition develops from failure of the fresh umbilical wound or weak scar to withstand the stress of raised intra-abdominal pressure associated with coughing, vomiting, or defecation in early life. Umbilical hernia is remarkably free from complications, with the most common being incarceration. 3 Nigerian infants who presented to the hospital between 1983 and 1996 with spontaneous rupture of an umbilical hernia are described. In 2 cases, hernias developed during the neonatal period following umbilical sepsis. Rupture occurred at ages 2 and 3 months, respectively, and was probably precipitated by raised intra-abdominal pressure resulting from excessive crying. The third child had a large, ulcerated umbilical hernia which ruptured at age 10 months and was precipitated by damage to the overlying skin. All cases were treated successfully.

Use of mercurochrome in the management of the large exomphalos.

The topical application of solutions containing mercury has remained popular in the conservative management of the large exomphalos, despite recent reports of high organ mercury levels occurring in neonates who have died following this type of treatment. There are few reports of mercury poisoning being recognized in survivors. This report records blood and urine mercury levels in four patients with no apparent sequelae after treatment with Mercurochrome and provides guidelines for the safer use of mercurial solutions in the conservative management of exomphalos: one thin application of 1% Mercurochrome be applied to the intact sac; thereafter, Mercurochrome be applied sparingly only to areas that remain moist; blood and urine levels of mercury be monitored routinely; and applications ceased whenever mercury levels exceed the minimum toxic level. Only with this sparing and judicious use of mercurial solutions is the hazard to the infant kept to a minimum.