Port-site infection due to nontuberculous mycobacteria following laparoscopic surgery.

Nontuberculous mycobacteria (NTM) are commonly found in soil and water and can cause nosocomial infections by contaminating equipment and disinfectants solution used in hospitals. NTM port-site infection after laparoscopic surgery is increasingly observed, but its clinical features, management, and prevention have not been reviewed adequately. We performed a comprehensive literature review of reports that described the clinical manifestation and management of NTM port-site infections following laparoscopic surgery. The perceived increase in NTM port-site infections is likely multifactorial, influenced by greater awareness, better diagnostics, changes in medical practice, increased prevalence of immunosuppression, and potential pathogen spread. Widespread resistance to common disinfectants is a major concern. Patients with NTM port-site infections typically present 1-3 months after the laparoscopic intervention with chronic local and minimal systemic symptoms. Surgical excision plays an important role in localized or refractory cases. Medical treatment should be guided by species identification and in vitro drug-susceptibility testing (DST) of the infecting NTM strain, with a combination of second-line antituberculosis agents, given for a prolonged duration. NTM port site infection is best prevented by meticulous skin preparation and infection control, using only sterilized supplies for laparoscopic surgery.

Patterns of reflux in gastroesophageal reflux disease in pediatric population of New South Wales.

This study is to determine the association of ambulatory pH monitoring (24hr pH) with symptoms of gastroesophageal reflux and its other investigations. The clinical and epidemiological profiles of subjects referred for reflux disorders are also studied. Symptoms or group of symptoms, profiles and prior investigations of 1259 consecutive pediatric subjects (with 1332 24hr pH studies performed) referred for evaluation of reflux disorders between 1988 and 2012 were retrospectively studied. Chi-square or fisher exact test was used for hypothesis testing, student t-test for the comparison of means and the Wilcoxon rank-sum test for comparing medians of continuous variables. Gastroesophageal reflux disease (GERD), defined as reflux causing major symptoms and complications, was diagnosed in 57.5% subjects of the total sample. Forty-three percent were girls and 56.7% were boys. The most common age group was between 4 months and 2 years (51.2%). Vomiting (64.4%) and irritability (74%) were the most common symptoms with the neurological conditions (23.2%) being the most frequent underlying condition. The parameters used in 24hr pH were significantly higher in those diagnosed with GERD (P < 0.0001). The prevalence of GERD was found to be significantly higher when both gastrointestinal and respiratory symptoms were present (P = 0.008) at 66.4% than when compared with gastrointestinal (56.5%) and respiratory (52.2%) symptoms in isolation. Symptoms alone were not reliable in diagnosing GERD. Only 57.5% had GERD among patients referred for reflux disorders. 24hr pH is reliable and should be considered routine in reflux disorders, as it identifies patients with pathologic reflux and avoids a needless surgery.

Predictors of postoperative complications in HIV-infected children undergoing surgery.

BACKGROUND: An increasing number of HIV-infected children require a surgical procedure. The aim of this study was to investigate factors associated with the development of complications in HIV-infected children undergoing surgery. METHODS: A prospective study of HIV-infected children younger than 60 months undergoing surgery at a tertiary referral pediatric hospital from July 2004 to July 2008 was performed. Children were followed postoperatively for the development of complications, length of stay, and mortality. RESULTS: Eighty-two HIV-infected children, with a median age of 11.5 months (interquartile range, 6-24 months), were enrolled. Most (68; 82.9%) had World Health Organization stage 3 or 4 HIV disease, 72 (88%) had Centers for Disease Control and Prevention stage 2 or 3 disease, and 60 (73%) were taking highly active antiretroviral therapy. Half (41; 50%) were underweight, 37 (45.1%) underwent emergency surgery, 28 (34.2%) required major surgery, and 40 (48.7%) had surgical site contamination at the time of surgery. The median length of hospital stay was 4 days (interquartile range, 2-14 days), and in-hospital mortality was 6 (7%). Thirty-four (42%) children developed 37 complications. On univariate analysis, malnutrition, HIV stage, or type of surgery was not associated with development of complications. In contrast, young age (6 vs 13.5 months; P = .0004), low hemoglobin (9.6 vs 10.5 g/dL; P = .04), or having a major procedure (14 [42%] vs 9 [18%]; P = .03; relative risk, 2.2 [1.2-4.8]) was associated with complications. On logistic regression, younger age (odds ratio = 4.3; P = .004; 95% confidence interval, 1.6-11.9) and major surgery (odds ratio = 6.8; P = .001; 95% confidence interval, 1.5-31.4) were associated with development of a complication. CONCLUSION: Young age and major surgery were the main predicators of complications in HIV-infected children undergoing surgery.

Effect of maternal human immunodeficiency virus status on the outcome of neonates with necrotizing enterocolitis.

AIM: The aim of the study was to assess the impact of human immunodeficiency virus (HIV) exposure on survival and extent of disease in necrotizing enterocolitis (NEC). PATIENTS AND METHODS: All patients with NEC requiring surgery between June 1998 and June 2008 were analyzed. Three groups were identified: those born to HIV-positive (HIV+) mothers, those born to HIV-negative (HIV-) mothers, and those with an unknown HIV status. Primary outcome measure was survival to discharge. Secondary outcome measure was extent of disease. RESULTS: One hundred nine infants (mean gestational age, 31 weeks; birth weight, 1413 g) underwent surgery for NEC. Gestational age, birth weight, and day of presentation were similar in all 3 groups, showing no statistical difference. The HIV+ group consisted of 22 infants, of which 13 (59%) died and 2 (9%) had panintestinal necrosis. The HIV- group consisted of 48 infants, of which 11 (23%) died, with 3(6%) having panintestinal necrosis. The remaining group of HIV (unknown) consisted of 38 infants, of which 14 (37%) died, with 2 (5%) having panintestinal necrosis. The latter group was not included in the analysis; but comparing the HIV+ and HIV- groups, there was a statistically higher chance of death (odds ratio = 4.8, P = .05). There was no difference statistically in the extent of disease. CONCLUSION: Neonates with NEC born to HIV+ mothers have a higher mortality.

Porcine dermal collagen (Permacol) for chest and abdominal wall reconstruction in thoraco-omphalopagus conjoined twin separation.

Each set of conjoined twins presents a unique challenge, which centers on the ability to separate and if necessary reconstruct shared organs and to achieve subsequent skin cover of the often very large residual defect after completion of the separation. This report describes the use of a bioprosthetic Permacol derived from porcine dermal collagen to reconstruct the chest and abdominal wall.

Outcomes of human immunodeficiency virus-infected and -exposed children undergoing surgery--a prospective study.

AIM: Human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) is a worldwide pandemic. Mother-to-child transmission programs should theoretically minimize vertical transfer of the virus, but with variable effectiveness of implementation a significant number of children become infected and may present for emergency, diagnostic, and elective surgery. The aim of this study was to prospectively document the clinical presentation, the spectrum of pathology, and surgical outcomes of patients presenting to our hospital. This formed part of a pilot study of a collaborative international working group studying HIV infection in children, which included the Buzzi Children's Hospital Milan, Italy; the University of San Diego, California, USA; and the Red Cross War Memorial Children's Hospital and University of Cape Town, School of Adolescent and Child Health, Cape Town, South Africa. METHOD: Clinical data from all children admitted to the surgical service of the Red Cross War Memorial Children's Hospital between July 2004 and December 2006 with either a history of HIV exposure (born to an HIV-infected mother) or confirmation of HIV infection by ELISA or polymerase chain reaction was collected. The clinical course was documented prospectively for the duration of admission and subsequent follow-up as recorded in case records review. The spectrum of pathology, surgical intervention, outcome, complications, World Health Organization stage of AIDS, and type of antiretroviral therapy were all noted. Comparative outcomes and subgroup analysis were not done in this part of the study. RESULTS: One hundred and thirteen patients were included in the study over the 30-month period. The average age was 24 months (1 day to 11 years). Seventy-nine (70%) of the 113 patients were infected and 34 (30%) were exposed, 9 of whom subsequently tested negative. Of the infected group, 53 (67%) patients were on antiretroviral therapy. The extent of disease in the infected group of patients according to the 2006 World Health Organization criteria was as follows: stage 1, 4 (5%); stage 2, 12 (15%); stage 3, 51 (65%); and stage 4, 12 (15%). All patients had nutritional assessments and were plotted on growth curves. Sixty-two (54%) were found to be malnourished and 41 (36%) of the children were found to have comorbid disease processes. Eighteen patients (16%) were treated with antibiotics or conservative therapy alone. The remaining 95 patients (84%) underwent an average of 1.6 procedures (range, 1-35), 59 (52%) in an elective manner and 36 (31%) as an emergency. When assessing the relationship of HIV to the presenting disease state, 58 (73.4%) had HIV-related diseases and 52 (46%) presented with sepsis. A total of 29 (25%) patients had surgical complications of which 6 (20%) were not considered to be HIV related. Nine (31%) had, in retrospect, incorrect management of the presenting disease, leaving 14 (48%) who potentially had HIV-related complications of poor wound healing and sepsis. A total of 100 (88%) were discharged alive, 6 (5.3%) died, and 7 (6 %) were lost to follow-up. Long-term follow-up of 50 patients for an average of 8 months revealed one further mortality. CONCLUSION: Human immunodeficiency virus-positive and -exposed patients present a unique challenge in management which is complicated by concomitant disease and poor nutrition. These patients require an expanded differential diagnosis. We believe that, although on the surface there may be a higher complication rate, this needs to be confirmed in an expanded comparative cohort study, which is underway and that patients should still receive the benefit of full surgical intervention.

Laparoscopic resection of benign ovarian tumours in children with gonadal preservation.

PURPOSE: Ovarian tumours are often regarded as an indication for open oophorectomy, especially following torsion. We wish to report our results of laparoscopic ovarian cystectomy with ovarian preservation. METHODS: Retrospective review of clinical records of patients who where managed with laparoscopic ovarian cystectomy with ovarian preservation. RESULTS: Twelve records were identified over a 3-year period. The average age was 11.8 years (9-15). Presentation was of a mass in nine patients and torsion in three patients. Average size of the mass was 8.2 cm (5-18). Two patients had bilateral lesions. All patients were noted to have normal tumour markers. Successful cystectomy with ovarian preservation was accomplished in all cases using 3-port laparoscopy. The bilateral lesions were addressed at the same surgery with no increased length of stay or morbidity. In the three patients with acute torsion, an initial laparoscopic detorsion was performed with delayed laparoscopic cystectomy and ovarian preservation 7-10 days later. There was one complication of a minor umbilical port site infection. Histology was of a mature teratoma in ten cases and simple cyst in two. Six patients underwent routine ultrasonographic follow-up at 2-5 months at which time the involved ovary assumed a size and shape and blood flow comparable to the contra-lateral ovary in five patients. In one patient the affected side was smaller, 8.6 ml compared to 10 ml on the contra-lateral ovary. The remaining patients have been followed up clinically and remain asymptomatic. CONCLUSION: Laparoscopic cystectomy with ovarian preservation can be successfully applied to benign ovarian tumours. Acute ovarian torsion is not a contraindication to this technique where a two stage procedure still enables us to offer ovarian preservation.

Difficulties in the management of mesenchymal hamartomas.

AIM: Mesenchymal hamartoma of the liver is an entity with a varied presentation and frequent initial delay in diagnosis. The macroscopic appearance too is quite heterogeneous with solid, cystic and mixed variants being present with varying degrees of vascularity. Management will depend on presentation and expertise available. We look at a single centre experience with the mesenchymal hamartomas. METHOD: Retrospective patient record review of the past 30 years, 1976-2006. RESULTS: Seventeen patients aged 1 day to 15 years were identified, with a histopathological diagnosis of mesenchymal hamartoma of the liver. The anatomical location in the liver was 12 in the right liver and the 5 in the left. All patients presented with abdominal distension, eight had significant anorexia and or vomiting. Ultrasound scan was done in all patients. Findings were that of a mass and or cysts. The cysts were multiple in all cases but one and were interspersed with solid elements. Calcification was noted in only two of the patients. Operative approaches were six right hepatectomy, four wedge excision, seven tumour excisions by division of its pedicle; two of these were done laparoscopically, by cyst drainage and excision of the solid component. The tumours were all confirmed as mesenchymal hamartomas; size ranged from 412 to 2,230 g. Complications included three related to misdiagnosis (hydatid disease, and hepatoblastoma). Intraoperative problems consisted of preoperative bleeding resulting in an on-table hypovolaemic arrest and in a second case a bile duct injury. Postoperative problems consisted of an initial incomplete resection, with residual tumour on the IVC. There was rapid regrowth of tumour and death after a second exploration. Two children developed fluid collections requiring re-exploration and drainage. The surviving children have been followed up for a median time period of 4 months (range 1 month-11 years) and are well. CONCLUSION: Although hamartomas of the liver are histologically benign, their clinical course and the complications of surgical treatment can be significant. They can often pose diagnostic dilemmas and may have a propensity for local recurrence and malignant degeneration.