The use of botulinum toxin in the acute management of symptomatic complex incisional hernia: a case series.

PURPOSE: Complications of incisional hernia are amongst the commonest presentations to the emergency surgical take. Outcomes from emergency hernia repair are poor, particularly for those with complex defects and for the growing population of comorbid, high-risk patients. Attempts to avoid emergency surgery by improving success rates of non-operative management could prove hugely beneficial. Botulinum toxin A (Botox) is already used in the elective management of incisional hernia and this study evaluates if the relaxation produced could be used to augment the outcomes of conservative management of acutely presenting incisional hernia. METHODS: Patients presenting between October 2020 and April 2022 without evidence of visceral ischaemia, who had been selected for a non-operative approach, were given 300 units of Botox under image guidance to the abdominal wall in addition to standard conservative measures. RESULTS: Twelve patients were eligible for Botox administration. Median age was 75 years and median BMI was 36.45 kg/m2. All patients were high risk; minimum ASA score was 3, and median frailty score was 5. In ten patients, symptoms resolved following Botox allowing for discharge without further complication. Seven subsequently referred on to the abdominal wall team. Symptoms did not settle in the two remaining patients; one required emergency laparotomy and the second was palliated. CONCLUSION: Botox may be a useful adjunct to established non-operative measures in patients with acute presentations of incisional hernia. It may improve the acute symptoms, eliminate the need for high-risk emergency surgery, or provide a bridge to abdominal wall reconstruction.

Sensory wellbeing workshops for inpatient and day-care patients with anorexia nervosa.

BACKGROUND: The wellbeing of patients with eating disorders is one of the priorities in the "bigger picture" of treatment for eating disorders. Sensory soothing strategies for sensory sensitivities are supportive tools which could be useful in day-care and inpatient clinical programmes. METHODS: Evaluation of multiple separate sensory wellbeing workshops consisting of psychoeducation and experiential components delivered in inpatient and intensive day-care services was performed. Participants' self-report questionnaires were evaluated pre- and post-workshop. Additionally, patients' comments and qualitative feedback was collected after completion of the workshop. RESULTS: There was strong evidence that self-reported awareness of sensory wellbeing, awareness of strategies to enhance sensory wellbeing, and confidence in managing sensory wellbeing increased after the workshops with positive qualitative feedback from participants. The feedback questionnaires highlighted that patients found the sessions useful and were able to use some of the skills and strategies they learned in the workshop. CONCLUSION: This pilot work on sensory wellbeing workshops with a protocol-based format was feasible and beneficial for the patient group. Preliminary evidence suggests that delivery of similar workshops could be sensible in addition to treatment as usual in inpatient and day-care programmes.

Retained central venous lines (CVLs) after attempted removal: an 11-year series and literature review.

BACKGROUND: Central venous lines (CVLs) are frequently used in the management of many neonatal and pediatric conditions. Failure to remove the luminal part of the line (retained CVL) is rare. Consequently, there is lack of experience and consensus in its optimal management. AIM: To document the incidence and management of retained CVLs in a tertiary pediatric surgical centre with access to interventional cardiology services. To review the literature and report efficacy/morbidity of attempted extraction of retained CVLs. METHODS: Children with retained CVLs were identified from departmental morbidity and mortality records over an 11-year period. A literature search was performed in PubMed and Scopus to identify studies reporting retained CVLs (earliest date to 1 January 2012). This was supplemented by scanning bibliographies of retrieved articles. RESULTS: The 11-year incidence of retained CVL was 0.3% (n=10; median duration in-situ 66.5 {range 47-146} months). The underlying pathology in 8 was cystic fibrosis. Antegrade transfemoral snare retrieval was successful in 6 of 7 attempts. In the remaining 3, a conservative approach was adopted following consultation with the family. None of the 4 with retained CVL developed complications (median follow-up 7.5 {range 1-53} months). The literature describes 38 pediatric index cases (including 10 from the current series). Seventeen (49%) were managed conservatively either intentionally or by default after failed endovascular removal attempt (n=4). No complications directly attributed to retained CVLs have been reported (median follow-up 40 {range 1-120} months). Reported morbidity associated with endovascular retrieval includes: procedural failure 30%, line embolization 8%, and intra-operative thrombo-embolism 8%. CONCLUSION: Literature regarding management of retained CVLs is anecdotal. Although uncommon, the complication should feature in consent for removal of CVLs. Conservative management carries long-term risks of infection, thrombosis, and even migration, albeit unquantified over a child's lifetime. Endovascular retrieval is feasible with appropriate expertise.

Infections in gastroschisis: organisms and factors.

This study aimed to define the incidence, causative organisms and predisposing factors leading to infection related morbidity in newborns with gastroschisis. All gastroschisis patients admitted over the 5-year period (1999-2004) were retrospectively reviewed. Surveillance samples, wound, blood, urine and fecal cultures were analyzed. Duration of total parenteral nutrition, antibiotic therapy, feeding regimes and demographic data were also analyzed. Multiple logistic regression was employed using the SPSS system and p < 0.05 was considered as significant. Seventy-two neonates were identified with 53% having abnormal gut carriage mostly due to Enterobacter and Klebsiella. Wound infection occurred in 20% of cases. Abnormal gut carriage predisposed to the development of wound infection. Line sepsis occurred in 21% of neonates. Endogenous coagulase negative Staphylococcus caused 74% of septic episodes. There was no correlation between abnormal gut carriage and the development of line sepsis. Overall survival was 96%. The cause of infections in gastroschisis patients appears to be multifactorial. A multidisciplinary team can play an important role in reducing the incidence of infections. Strict aseptic protocols and auditing practice can be the invaluable tools in decreasing morbidity rates.

Surgical strategies in the management of ecthyma gangrenosum in paediatric oncology patients.

Clinical presentation and microbiology profiles of neutropenic paediatric oncology patients presenting with ecthyma gangrenosum (EG) were studied. Surgical strategies deployed for these critically ill children are reported. Between 1994 and 2005, all children with EG were identified. Case notes were reviewed. Hospital course and long-term outcome were documented. Ten patients were identified. Eight had acute lymphoblastic leukaemia, one child had acute myeloid leukaemia and another had rhabdomyosarcoma. Lesions occurred in the perineal region (n = 5), buttocks (n = 2), thigh (n = 2) and the face (n = 1). Seven children had positive blood cultures for Pseudomonas aeruginosa. Surgery included (1) radical debridement, and (2) debridement with covering colostomy for four of those with perianal lesions. Ecthyma gangrenosum is a rapidly spreading and potentially lethal condition. Paediatric oncology patients with neutropenia are at a high risk. Surgical excision is crucial for progressive lesions to prevent mortality.

Less is best? The impact of urokinase as the first line management of empyema thoracis.

To assess the impact of intrapleural urokinase and small tube thoracostomy on the management of childhood empyema thoracis. The study population included 38 children presenting consecutively to a regional surgical unit with empyema thoracis from January 2001 to December 2003. Children with malignancy, immunodeficiency and complex intercurrent illness were excluded. Primary outcome variables were the need for second intervention and duration of stay, with other variables including duration of antibiotics, serial CRP and amelioration of pyrexia. Interventions were: tube thoracostomy (16-20 Fr) alone (n=2), tube thoracostomy (6-10 Fr)+urokinase (n=17), thoracoscopy (tube: 20-24 Fr) (n=9), thoracotomy (tube: 16-24 Fr) (n=10). There were no differences in age, weight or length of prodromal symptoms, between treatment groups. There were no differences in primary outcome variables, although no child undergoing thoracotomy required further intervention. The duration of intravenous antibiotics was similar in all groups. Amelioration of pyrexia was more rapid in children undergoing thoracotomy. There were no differences seen with regard to decline in CRP level. Small tube thoracostomy and intrapleural urokinase had a similar outcome to more invasive therapies such as thoracotomy or thoracoscopy thereby supporting the evidence base for urokinase and tube drainage as first line intervention.

Surgical management of inflammatory bowel disease.

AIM: To evaluate the outcome and morbidity after major surgical interventions for inflammatory bowel disease (IBD). METHODS: Retrospective case note analysis of 227 children referred to a tertiary referral centre between 1994 and 2002 for treatment of IBD. RESULTS: 26 of 125 children with Crohn's disease (21%) required surgical management. 13 with disease proximal to the left colon underwent limited segmental resections and primary anastomosis, without significant morbidity. Primary surgery for 13 children with disease distal to the transverse colon included 6 subtotal-colectomies or panprocto-colectomies. All seven children undergoing conservative segmental resections (three with primary anastomosis, four with stoma formation), required further colonic resection or defunctioning stoma formation. All three children undergoing primary anastomosis developed a leak or fistula formation. 22 of 102 children with ulcerative colitis (22%) required surgery. Definitive procedures (n = 17) included J-pouch ileoanal anastomosis (n = 11), ileorectal anastomosis (n = 2), straight ileoanal anastomosis (n = 3), and proctectomy/ileostomy (n = 1). Five children await restorative surgery after subtotal colectomy. Median daily stool frequency after J-pouch surgery was 5 (range 3-15), and 10 of 11 children reported full daytime continence. All three children with straight ileoanal anastomosis had unacceptable stool frequency and remain diverted. CONCLUSION: The complication rate after resectional surgery for IBD was 57% for Crohn's disease, and 31% for ulcerative colitis. In children with Crohn's disease, limited resection with primary anastomosis is safe proximal to the left colon. Where surgery is indicated for disease distal to the transverse colon, subtotal or panproctocolectomy is indicated, and an anastomosis should be avoided. Children with ulcerative colitis had a good functional outcome after J-pouch reconstruction. However, the overall failure rate of attempted reconstructive surgery was 24%, largely owing to the poor results of straight ileoanal anastomosis.

The efficacy of topical hyaluronic acid in the management of recurrent aphthous ulceration.

BACKGROUND: The aim of this study was to evaluate the efficacy of a topical hyaluronic acid (HA) preparation (0.2%) in the management of recurrent aphthous ulceration (RAU). METHODS: One hundred and twenty patients with RAU participated in a randomized, placebo controlled, double-blind trial to evaluate the efficacy of the topical HA and preparation. Outcome measures include soreness relief on immediate application (recorded over 60 min). Thereafter, patients completed a log diary recording soreness from the ulcers, occurrence of new ulcers and ulcer duration. RESULTS: Both topical HA and placebo resulted in a significant reduction in ulcer soreness following immediate application (P = 0.0004). Throughout the rest of the investigation period, there was no significant differences (P > 0.05) between the treatments for reducing soreness. Patients treated with topical HA recorded few ulcers on day 5 of the investigation than those treated with placebo (P < 0.001). Likewise, the occurrence of new ulcers was lower in the HA treated group on day 4 when compared with placebo (P = 0.047). CONCLUSION: Topical HA (0.2%) may be of benefit in the management of RAU. Immediate reduction of symptoms appears to be a barrier effect.

Surgical implications of the Smith-Lemli-Opitz syndrome.

Smith-Lemli-Opitz syndrome (SLOS) is a syndrome of rare multiple congenital anomalies/mental retardation associated with low plasma cholesterol levels. Prior to receiving the diagnosis of SLOS, affected children may present as a neonatal surgical emergency with ambiguous genitalia, Hirschsprung's disease, and pyloric stenosis. We present two fatal cases of SLOS with near-total Hirschsprung's disease; the surgical, anaesthetic, and medical aspects of the cases are discussed, and a literature review is presented.

Comparison of functional outcomes of Duhamel and transanal endorectal coloanal anastomosis for Hirschsprung's disease.

PURPOSE: The aim of this study was to determine the morbidity and medium-term functional outcome of the Duhamel operation and laparotomy and transanal endorectal coloanal anastomosis (TECA) for Hirschsprung's disease (HSCR). METHODS: The study populations were 34 consecutive children who underwent the Duhamel operation (or Lester Martin modification) and 37 who had the TECA. Demographic details were obtained by case note review, and functional outcome was determined by a combination of outpatient interview, questionnaire, and telephone enquiry. RESULTS: There was no difference between the groups with respect to age, gender, and length of aganglionic segment. Seventy percent presented as neonates (Duhamel, 24 of 34; TECA, 26 of 37). A single-stage primary pull-through was performed in 17 of 37 children in the TECA group, and in 1 of 34 from the Duhamel group. There was a single perioperative death in the Duhamel group and an unrelated, late death in the TECA group. Postoperative enterocolitis was seen in 13 of 37 TECA children and in a single child from the Duhamel group. A stricture of the pull-through segment was seen in 7 of 37 children after TECA and required temporary diversion in 2 of 9. Late division of a rectal spur was required in 6 of 33 Duhamel children. Requirement for late myectomy was the same in both groups (Duhamel 3 of 33, TECA 4 of 37). Complications requiring stoma formation occurred in 5 of 37 after TECA and 2 of 33 after the Duhamel operation. Two children from the TECA group and 1 from the Duhamel group remain diverted. One child from each group required a re-pull-through procedure. Two patients were lost to follow-up in the TECA group, leaving 34 children in this group and 33 in the Duhamel group in whom functional outcome could be assessed. Functional outcome was similar in the 2 groups. CONCLUSIONS: TECA and Duhamel procedures have similar medium-term functional outcomes. TECA has a high incidence of postoperative enterocolitis and transient stricture formation but is suitable for single-stage neonatal treatment of HSCR.

Colonic transit time--what is normal?

BACKGROUND: Constipation is a common problem in childhood, and various radiologic methods have been advocated for investigation. Colonic transit time (CTT) has been used in adults to investigate colonic motility, but few studies evaluate this method in children. Data on CTT in the normal paediatric population are scarce. METHODS: The colonic transit time was measured in 22 healthy children (median age, 10 years; range, 4 to 15 years) by Abrahamsson's method. Children took bolus ingestions of radiopaque markers on 6 consecutive days, and on day 7 a single abdominal x-ray was performed. This was evaluated for total and segmental colonic transit time. RESULTS: The mean total CTT was 40 hours, and the upper limit of normal (95th percentile) was 84 hours. The upper limit of normal for segmental transit time was as follows: 14 hours for the ascending, 33 hours for the transverse, 21 hours for the descending, and 41 hours for the rectosigmoid colon. CONCLUSIONS: CTT provides an objective measure to assess childhood constipation. To date, 6 studies using 5 different methods have been published reporting values for healthy children. Comparing these, Abrahamson's method has low radiation exposure and is well tolerated. This study contributes additional normal values in children.

After the honeymoon--medium-term outcome of antegrade continence enema procedure.

PURPOSE: The aim of this study was to determine medium-term outcomes of the antegrade continence enema (ACE) procedure. METHODS: A retrospective casenote review plus telephone questionnaire was conducted. The study was performed at a regional paediatric surgical centre. The subjects were consecutive children undergoing the ACE procedure over a 5 year period. Main outcome measures were use of the ACE; reversal rates; complications, ease of use, effectiveness, and satisfaction scores. Data are expressed as median (range). RESULTS: Thirty-two (52%) of 62 children undergoing the ACE procedure were girls. The age at the time of operation was 11.5 (3.8 to 17.6) years. Underlying diagnoses included spina bifida (n = 31), anorectal malformations (n = 15), slow-transit constipation (n = 9), Hirschsprung's disease (n = 2), sacral agenesis (n = 2), and trauma/tumour (n = 2). Median follow-up was 5.4 (3.25 to 8.25) years. Eleven of 62 (18%) children were no longer using the ACE (n = 5) or had it surgically reversed (n = 6; 14.1 +/- 9.3 months postprocedure). Reasons for disuse/reversal were lack of effectiveness (n = 4), complications (n = 2), noncompliance (n = 3), independent continence (n = 1), and pain (n = 1). Five (8%) children currently have a colostomy. Gender (P =.31; Fisher's Exact), age (Pearson), and underlying diagnoses (P =.07, Chi2) were not predictors of failure. Overall, stomal stenosis was the most common complication, affecting 26 of 62 (41%) children. Of 32 questionnaire respondents to linear scores, ease of use was rated as 2 (0 to 8, 0, very easy; 10, very difficult), discomfort on use as 3 (0 to 9; 0, no pain; 10, very painful), overall satisfaction as 9 (0 to 10; 0, completely dissatisfied; 10, completely satisfied). Eighty-four percent were completely continent or had soiling less than once a month. There was a significant correlation between the level of continence and satisfaction with the procedure (P =.04; Pearson). CONCLUSIONS: The ACE procedure offers significant benefits to some children with incontinence or intractable constipation. However, it is not universally successful, and other continence promoting strategies may need to be considered.

Impact of age, submersion time and water temperature on outcome in near-drowning.

BACKGROUND: Because children have less subcutaneous fat, and a higher surface area to body weight ratio than adults, it has been suggested that children cool more rapidly during submersion, and therefore have a better outcome following near-drowning incidents. AIM OF THE STUDY: To study the impact of age, submersion time, water temperature and rectal temperature in the emergency room on outcome in near-drowning. MATERIAL AND METHODS: This retrospective study included all near-drowning victims admitted to the intensive care units of Helsinki University Central Hospital after successful cardiopulmonary resuscitation between 1985 and 1997. RESULTS: There were 61 near-drowning victims (age range: 0.5-60 years, median 29 years). Males were in the majority (40), and 26 were children (<16 years). The median water temperature was 17 degrees C (range: 0-33 degrees C). The median submersion time for the 43 survivors (70%) was 10 min (range: 1-38 min). Intact survivors and those with mild neurological disability (n=26, 43%) had a median submersion time of 5 min (range: 1-21 min). In non-survivors the median submersion time was 16 min (range: 2-75 min). Submersion time was the only independent predictor of survival in linear regression analysis (P<0.01). Patient age, water temperature and rectal temperature in the emergency room were not significant predictors of survival. CONCLUSIONS: Although submersion time is usually an estimate, it is the best prognostic factor after a near drowning incident. Children did not have a better outcome than adults.

Use of videotapes for viewing at home to inform choice in Down syndrome screening: a randomised controlled trial.

A randomised trial was carried out to assess the effect of a Down syndrome screening video on test uptake, knowledge and psychological stress. A total of 2000 women referred for antenatal care were allocated to two equal groups: one to be sent a video to their home, before their hospital booking visit, and a control group. All women also received screening information in the form of a leaflet before booking and from a midwife at booking. The video had no effect on the screening uptake rate: 638/993 (64.2%) and 652/1007 (64.7%) in the video and control groups, respectively. Women were requested to return the video for reuse in other pregnancies and 612 (62%) did so. A subset of 1200 women were selected to be posted at 17-19 weeks' gestation a self-completed questionnaire to assess the psychological endpoints. Knowledge of screening was increased in the video group with a mean score of 7.3 compared with 6.7 in the controls, a statistically significant difference (t=3.24, p=0.0005). There were no significant differences between the groups in specific worries about abnormalities in the baby, and general anxiety. We conclude that a video can increase knowledge without affecting the uptake of the test, or psychological stress.

Mycotic aortic aneurysm in the newborn.

A fatal case of mycotic aneurysm of the aorta is presented. This was probably the consequence of umbilical artery catheterization. Unfortunately, the 29-weeks-old newborn died from septic complications.

Intubation and survival in severe paediatric blunt head injury.

The majority of severe childhood injuries are due to head injuries. We studied the impact of emergency intubation in a cohort of children suffering severe blunt head trauma. A 10-year retrospective case note analysis was performed on 176 children (age < 16 years) with severe blunt head trauma (abbreviated injury scale > or =4) in Southern Finland, who required intensive care in a level 1 trauma centre, or who died despite initiation of life supporting measures at the scene. Children in whom emergency intubation was performed either at the scene, or in the emergency room (ER) were analysed. Of the 59 children who fulfilled the study criteria, 20 had an isolated head injury. Most injuries (56/59) were caused by road traffic accidents. Field-intubation was performed in 24 children, and emergency intubation in the ERs of regional hospitals or the level 1 trauma centre, in 13 and 22 children respectively. Mortality was 54.2% (32/59), and was highest in children intubated in regional hospital ERs or in the field. Children intubated at the scene or in the ER of regional hospitals, had significantly worse AIS (head/neck), injury severity score (ISS), and Glasgow coma (GCS) scores than those children intubated in the ER of the level 1 trauma centre. Survival was better in field-intubated children compared with those intubated in regional hospital ERs, despite similar trauma scores (p = 0.05). It is concluded that although children with severe (AIS > or =4) head injury who require emergency intubation have a high overall mortality, field-intubation may improve survival, compared with 'scoop and run' with BLS airway management and deferred emergency intubation.

Paediatric anatrophic nephrolithotomy; stone clearance - at what price?

OBJECTIVE: To evaluate the functional outcome of anatrophic nephrolithotomy in children. PATIENTS AND METHODS: All children undergoing anatrophic nephrolithotomy for complex branching and multiple renal calculi over an 11-year period were studied prospectively. Demographic data, treatment details and outcome, as assessed by X-ray, ultrasonography and isotope studies, were recorded. Anatrophic nephrolithotomy was carried out with surface cooling of the kidney followed by nephrostomy drainage for 5-7 days. RESULTS: Nine children (median age 4 years, range 7 months to 9 years) underwent anatrophic nephrolithotomy. Predisposing factors included urinary tract infection (by Proteus mirabilis) in all and hyper-calciuria in two children. The median (range) total ischaemic time at operation was 25 (15-40) min and the operative duration 150 (120-200) min. Three children required a blood transfusion. Stone clearance was incomplete in one child. There was no recurrent stone formation after a long-term follow-up (median 32 months, range 14-107) in the other patients. Isotope studies showed impaired split renal function (<40%) in six children before surgery; there was a significant decline (>5%) in divided function in five children (range 6-16%) after surgery. CONCLUSION: Anatrophic nephrolithotomy is an effective means of rendering children with branching calculi stone-free, but this study suggests that it leads to some further parenchymal damage.

Two Less Common Causes of Headache in Systemic Lupus Erythematosus that May Require Specific Measures.

Headache is a frequent occurrence in patients with systemic lupus erythematosus (SLE). We present two cases of young women with headache and papilledema. One patient had this as a presenting manifestation of SLE, and the other had known active SLE. The first patient had a diagnosis of cerebral venous thrombosis, and the other pseudotumor cerebri. Both of these conditions are rare but have known associations with lupus. In the lupus patient with headache, it is essential that the clinician rule out these potentially treatable conditions by carefully taking a history and performing a physical examination as well as using ancillary investigations, including lumbar puncture, computed tomograph and magnetic resonance imaging as required. These uncommon causes of headache in the lupus patient must not be missed, because there is significant potential for morbidity, such as visual loss, or even mortality.