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.

Endoscopic vs laparoscopic paediatric gastrostomies: Time to change our practice?

BACKGROUND: Gastrostomy insertion is a common procedure for paediatric surgeons, with the percutaneous endoscopic gastrostomy (PEG) technique long favoured for its simplicity and speed. However, there is growing evidence to suggest that primary laparoscopic balloon gastrostomy (LBG) insertions may have lower complication rates. This study aimed to determine the relative safety and healthcare resource burden of PEG and LBG. METHODS: A retrospective review of all primary gastrostomy insertions (2011-2019). Primary outcome measures included return to theatre for emergency laparotomy and healthcare burden (total gastrostomy-related admissions, length of stay and total theatre utilisation). RESULTS: 338 PEGs and 277 LBGs were inserted with a minimum follow-up period of six months. Following PEG insertion 12/338(3.6%) children required an emergency laparotomy for gastrostomy-related complications. This compared to 2/277(0.7%) following LBG insertion (ARR2.8% (95%CI0.6-5.0), p < 0.0267). When considering all gastrostomy related admissions, there was no significant difference in total theatre utilisation (PEG = 85 [IQR58-117] minutes, LBG = 86 [IQR75-105] minutes, p = 0.12). However, PEGs were found to have an overall longer length of stay 4 [IQR3-7] vs 3 [IQR2-4] days. CONCLUSIONS: LBGs carry a significantly lower rate of major complications and are not associated with an increased healthcare burden. LBG should be considered as the first line method of gastrostomy insertion in children.

Combined creatinine velocity and nadir creatinine: A reliable predictor of renal outcome in neonatally diagnosed posterior urethral valves.

INTRODUCTION: Nadir creatinine (lowest creatinine during the first year following diagnosis) is a recognised indicator of future chronic renal impairment (CRI) in posterior urethral valve (PUV) patients. We recently described "creatinine velocity" (Cvel), the rate of change of creatinine following initial bladder drainage, as a new early predictor of CRI in neonatally diagnosed PUV. Rising Cvel (>3 µmol/L/day) is associated with increased risk of CRI. OBJECTIVE: We studied these two prognostic indicators in combination, as a test for future CRI in neonatally diagnosed PUV patients. STUDY DESIGN: Medical records for patients treated by endoscopic valve ablation at our institution between 1993 and 2004 were reviewed. Simple linear regression was used to calculate Cvel. Creatinine velocity and nadir creatinine were considered predictive of future CRI if they were greater than 3 µmol/L/day or greater than 75 µmol/L (0.85 mg/dL), respectively. Chronic renal insufficiency was defined as CKD2 or higher. Outcomes in test groups were analysed by Fisher exact test. Statistical significance was defined as p < 0.05. RESULTS: Sixty-two patients were treated within the first 30 days of life and had sufficient data to calculate both Cvel and nadir creatinine. Mean follow-up was 9.4 years. Patients were grouped as having both risk factors (Group A), one risk factor (Group B), or neither risk factor (Group C). All four (100%) patients from Group A developed CRI, compared with 11 of 17 (64.7%) patients from Group B and three of 41 (7.3%) patients from Group C (p ≤ 0.0005). As a diagnostic test for future CRI, "presence of at least one risk factor" had a specificity of 86.4%, sensitivity of 83.3%, positive predictive value of 71.4%, and negative predictive value of 92.7%. Additional prognostic information was obtained by assigning a score from 1 to 3 for each prognostic indicator (Table). The sum of these scores gave a PUV Risk Score. No patient with a PUV Risk Score of 2 developed CRI, while all patients with a Score of 6 developed CRI. Incidence of CRI in patients with PUV Risk Scores of 3, 4, and 5 was 8.3%, 50%, and 63.6%, respectively (p ≤ 0.0005). CONCLUSION: Considered together, these prognostic indicators provide a powerful test for future CRI. Presence of at least one of these risk factors should be considered "at risk for CRI". Patients with neither risk factor are unlikely to develop CRI. Calculation of the PUV Risk Score provides an even more accurate prognosis.

Posterior urethral valves: creatinine velocity, a new early predictor of renal insufficiency.

AIM: Antenatal screening has led to early detection of posterior urethral valves (PUV). However, despite early intervention, a proportion of children will develop chronic renal insufficiency. We studied the trend of serum creatinine following urinary tract decompression during the neonatal period in infants as a possible predictor of chronic renal insufficiency. METHODS: Patients treated by endoscopic resection of posterior urethral valves between 1993 and 2004 were identified. From these, infants treated within the first 30 days of life were identified. Serum creatinine values taken within the first 5 days following initial drainage were recorded. A creatinine velocity for each patient was calculated by linear regression analysis. Creatinine was considered rising if velocity was >3 µmol/L/day, or falling if velocity was <-3 µmol/L/day. Chronic renal insufficiency was defined as CKD2 or higher. RESULTS: Sixty-four neonates had decompression of the urinary tract. Of these, 16 had rising creatinine despite drainage, 10 had a plateau in creatinine level, and 36 had falling creatinine following drainage. Insufficient data were available in two to calculate creatinine velocity. Progression to renal insufficiency was significantly higher in patients with an initial rise in creatinine (62.5%) than in those with plateau creatinine (40%) or falling creatinine (8.6%) (P ≤ 0.0005 by Fisher exact test). Mean follow-up was 9.2 years. CONCLUSIONS: Rising creatinine, even transiently, following urinary tract drainage in neonates with posterior urethral valves is significant and is a new and important indicator of long-term prognosis.