Surgical management of extrahepatic portal vein obstruction in children: advantages of MesoRex shunt compared with distal splenorenal shunt.

PURPOSE: To review surgical management of extrahepatic portal vein obstruction (EHPVO) at Red Cross War Memorial Children's Hospital and compare MesoRex shunt (MRS) with distal splenorenal shunt (DSRS). METHODS: This is a single-centre retrospective review documenting pre- and post-operative data in 21 children. Twenty-two shunts were performed, 15 MRS and 7 DSRS, over an 18-year period. Patients were followed up for a mean of 11 years (range 2-18). Data analysis included demographics, albumin, prothrombin time (PT), partial thromboplastin time (PTT), International normalised ratio (INR), fibrinogen, total bilirubin, liver enzymes and platelets before the operation and 2 years after shunt surgery. RESULTS: One MRS thrombosed immediately post-surgery and the child was salvaged with DSRS. Variceal bleeding was controlled in both groups. Significant improvements were seen amongst MRS cohort in serum albumin, PT, PTT, and platelets and there was a mild improvement in serum fibrinogen. The DSRS cohort showed only a significant improvement in the platelet count. Neonatal umbilic vein catheterization (UVC) was a major risk for Rex vein obliteration. CONCLUSION: In EHPVO, MRS is superior to DSRS and improves liver synthetic function. DSRS does control variceal bleeding but should only be considered when MRS is not technically feasible or as a salvage procedure when MRS fails.

Paediatric Surgery training in South Africa: Trainees' perspectives.

PURPOSE: There is very little documented evidence regarding the training of paediatric surgeons in South Africa since its inception as a formal speciality in 2007. This study aims to assess South African paediatric surgical trainees' perspectives regarding their training. METHODS: A prospective study was conducted via an emailed electronic survey. The sample population included all current paediatric surgical trainees in South Africa. The questionnaire covered the trainees' demographics, exposure to different aspects of paediatric surgery, extent of after-hours clinical service, self-reported surgical competency and consultant supervision. RESULTS: Forty one (95%) out of 43 trainees responded to the survey with 29 (71%) being female. Reported training deficits included lack of exposure to burn care in 12 trainees (30%), no urology exposure in 8 (20%), no paediatric trauma or minimally invasive surgery exposure in 6 (15%). Eighteen trainees (44%) reportedly worked more than 65 h per week with clinical responsibilities being the biggest hindrance to attending academic teaching. Trainees were more comfortable performing open procedures compared to laparoscopic but most respondents felt adequately supervised. CONCLUSION: There exists a significant heterogeneity amongst the different training institutions with protected academic time and exposure to burns, urology and minimally invasive surgery remaining major obstacles in training.

Predictors of multiple readmissions or death in the first year after Nissen fundoplication in children.

PURPOSE: Nissen fundoplication (NF) is commonly performed in children with gastro-esophageal reflux disease (GERD). Patients undergoing NF often have co-morbidities. Reported outcomes of NF vary considerably. This study investigated which factors might predict multiple readmissions or death in the first year following NF at our institution. METHODS: A retrospective chart review of 187 children who underwent NF at our institution between January 2004 and December 2015 was undertaken. Underlying medical conditions, age, weight, presence of malnutrition, length of hospital stay prior to surgery and type of surgery were recorded. Patients who had more than one admission in the first post-operative year were compared to those who had one or none, and patients who died within the first post-operative year were compared to those who did not. RESULTS: Risk factors for multiple readmissions were underlying cardiac disease (p = 0.011), esophageal atresia (EA) (p = 0.011), and esophageal stricture (p = 0.0002). Risk factors for death included younger age (p = 0.028), need for gastrostomy tube (GT) (p = 0.01) and prolonged pre-operative hospital admission (p = 0.0003). CONCLUSION: This study identified multiple factors associated with readmission and death in the first year after NF. These findings will help with the counseling patients and caregivers regarding expectations following NF.

Correlation of 99mTc sucralfate scan and endoscopic grading in caustic oesophageal injury.

PURPOSE: To determine a correlation between the 99mTc sucralfate scan and the endoscopy findings in children with caustic oesophageal injury. METHODS: This is an observational analytic study of children who had both 99mTc sucralfate scan and endoscopy after caustic substance ingestion at our institution in a period between January 2009 and September 2016. The oesophageal injury was classified into low grade and high grade according to the degree of adhesion on 99mTc sucralfate scan and modification of Zargar endoscopic grading. RESULTS: Out of a total of 197 children, 40 children were identified who had both investigations done on average 26 h post-injury. Low-grade adhesion on 99mTc sucralfate scan was found in 27 children (68%), and all had low-grade Zargar's oesophageal injuries. None of these subsequently developed residual pathology. Thirteen had high-grade adhesion and five of these had high-grade injury on endoscopy. Three (23%) developed oesophageal strictures. Correlation of 99mTc sucralfate and endoscopic findings reached statistical significance with a p value of 0.0014. No morbidity was associated with either the scan or endoscopy. CONCLUSIONS: We concluded that low-grade sucralfate scan finding has the potential to successfully eliminate the need for invasive endoscopy under general anaesthesia and thereby reducing procedure-related morbidity, hospitalization and associated costs. However, mandatory endoscopy is required in children with high-grade adhesion seen on 99mTc sucralfate scan. This requires confirmation using a larger prospective study.

Pediatric surgeon density in South Africa.

BACKGROUND: There are limited data regarding the available pediatric surgical workforce in South Africa and their employment prospects on completion of their specialist training. METHODS: This aim of this study was to quantify and analyze the pediatric surgical workforce in South Africa as well as to determine their geographic and sector distribution. This involved a quantitative descriptive analysis of all registered specialist as well as training pediatric surgeons in South Africa. RESULTS: The results showed 2.6 pediatric surgeons per one million population under 14 years. More than half (69%) were male and the median age was 46.8 years. There were however, more female surgical registrars currently in training. The majority of the pediatric surgical practitioners were found in Gauteng, followed by the Western Cape and Kwa-Zulu Natal. The majority of specialists reportedly worked in the public sector, however the number of public sector pediatric surgeons available to those without health insurance fell below those available to private patients. CONCLUSION: Interprovincial differences as well as intersectoral differences were marked indicating geographic and socioeconomic maldistribution of pediatric surgeons. Addressing this maldistribution requires concerted efforts to expand public sector specialist posts. STUDY TYPE: Descriptive audit LEVEL OF EVIDENCE: IV.

Outcomes of Esophageal Replacement: Gastric Pull-Up and Colonic Interposition Procedures.

AIM: No consensus exists about the optimal surgical technique for esophageal replacement. This study reports the surgical outcomes for the gastric pull-up and the colonic interposition procedures. MATERIALS AND METHODS: A retrospective review of children undergoing esophageal replacement surgery between January 2001 and June 2015 across four different pediatric surgery centers was conducted. Data collected included indications, epidemiology, surgical technique, complications, and outcomes. Patients were divided into group A, those that had a gastric pull-up procedure and group B, those that had a colonic interposition procedure. RESULTS: In total, 50 patients were included; 29 in group A and 21 in group B. Indications included esophageal atresia, caustic ingestion, and infective esophageal stricture. The median age at the time of surgery was 13 months. The mean length of follow-up was 5.2 years. Three patients died giving a mortality rate of 6%; 2 in group A and 1 in group B.In both groups, early postoperative complications included infective complications, such as wound infections, sepsis, and pneumonia (11), anastomotic leak (7), and respiratory complications (7). Late complications included adhesive bowel obstruction (2), anastomotic strictures (4), redundancy (1), and jejunostomy problems (1). Septic complications and anastomotic strictures occurred more frequently in group B. Further surgery was needed in eight patients; this was significantly higher in group B. Full oral feeding was achieved within 6 months in 91.5%. CONCLUSION: The gastric pull-up and colonic interposition have comparable mortality and outcomes. The colonic interposition was associated with a higher rate of early septic complications, anastomotic strictures, and need for further surgery.

International Study of the Epidemiology of Paediatric Trauma: PAPSA Research Study.

OBJECTIVES: Trauma is a significant cause of morbidity and mortality worldwide. The literature on paediatric trauma epidemiology in low- and middle-income countries (LMICs) is limited. This study aims to gather epidemiological data on paediatric trauma. METHODS: This is a multicentre prospective cohort study of paediatric trauma admissions, over 1 month, from 15 paediatric surgery centres in 11 countries. Epidemiology, mechanism of injury, injuries sustained, management, morbidity and mortality data were recorded. Statistical analysis compared LMICs and high-income countries (HICs). RESULTS: There were 1377 paediatric trauma admissions over 31 days; 1295 admissions across ten LMIC centres and 84 admissions across five HIC centres. Median number of admissions per centre was 15 in HICs and 43 in LMICs. Mean age was 7 years, and 62% were boys. Common mechanisms included road traffic accidents (41%), falls (41%) and interpersonal violence (11%). Frequent injuries were lacerations, fractures, head injuries and burns. Intra-abdominal and intra-thoracic injuries accounted for 3 and 2% of injuries. The mechanisms and injuries sustained differed significantly between HICs and LMICs. Median length of stay was 1 day and 19% required an operative intervention; this did not differ significantly between HICs and LMICs. No mortality and morbidity was reported from HICs. In LMICs, in-hospital morbidity was 4.0% and mortality was 0.8%. CONCLUSION: The spectrum of paediatric trauma varies significantly, with different injury mechanisms and patterns in LMICs. Healthcare structure, access to paediatric surgery and trauma prevention strategies may account for these differences. Trauma registries are needed in LMICs for future research and to inform local policy.

Caustic ingestion in children-A review.

Various domestic or industrial chemicals may cause significant upper aerodigestive tract burns. Preventive measures should be up-scaled, especially in the developing world, to reduce the epidemic of accidental victims, largely unsupervised preschool children. External signs do not predict degree of injury. Non-invasive diagnostic screening includes radio-nuclear imaging, but early oesophago-gastroduodenoscopy remains the standard to predict stricture formation from circumferential submucosal scarring. Serial dilation is the mainstay of oesophageal stricture therapy, with oesophageal replacement reserved for severe refractory strictures. Intra-lesional steroid or mitomycin C may decrease the dilatations required for severe strictures, although long-term effects are unknown. Risk of secondary oesophageal carcinoma mandates long-term surveillance.

Temporary Vacuum-Assisted Closure of the Open Abdomen in Neonates.

Introduction The need for open abdomen in the treatment of severely ill neonates will increase in time as more complex abdominal procedures are undertaken. However, the experience of temporary closure of an open abdomen using vacuum-assisted closure (VAC) system is still relatively limited in premature and term neonates. The aim of this study is to describe and review our experience in the use of temporary VAC of the open abdomen for neonates with varying pathological processes. Materials and Methods A retrospective folder review of all neonates treated with VAC for open abdomen over the study period of 2010 to 2014 at our institution was performed. Results A total of 15 neonates were included in this study. Mean gestational age and postbirth age at VAC application were 33.6 ± 4.1 (28-40) weeks and 14 ± 10.2 (2-30) days, respectively. Mean weight at VAC application was 1,797.7 ± 730.8 (960-3,200) g. Initial diagnoses were necrotizing enterocolitis (seven), intestinal perforation (three), gastroschisis (two), congenital diaphragmatic hernia (two), and primary abdominal compartment syndrome (ACS) (one). Reasons for VAC application included confirmed ACS (2) and application to prevent ACS (13). Duration of VAC use was 4 ± 3.4 (0-13) days during which 2 ± 1.2 (1-5) applications were performed. Overall survival rate was 80% (12 of 15 patients). One patient with primary ACS died from sepsis with an open abdomen. The only potential VAC-related complication was an enterocutaneous fistula. Conclusion Temporary VAC of the open abdomen is a safe method of temporary abdominal closure to prevent ACS in high-risk postoperative conditions in neonates of any gestational age and birth weight.

Birth Prevalence of Anorectal Malformations for the Western Cape Province, South Africa, 2005 to 2012.

Introduction Anorectal malformations (ARMs) are a major birth anomaly worldwide. South Africa has ethnically and geologically diverse populations. A recent publication indicated an increased birth prevalence of ARMs in the Witwatersrand referral area between 2005 and 2010. The purpose of this study was to determine the birth prevalence of ARM and its various subtypes in the Western Cape referral district over an 8-year period. Methods For an 8-year period from January 1, 2005, to December 31, 2012; retrospective data were collected from the Pediatric Surgical Departments of Red Cross War Memorial Children's Hospital, Tygerberg Children's Hospital, as well as the private sector health registries. The number of live births per year for a specific municipal district was obtained from the National Department of Health. The chi-square for trend test was used to determine statistical significance. Results The birth prevalence for ARM in the Western Cape Province (WCP) in 2012 was shown to be 1:5,572 live births (1.79/10,000 live births). The West Coast municipality district had the highest average birth prevalence rate of 1:3,063 (3.26/10,000) live births for years studied. There was a male predominance (1.6:1), the most common ARM was the vestibular fistula (19.2%) and in 26% of the patients, there was an initial delay in the diagnosis. Conclusion This study has provided some recent data for ARMs for the WCP. There was no statistical significant change in the prevalence of ARMs over the 8-year period for the WCP as well as in any of the individual six municipal health districts (χ2 for trend, p = 0.52). The number of delayed diagnosis of ARM is of concern.

Outcomes of children with rhabdomyosarcoma treated with intensive chemotherapy, surgery, and radiotherapy through a period of protocol revision at a South African center, 1990-2010.

A total of 75 children with biopsy-proven rhabdomyosarcoma were treated at our institution between 1990 and 2010. Five-year overall survival (OS) for the entire cohort was 58.7%. OS by stage was as follows: Stage 1 (80%), Stage 2 (80%), Stage 3 (54.1%), and Stage 4 (38.5%). There was a trend to suggest that revision of treatment approaches improved crude survival over time: pre-2003 (OS 42.1%); 2003-2005 (OS 50.0%); 2005-2010 (OS 60.8%).

Using telemedicine to teach paediatric surgery in resource-limited countries.

Halstedian method of surgical training has been the mainstay of surgical education for many decades. Onsite knowledge sources in surgery have traditionally been textbooks, which are often a number of years out of date or teaching rounds with a Professor or senior colleague that enables a small number of trainees to benefit from. Congresses have been a good way of learning new developments in the field, but they often require travelling and are very costly. We have identified web-based education as a means of linking experts with trainees, regardless of their geographic location and often without requiring any substantial capital. Web meetings have been running on a weekly basis from University of Cape Town, Division of Paediatric Surgery since 2010. This enabled speakers from Australia to Venezuela, across the globe share their expertise with individuals and paediatric surgical teams both in resource limited and developed countries. Attendance to meetings has grown significantly as the users become more familiar with the meeting software and also internet connection and availability of bandwidth increased. Adobe Connect® has been the main platform we used with its functions, including camera and video transmission, sharing of presentations, and ease of creating polls to encourage participant enrolment. Recordings are also made available and viewed over 300 times/month through the website www.surgicalskills.co.za . Other applications using the same platform has been explored which included transfer of hands on surgical skills, such as laparoscopy, burns surgery and fibre optic endoscopy as well as conducting administrative meetings for professional societies. Web meetings have added another dimension to surgical education. This will likely grow more in the future, and transform peer to peer knowledge transfer into a global environment.

Total Esophageal Gastric Dissociation for the Failed Antireflux Procedure in a Child with Microgastria.

Microgastria is a very rare anomaly characterized by a very small tubular stomach that presents with severe gastroesophageal reflux disease due to the small reservoir capacity of the stomach. We present a patient with microgastria-related reflux and a failed fundoplication who was treated with total esophageal gastric dissociation (TEGD) resulting in an excellent outcome. In our experience with this good long-term result, we would suggest that TEGD be added to the armamentarium of procedures that can be used in the treatment of microgastria.

Comparison in the incidence of anorectal malformations between a first- and third-world referral center.

PURPOSE: Aim of study was to evaluate the differences in incidence and presentation of anorectal malformations (ARMs) between selected Pediatric Surgery Divisions in the Republic of South Africa (ZAR) and Italy. METHODS: A retrospective cohort study involved analysis of clinical records of patients with ARM born between 2005 and 2012. Type of ARM, maternal age, birth weight, gestational age, presence of associated anomalies and delayed diagnosis were analyzed. RESULTS: 335 patients were included in this study. Of note, statistically significant differences between the African and European patient groups were observed in a male predominance in the ZAR patient population. In addition, female recto-perineal fistulas were diagnosed in significantly more Italian patients than in ZAR. Furthermore, a more advanced maternal age and a lower gestational age was noted in the European cohort with a minimal delay in initial diagnosis as opposed to the African counterpart. Both centers reported recto-perineal fistula as the most common malformation in male patients. CONCLUSION: With the exception of perineal fistulas in females, the incidence of specific subtypes of ARMs was similar in the two groups. This may be of importance when extrapolating European study conclusion to the South African setting.

Impact of revascularization on hypertension in children with Takayasu's arteritis-induced renal artery stenosis: a 21-year review.

BACKGROUND: Surgery for reno-vascular hypertension (RVH) is complex, and the techniques utilized vary with anatomical presentations of the disease. The long-term outcome of revascularization on RVH in children with Takayasu's arteritis (TA)-induced renal artery stenosis (RAS) at our centre was reviewed. METHODS: This study was a 21-year retrospective review of pre- and post-intervention RVH in children with angiographically confirmed RAS. The outcome of hypertension was defined as follows: (1) cured (normotensive off anti-hypertensives), (2) improved (normotensive on same or reduced number of medications), or (3) failure (no cure or improvement in number of medications). RESULTS: The medical histories of 59 children (median age 9.98 years) were reviewed, of whom 20 (44 %) had revascularization procedures. All were hypertensive, with a mean systolic and diastolic blood pressure of 161.5 ± 36 and 106.5 ± 31 mmHg, respectively. RAS was present in 45 (76.3 %) children. Twenty-four revascularization procedures were performed in 20 children (44 %), of whom five had contralateral nephrectomies. Outcome was available for 17 patients at the 3- and 6-months follow-up, with cure, improvement and failure rates at 3 months of 2/17 (11.8 %), 7/17 (41.2 %) and 8/19 (47 %), respectively, and similar rates at 6 months. Associations between outcome and age (p = 0.51), sex (p = 0.32), number of pre-surgery anti-hypertensives (p = 0.18) and stenosis sites (p = 0.22) were not statistically significant. CONCLUSIONS: Revascularization was beneficial to the management of blood pressure control in about half of our RVH patients.

Online resources in pediatric surgery: the new era of medical information.

Tele-education has the potential to facilitate rapid sharing and dissemination of current research and knowledge among pediatric surgeons around the world. Classically, the exchange of surgical research occurred via national surgical conferences, articles published in peer-reviewed journals, and textbooks. The advent of Web 2.0 and the rapid pace of technologic advancement have allowed knowledge, education, and research to be exchanged online. Virtual symposiums act as online conferences where participants present and debate new research and surgical techniques in real-time web meetings. Resource libraries allow up-to-date information to be archived and viewed at the user's convenience, bypassing the need to wait long periods for paper publications. Tele-education allows pediatric surgeons to connect and share ideas around the world, while saving time and money.

Management of nine cases of Wilms' tumour with intracardiac extension - a single centre experience.

AIM: The aim of this study was to review the management of children with Wilms' tumour who have intracardiac extension. PATIENTS AND METHODS: Data were collected from patient notes regarding presentation, operative details, and outcome. RESULTS: From 1984 through 2011, 264 children with Wilms' tumour were treated at our hospital. Nine (3.4%) had cavo-atrial extension of the tumour thrombus. The thrombus extended into the right ventricle in two children and involved the hepatic veins in both, and also two others. Pre-operative chemotherapy was administered in eight children with complete regression of the intra-cardiac tumour thrombus in two cases. One child died preoperatively of septicaemia and respiratory failure after two doses of chemotherapy. Six children with intra-cardiac tumour were operated on under cardiopulmonary bypass (CPB) with deep hypothermia and circulatory arrest (DHCA). The mean ischemic time was 30 min. There was one peri-operative death in a child with hepatic vein involvement and Budd-Chiari syndrome. All others made a good postoperative recovery. All tumours were favourable histology. To date four children are still alive and disease free. Three children have died as a result of pulmonary metastases. CONCLUSION: Intracardiac extension of Wilms' tumour is rare, and the management is technically challenging. Pre-operative chemotherapy is effective. CPB and DHCA for excision of the cavo-atrial tumour thrombus may be necessary. Distant metastatic disease is common and determines long term prognosis. Hepatic vein extension complicates surgery and remains challenging.

Magnetic bead toy ingestion: uses and disuses in children.

A 2-year-old female presented acutely with peritonitis and small bowel obstruction. An abdominal radiograph demonstrated a radiopaque foreign body. At laparotomy she was found to have bowel perforations with entero-enteric fistulae caused by four magnets. The magnets were removed, and debridement and closure of the perforations performed. We review our case and highlight this problem to other medical practitioners as a potential cause of significant morbidity and mortality in the paediatric population.