Measurement of testicular blood flow at orchiopexy with a solid state laser.

We have evaluated the solid state laser as a means of determining testicular blood flow at operation. A solid state laser was used to measure blood flow before mobilization of cryptorchid testes, and subsequently after mobilization and placement within a subcutaneous scrotal pouch. Testicular volume was calculated. The median blood flow (ml/100 gm/min) before mobilization was 8.96 (range, 3.43 to 27.2). After mobilization a modest rise to 9.39 (range, 1.82 to 23.75) occurred, which was not statistically significant. However, heterogeneity existed in the response; 11 testes showed a median fall of 8.07 (range, 1.59 to 15.36), which was significant compared to the initial value; 16 testes showed a variable degree of hyperemia with a rise of 2.57 (range, 0.1 to 12.7), which was also significant compared to the initial value; two testes showed no change. The testes that showed a fall in blood flow were all high abdominal testes, which required the most mobilization. The mean testicular volume was 0.38 cc (SEM, 0.03 cc). No difference was noted in size between testes with a net rise in blood flow (mean volume, 0.38 cc) and testes with a net fall in blood flow (mean volume, 0.375 cc). No relationship was noted between testicular size and blood flow. We conclude that the solid state laser is a simple means of measuring testicular blood flow at orchiopexy and may provide a method of deciding which testes should undergo microvascular replantation on the basis of inadequate perfusion per-operatively.

Scrotal fixation: a different surgical approach in the management of the low undescended testes.

OBJECTIVES: To evaluate the feasibility of using the scrotal approach in patients with undescended testes. METHODS: Over an 18-month period, 165 patients were diagnosed to have 208 undescended testes. Of these, 28 were nonpalpable. RESULTS: At exploration, 7 testes were abdominal, 33 were canalicular, 165 were in the region of the external ring/pubic tubercle, and 1 was perineal. There were 2 cases of unilateral monorchism. The operative procedure performed was as follows: orchiectomy for 6 abnormal testes, orchiopexy for 142, and scrotal fixation (SF) for 58. (In this series, 9 patients were converted from SF to an orchiopexy at the time of the initial operative procedure.) SF involves a scrotal incision extending down to the tunica vaginalus. The cord is then mobilized from below, after which the testis is placed in an extra-dartos pouch. CONCLUSIONS: Our study has shown that there are a significant number of undescended testes that lie in the region of the pubic tubercle, lack a hernial sac, and can be managed by a scrotal mobilization alone. Based on our experience with SF, we have used a simple classification of undescended testis that has therapeutic and prognostic justifications.

Biliary and anorectal atresia.

This is a report of a unique case of biliary and rectal atresia.

Bilateral megaureters presenting as an inguinal hernia.

A 4-week-old male presented with a swelling in the right groin. At herniotomy a megaureter was discovered and a subsequent IVU demonstrated bilateral megaureters.

Simultaneous symptomatic biliary and renal calculi in a child.

We report on the unusual finding of both symptomatic biliary and renal calculi in a child. A review of the literature failed to provide any definite common etiologic factors, although the possible role of systemic infection cannot be ruled out.

Acute pancreatitis and gastric volvulus occurring in a congenital diaphragmatic hernia.

Many complications are known to occur in association with congenital diaphragmatic hernia. Acute pancreatitis in this situation is very rare. A case is reported and guidelines are given for the management of this complication.

Esophageal pH monitoring for gastroesophageal reflux: a United Kingdom study.

Esophageal pH monitoring is the accepted standard for the investigation of gastroesophageal reflux (GER) in adults. A postal questionnaire was sent to 912 United Kingdom paediatric physicians & surgeons. Five hundred forty-seven (61%) replied, with 124 (22.7%) currently using the technique, mostly in conjunction with barium swallow and/or esophagoscopy. The use of pH monitoring to quantify GER was also accepted in principal as being the best determinant of reflux by a further 186 (34%), but as yet was unavailable in their hospitals. Pediatricians were also questioned as to their management of children with GER. The majority were treated medically with a variety of antireflux medication, with only 237 (42%) referring cases for surgery.

Congenital small bowel diverticulosis and intestinal atresia: a rare association.

An unusual case of multiple intestinal atresias with multiple small bowel diverticulae is presented. To the best of our knowledge this is the first reported case of its kind in the literature.

Short-bowel syndrome: a collective review.

Neonates can now be expected to survive with very short lengths of bowel because of advances in pediatric neonatal care and in parenteral and enteral nutrition. Most pediatric surgeons have only a few patients with this problem under their care, so individual experience is limited. This collective survey, carried out by postal questionnaires to pediatric surgeons in the British Association of Paediatric Surgeons in the United Kingdom with an interest in the gastrointestinal tract, documents current techniques of management, the complications encountered, and reviews the clinical and economic consequences of prolonged total parenteral nutrition. We conclude that within the limitations of resources and our understanding of prognosis, neonates, especially if less than 35 weeks' gestation, with remaining jejunoileal segment of greater than 20 cm with an intact ileocecal valve (ICV) or greater than 30 cm without an ICV, should be considered salvageable.

Perioperative prophylaxis with sulbactam and ampicillin compared with metronidazole and cefotaxime in the prevention of wound infection in children undergoing appendectomy.

Sulbactam is a beta-lactamase inhibitor, which when administered with ampicillin, increases the latter agents antibacterial activity against beta-lactamase producing organisms. One hundred children between the ages of 5 and 14 undergoing emergency appendectomy were entered into a prospective randomized trial comparing sulbactam and ampicillin (SA) with metronidazole and cefotaxime (MC) as prophylaxis against postoperative wound infection. Patients in whom the appendix was perforated or gangrenous received a 72-hour course of antibiotics, others received a single dose only. The overall wound infection rate was 8% (14% in patients with perforation or gangrene and 4% in those without). There was no difference in infection rate between the two antibiotic groups; there were three wound infections and one subphrenic abscess in patients receiving SA and four wound infections in patients receiving MC. SA, therefore, appears to be a suitable antibiotic combination for use as prophylaxis in appendicitis in children.

Ambulatory esophageal pH monitoring in children as an indicator for surgery.

Twenty-four-hour esophageal pH monitoring was performed in 59 children with symptoms of gastroesophageal reflux using a miniature pH electrode and a portable recording system to establish the diagnosis. Significant reflux was seen in 26 (44%) of the patients and these were treated for six weeks with cimetidine, Gaviscon, and Nestargel. Five children who did not improve either symptomatically or on repeat pH monitoring while on treatment underwent antireflux surgery. The pretreatment reflux index in this group was 26.5 compared with a pretreatment reflux index of 11.2 in the 21 patients who improved on therapy (P less than 0.01). Esophageal pH monitoring has enabled selection of children for surgery and may be used as an early indicator of those who will not benefit from long-term medical therapy. Ambulatory and home monitoring techniques are more convenient and cost-effective and allow studies to be performed in the normal home environment.

The operative management of posterior urethral valves.

The surgical management of posterior urethral valves remains controversial. To examine the effects and results of operative treatment in boys with proven posterior urethral valves, a retrospective study was undertaken. The case records of 33 male children who presented with posterior urethral valves over a 10-year period were reviewed. Two patients died prior to definitive treatment and one died postoperatively. Following resuscitation and diagnostic procedures, the remaining patients had eradication of the posterior urethral valves by electrothermic fulguration. In 14 patients this was performed using the Innes-Williams diathermy hook under control of contrast enhanced radiography. In 16 patients the valves were fulgurated under direct cystoscopic visualization. All surviving patients had an uneventful postoperative recovery. However, of those undergoing cystoscopic fulguration, four developed symptomatic urethral strictures necessitating repeat cystoscopy and urethral dilatation. No cases developed strictures following the use of the diathermy hook. One patient from each treatment group developed dribbling. The Innes-Williams diathermy hook has been proven to be a safe, simple, and inexpensive technique. This has specific application in the neonate and small infant where cystoscopy poses technical problems because of anatomic size and where potentially traumatic urethral instrumentation should be avoided.

Wilms' tumor: a 25-year review of the role of preoperative chemotherapy.

PURPOSE: This 25-year population based, single institution review was conducted to investigate the impact of preoperative chemotherapy on surgical and histological staging in patients with Wilms' tumors. RESULTS: Forty-nine patients under the age of 15 years were identified from case notes to have had histologically verified Wilms' tumors over the 25-year period from January 1972 to December 1996. Twenty-six patients were treated initially with preoperative chemotherapy, 23 with immediate surgery. Eleven had treatment randomized within the UKCCSG WT9101 trial (UKWT3), and the remainder received initial treatment according to unit policy. Surgical stages in the two groups (preoperative chemotherapy and immediate surgery) were respectively, stage 1:14(28.5%) and 11 (22.5%), stage II: one (2%) and eight (16.3%), stage III: 11 (22.5%) and four (8.2%). Seven patients had clinical stage IV disease at presentation. Histology results were favorable in 45 patients and unfavorable in four. All patients received chemotherapy during treatment, whereas 25 (51%) also received radiotherapy. No significant difference was evident in the two groups with respect to treatment-related morbidity. Five patients relapsed, three of whom died within the period of review, but a fourth has since died. CONCLUSIONS: This study suggests that the use of preoperative chemotherapy does not put the patient at increased risk of postoperative morbidity or reduced survival. The distribution of surgical stages suggests that limited tumor downstaging may have occurred as a result of preoperative chemotherapy.

Second primary tumour following retinoblastoma.

Reported is a child who at the age of 18 months had presented with a left retinoblastoma. The lesion had involved the optic nerve (Stage IV), and was successfully treated by enucleation and radiotherapy. The radiation field did not include the mandible or the submandibular triangle. He was followed up until he left the area aged 11 years. He represented aged 12 years with a progressive swelling of the left submandibular gland. Histology of the surgically excised submandibular gland revealed a mucoepidermoid carcinoma of the submandibular gland. This case highlights the need for continual surveillance in survivors of retinoblastoma, as second primary tumours occur both within and outside of previous radiation fields. The clinical association between retinoblastoma and mucoepidermoid carcinoma of the submandibular gland has not been previously reported.