Delayed primary wound closure using skin tapes for advanced appendicitis in children. A prospective, controlled study.

In a 3-year period, 63 consecutive patients with advanced perforated (n=53) and gangrenous (n=10) appendicitis were allocated to undergo either immediate wound closure or delayed primary wound closure after emergency appendectomy. The incidence of wound infection between delayed primary wound closure and immediate wound closure was similar (24.0% and 21.1%, respectively). The duration for complete healing of infected wounds was slightly shorter in the group undergoing delayed primary wound closure (mean +/- SD, 24.3 +/- 9.2 days) than in the group undergoing immediate wound closure (mean +/- SD, 32.6 +/- 16.5 days), but the difference was not significant. However, healing of noninfected wounds was significantly prolonged in the group undergoing delayed primary wound closure (mean +/- SD, 19.3 +/- 10.1 days) compared with the group undergoing immediate wound closure (mean +/- SD, 7.0 +/- 0 days). The latter had been shown to associate with more nonseptic wound complications and therefore required longer rehabilitation. Our study showed that delayed primary closure did not offer additional advantage over immediate closure in the treatment of wounds associated with advanced appendicitis in children.

Case report: lingual thyroid, a cause of neonatal stridor.

Stridor implies partial airway obstruction, resulting from intrinsic or extrinsic abnormalities of the upper respiratory tract. In a neonate whose airway is small, soft and easily occluded this may be potentially life threatening. Its immediate diagnosis with prompt therapy is a rewarding challenge. When stridor occurs in a neonate with congenital hypothyroidism, surgically amenable cause of obstruction due to an ectopic thyroid or thyroglossal cyst has to be seriously considered. We report a case of neonatal stridor caused by a lingual thyroid, and discuss the imaging approach.

Ileoileocolic intussusception in children: diagnosis and significance.

The ileoileocolic type of childhood intussusception is difficult to diagnose pre-operatively and is associated with increased morbidity. This study describes the clinical and imaging features of 10 consecutive ileoileocolic intussusceptions diagnosed ultrasonically in 10 patients over a 36 month period. Ultrasound-guided hydrostatic reduction using Hartmann's solution was attempted in all 10 patients. Clinical and imaging features were compared with those of 28 ileocolic intussusceptions in 25 patients diagnosed and treated using the same methods during the same period. Most of the clinical and plain radiographic features of the patients with the ileoileocolic and ileocolic types of intussusception were similar. The two types of intussusception had the classical doughnut or pseudokidney, or both, signs on pre-reduction ultrasound scans. During the reduction process, when surrounded by fluid within the caecal lumen, the ileoileocolic type of intussusception had a typical complex appearance due to frond-like loops of intussuscepted small bowel. This finding was present in all cases. The hydrostatic reduction rate was only 10% (1/10) for ileoileocolic intussusception, compared with 92.9% (26/28) for the ileocolic type. All unsuccessfully-reduced cases underwent surgery, with surgical confirmation of the intussusception type in all cases. Only one patient was found to have a lead point, caused by a Meckel's diverticulum. In conclusion, the diagnosis of ileoileocolic intussusception can be made pre-operatively and these patients require surgical management.

Interposing fascial pedicle flap for the repair of urethral fistulae after hypospadias surgery.

A one-stage technique for the repair of urethral fistulae after urethroplasty for hypospadias is reported. A pedicle flap prepared from the facial layers of the scrotum is interposed between the urethra and the overlying skin. In the nine patients operated on, there was one failure, and it was due to postoperative hematoma formation. This technique is especially recommended for patients with multiple small urethral fistulae.

Training and delivery of pediatric surgery services in Asia.

PURPOSE: The purpose of this report is to obtain an overview of pediatric surgery training in Asia and to have a glimpse of its delivery. METHODS: A questionnaire survey was conducted, and the returns from 41 (67%) pediatric surgeons from 14 (88%) Asian countries were reviewed. RESULTS: The number of pediatric surgeons per million population is lowest in Indonesia (0.1) and highest in Japan (25). Two cities in China have 100 or more pediatric surgeons. The number of staff surgeons per center ranges from 1 to 36. Centers with 5 or fewer neonatal surgical operations per staff surgeon per year are located in Cambodia, China, and Japan, and centers with more than 40 neonatal surgical operations per staff surgeon per year are found in India, South Korea, Myanmar, and Thailand. There are centers in which more than 400 postneonatal pediatric surgical operations are performed per staff surgeon each year in Cambodia, India, Indonesia, South Korea, and Myanmar. After general surgery training, pediatric surgery training commonly lasts 2 to 3 years (71%). The shortest training period is 1 year in a center in 1 country to 5 or more years in a few countries. At the end of the training, a variety of exit examinations or assessments (clinicals, orals, written) are conducted in most countries. CONCLUSIONS: Pediatric surgery training programs in Asia are diverse. Clinical cases per trainee surgeon vary greatly. Although some countries have an adequate number of pediatric surgeons to deliver a high quality service, others are severely short staffed, and have huge caseloads, delivering pediatric surgical services under extremely difficult conditions. Governments subsidize the cost of surgical care in most countries (93%): self-payment is common (86%) and insurance is least practiced (64%).

Intestinal volvulus: an experience in a developing country.

Eighty-two children (47 boys and 35 girls) underwent surgery for a variety of causes resulting in volvulus. There were 20 neonates, 13 infants, 34 patients aged 1 to 5 years, and 15 children above 5 years of age. The majority (88%) of the patients were admitted in a state of shock and dehydration. Peritoneal signs were present in 74% of the patients. The resection rate was 61%. A high mortality rate of 38% was encountered, which was attributed to septicemia, shock, and multiorgan failure. The preventive health programs that are being actively implemented together with the improvements made in the transport and referral systems have fortunately resulted in much-improved survival rates in the recent few years.

Pediatric upper gastrointestinal endoscopy: a 13-year experience.

This report describes a series of 553 flexible upper gastrointestinal (GI) endoscopies performed on 382 children in two surgical centers between 1975 and 1987. Indications included abdominal pain (180), reassessment of known disease (149), upper GI bleeding (99), foreign body ingestion (77), vomiting (14), dysphagia (10), and miscellaneous (24). Findings were chronic peptic ulcer (47), gastritis/duodenitis (63), healing disease (92), nonhealing disease (22), recurrent disease (32), foreign body impaction (22), stricture (9), esophagitis (7), varices (7), mass (6 [3 polyp, 1 lymphoma, 1 fungus ball, 1 inflammation]), normal (209), and miscellaneous (37). Endoscopic diagnosis was uniformly correct except on two occasions, when the presence of recurrent tracheoesophageal fistula in small infants was missed due to use of an inadequate instrument. A pathologic lesion is likely to be identifiable in GI bleeding (84.8%). Endoscopic surveillance for progress of known disease was found to be valuable, particularly in peptic ulcer management, as both incomplete healing after standard therapy as well as recurrence are frequent. The recent practice of routine antral biopsy in children with severe "nonspecific abdominable pain" enabled four cases of Campylobacter pylori colonization in the stomach to be diagnosed, thus allowing appropriate treatment. Endoscopy was therapeutic on 61 occasions: injection sclerotherapy (32), foreign body removal (20), polypectomy (3), and stricture dilatation (6). Endoscopy-guided bougienage, in particular, represents a recent major advance. There was no morbidity or mortality in the entire series. It is concluded that pediatric upper GI endoscopy performed by experienced surgeons is safe and effective. As a result of better understanding and technological advances, a changing trend of wider and more rational applications of the procedure is now evident.

Pediatric surgeons can and should perform colonoscopy.

We describe our six-year experience in establishing a colonoscopy service in a pediatric surgical center in Hong Kong. A total of 65 colonoscopies on 60 children (aged 1 to 16 years) were performed, with the pediatric surgeon being the collaborator in the first 27 examinations and the endoscopist in the subsequent 38 examinations. Except on two occasions when bowel preparation was inadequate, all examinations were successful. General anesthesia was employed initially but with more experience, sedation alone (37 cases) was found to be adequate in most children and even in infants. Barium enema was available in 20 cases and had a low diagnostic accuracy in comparison to colonoscopy, being incorrect in six cases and inconclusive in one case. Therapeutic procedures with colonoscopy included removal of arteriovenous malformation (1) and polypectomy (37); 24 polyps were situated beyond the reach of rigid sigmoidoscopes and two patients had previous failed polyp removal by laparotomy in another hospital. There were no complications in our series. Our experience suggests that pediatric colonoscopy is a useful procedure that can be safely and effectively performed by pediatric surgeons after adequate training.

Gastric acid secretion and emptying rates in children with duodenal ulcer.

Gastric acid secretion was studied in 30 children with duodenal ulcer and 33 normal children. Both basal (BAO) and maximal (MAO) acid outputs were found to be significantly elevated in patients. In addition, among patients themselves, those with severe disease demonstrated significantly higher MAO than those with mild disease. A concomitant study on gastric emptying rates revealed no difference between patients and normal children.

Iatrogenic gastric volvulus during transposition for esophageal atresia: diagnosis and treatment.

A baby boy had had transhiatal gastric transposition for wide gap esophageal atresia in another hospital. Postoperatively, repeated vomiting, chest infection, and frequent attacks of dyspnea developed. After reexploration, the cause was not identified and he was referred to the authors' institution. The diagnosis of iatrogenic organoaxial volvulus with gastric outlet obstruction was made because barium meal studies and nuclear isotope scanning showed persistent obstruction of the gastric outlet but upper endoscopy showed no stenosis and a flexible scope could be passed easily into the duodenum. The diagnosis was confirmed by thoracotomy. After full mobilization of the stomach, the gastroesophageal anastomosis was divided and the thoracotomy was closed. The stomach was reduced into the abdomen via laparotomy, and it was tubularized and rerouted retrosternally for anastomosis to the cervical esophagus. Since the operation the patient has been asymptomatic.

Combined flexible endoscopy and fluoroscopy in the assessment of the gap between the two esophageal pouches in esophageal atresia without fistula.

The authors have used the technique of combined retrograde flexible endoscopy and fluoroscopy on two newborn babies with esophageal atresia (EA) without tracheoesophageal fistula (TEF). This technique accurately determined the gap between the two esophageal ends and predicted the feasibility and timing of delayed primary anastomosis. Esophagostomy was not performed, and continuous Replogle tube suction of the upper pouch was maintained during the period of waiting for 10 and 14 weeks, respectively. Gastrostomy feeding allowed satisfactory growth and development during the period of waiting for esophageal growth.

Surgical management of choledochal cysts: a review of 60 cases.

Sixty cases of choledochal cysts in children are reviewed. The series comprises 55 cases of Alonso-Lej. Type 1 cysts, two cases whose cysts were infraduodenal and retropancreatic in position, and three cases of choledochal cysts with both proximal and distal atresia of bile ducts. The following five types of operative procedures were employed for the 58 cases: (1) Choledochocystoduodenostomy in 12; (2) Partial excision, choledochorraphy and choledocho-duodenostomy in six; (3) Cyst excision, portal dissection and portojejunostomy in three; (4) Choledochocystojejunostomy Roux-en-Y in 20; and (5) Cyst excision with hepaticojejunostomy Roux-en-Y in 17 cases. Two patients did not receive definitive surgical treatment. Early complications included six cases of leakage, of which one died; and four cases of cholangitis and septicemia, resulting in fatality in all. The overall operative mortality was 5/58 (8.6%). This review, though retrospective in nature, further supports the more recent trend that radical cyst excision with hepaticojejunostomy is the treatment of choice. This procedure carried no mortality and low morbidity. All 17 patients treated in this manner are well and free from jaundice and recurrent cholangitis. Cyst excision eliminates the reservoir for bile stasis, biliary obstruction, cholangitis, and biliary cirrhosis. It also removes the possibility of malignant change in the cyst and spontaneous rupture.

Direct sagittal CT scan: a new diagnostic approach for surgical neonates.

Because of their small body size, neonates can be placed in the plane of the CT scanner gantry (aperture diameter 70 cm) instead of across it. This direct sagittal scanning technique allows accurate delineation of surgical lesions, particularly midline ones, unobtainable with conventional axial imaging. In addition, the sagittal image provides a perspective of anatomic arrangement more familiar to the surgeon than that provided by axial sections and therefore allows for easier interpretation. In imperforate anus, sagittal CT identifies the blind rectal end by the meconium tissue interphase and therefore avoids the pitfalls of invertogram, which depends on the bowel gas pattern for interpretation. With this new approach, we correctly classified six cases of imperforate anus into high types (3) and low types (3), visualized the associated fistula and had knowledge of the exact distance of the blind rectal end from the skin level preoperatively. In tracheoesophageal fistula (2), sagittal CT demonstrated the air-filled blind pouch and fistula to allow preoperative classification and assessment of the gap distance. In sacrococcygeal teratoma (3) and laryngeal cyst (1), its use allowed an accurate assessment of possible extension of the lesion into neighboring structures. Our experience with direct sagittal CT scan therefore suggests that this new and noninvasive technique is a useful adjunct in the management of a variety of common neonatal surgical problems.

Diagnosis of peptic ulcer in children: the past and present.

The problem of diagnosis of peptic ulcer in children was analysed in a series of 50 consecutive cases. Atypical symptomatology occurred frequently and resulted in errors in diagnosis in six instances: perforated ulcer was misdiagnosed as appendicitis in five and bleeding ulcer was misdiagnosed as Meckel's diverticulitis in one. Barium meal was the investigation employed in earlier years but had proven unsatisfactory, being incorrect in four out of 22 examinations. Fiberoptic endoscopy was introduced in recent years and having achieved correct diagnosis in 20 patients with no errors, has established itself as the choice of investigation.

Peptic ulcer in children.

From January 1983 to April 1989, 39 children were diagnosed as suffering from primary peptic ulcer. Of these ulcers, 30 were duodenal, seven prepyloric, and two patients had a combination of both. Among 36 patients with H2-blocker therapy, 33 had treatment completed with ulcer healing assessed by endoscopic examinations. Sixteen patients (49%) had ulcer healing within a single 6-week course of treatment, whereas 17 patients (51%) required multiple 6-week courses. The latter group had a mean basal acid output (BAO) of 0.13 +/- 0.06 mmol/kg/h and a mean maximal acid output (MAO) of 0.48 +/- 0.12 mmol/kg/h, which is significantly higher (P less than .05 and P less than .005, respectively) than the mean BAO (0.08 +/- 0.06 mmol/kg/h) and mean MAO (0.31 +/- 0.11 mmol/kg/h) in patients whose ulcers healed within 6 weeks of treatment. Subsequent follow-up with endoscopy over a mean period of 1.8 years (range, 3 months to 6 years) showed 10 patients with recurrent ulcers. Life-table analysis showed a recurrence rate of 35% within 1 year after ulcer healing. Five patients required surgery for ulcer complications--obstruction (2), perforation (2), and bleeding (1). In two of these patients initial H2-blocker therapy was unsuccessful.

Long-term follow-up of childhood duodenal ulcers.

PURPOSE: This study reports the long-term results in children who have duodenal ulcers diagnosed by endoscopy who were treated with H2-receptor antagonist. METHODS: The medical records of 32 children admitted into The Queen Mary Hospital with endoscopically proven duodenal ulcers between 1975 and 1988 were reviewed to evaluate the long-term outcome of childhood duodenal ulcers after initial treatment with H2-receptor antagonist (H2RA). Follow-up details were updated and patients who had been lost to follow-up were recalled. The age of the 22 boys and 10 girls at the time of diagnosis of the ulcers ranged from 3 to 16 years (mean, 11.8 yrs). The duration of follow-up ranged from 8.5 to 21 years (mean, 11.6 yrs). RESULTS: Their primary presentations included epigastric pain (n = 9, 28.0%); nonsteroidal antiinflammatory drug (NSAID)-induced gastrointestinal bleeding (GIB, n = 6, 18.7%); unprovoked GIB (n = 12, 37.5%); perforation (n = 4, 12.5%); and pyloric obstruction (n = 1, 3.0%). All 13 patients who had NSAID-induced ulcers (pain and bleeding) responded to H2RA therapy and required no further treatment. All 14 patients who had unprovoked ulcers who presented with pain or bleeding did not respond to H2RA treatment. Ulcer healing was achieved only after eradication of Helicobacter pylori with antibiotics (n = 8) or definitive surgery involving either truncal vagotomy and pyloroplasty (VP, n = 4) or proximal gastric vagotomy (PGV, n = 2). The patient who had gastric outlet obstruction had vagotomy and antrectomy. All four patients who had perforation were initially treated with patch repair, but two had persistent ulceration despite H2RA treatment and required PGV. Complications developed in none of the four patients who had PGV, whereas two of the four patients with VP had problems (diarrhea, n = 1; bezoar obstruction, n = 1). CONCLUSIONS: Unprovoked childhood duodenal ulcer is associated with significant long-term morbidity and requires continued follow-up. The majority of the ulcers are resistant to H2RA treatment alone and ultimately require either eradication of H. pylori or surgery. In the absence of obstruction, PGV may be enough to resolve the ulcer diathesis.

The involvement of two or more systems and the severity of associated anomalies significantly influence mortality in esophageal atresia.

PURPOSE: The aim of this study was to examine the influence of associated anomalies in babies born with esophageal atresia (EA). METHODS: A retrospective review of the records of 41 consecutive cases of esophageal atresia managed over an 11-year period was undertaken. RESULTS: A higher incidence of associated anomalies was seen in those babies with lower birth weights. Although all five (100%) babies with EA who weighed less than 1,800 g had associated anomalies, those who weighed 1,800 to 2,500 g and more than 2,500 g were associated with 67% (10 of 15) and 43% (9 of 21) anomalies, respectively. The most common system in which anomalies occurred was the cardiovascular system (37%) followed by gastrointestinal (24%), musculoskeletal (17%), genitourinary (7%), chromosomal (5%), and others (12%). All 17 (41%) babies with no associated anomalies survived. Four of the 10 babies who had two or more systems involvement died, whereas only one of 31 babies with less than two systems involvement died; the difference between these two groups was highly significant (Fisher's Exact test, P = .009). The overall mortality rate was 12%. Three of the deaths were associated with severe anomalies that were incompatible with life such as bilateral renal agenesis, trisomy 18, and complex cardiac anomalies. CONCLUSION: The association of two or more system anomalies and the severity of associated anomalies influence mortality in esophageal atresia.

Childhood recurrent pyogenic cholangitis.

Recurrent pyogenic cholangitis (RPC) is characterized by repeated attacks of bacterial infection of the biliary tract by enteric organisms resulting in formation of strictures and stones in the intrahepatic as well as the extrahepatic bile ducts. Between 1973 and 1984, we managed ten children with RPC. Presentation was acute, septicemia being invariably present. Four children responded to vigorous intravenous (IV) fluid and antibiotic therapy; of these, three subsequently required elective transduodenal sphincteroplasty. Six children required emergency biliary tract decompression surgically and three of them also had concomitant definitive drainage procedures (transduodenal sphincteroplasty, two; supraduodenal choledochoduodenostomy, one). The other three had T-tube drainage initially followed by elective drainage procedures (transduodenal sphincteroplasty, one; supraduodenal choledochoduodenostomy, two). At exploration, pigment stones and/or mud were invariably present in the bile ducts. One child required reexploration for hemostasis following sphincteroplasty, and one child died from septicemia and respiratory failure following operation. The rest are well, having been followed for 3 to 12 years. Major advances in recent years include (1) endoscopic retrograde cholangiopancreatography (ERCP) for accurate definition of the biliary tract and confirmation of the presence and location of stones during the quiescent phase, (2) the intraoperative choledochoscopic extraction of intrahepatic and extrahepatic stones, and (3) postoperative stone removal via the T-tube tract.

Acute pancreatitis in children.

Twenty-nine children with acute pancreatitis were managed during the period 1971 to 1983. Aetiology included trauma (5), mumps (5), drug therapy (4), biliary disease (1), and cystic fibrosis (1); 13 cases were classified as idiopathic. Diagnosis could be difficult, and unnecessary laparotomies were performed in 7 instances for suspected appendicitis. One patient, however, had a well-justified laparotomy revealing coexisting severe appendicitis and pancreatitis. Morbidity included relapses (7), pseudocysts (3), obstructive duodenal hematoma (1), and miscellaneous problems (4). Improvements in management included endoscopic retrograde cholangio-pancreatography (ERCP) to exclude anatomical anomalies in relapsing cases, ultrasonography for the diagnosis of pseudocysts and for follow-up measurements in two such cases successfully managed conservatively, and increasing use of total parenteral nutrition in cases with protracted disease or serious complications.

Parapharyngeal teratoma in the newborn.

A parapharyngeal teratoma in a newborn was the cause of acute respiratory distress, which was relieved by tracheostomy. Subsequent investigations by soft tissue x-rays of the neck, computed tomography, and examination under anesthesia defined the anatomic location of the tumor, its extent, and its likely nature. The tumor was removed completely by the transcervical approach. Mandibulotomy was not required. Histological examination showed the presence of a large amount of mature brain tissue, a moderate amount of collagenous fibers and smooth muscle cells, and a minute amount of cartilage and epithelial structures. The postoperative course was satisfactory. No recurrence was seen 6 years after surgery. The computed tomography scan was found to be the most useful investigative method. To the authors' knowledge, this is the first comprehensive report of a teratoma occupying the parapharyngeal space in a newborn.