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.

The history of the formation of the Pan African paediatric surgical Association (PAPSA).

Political change in the 1990s in Southern Africa influenced the long awaited formation of a children's surgical association in Africa. Here, within is the historical account of the formation of the Pan African Association of Paediatric Surgeons (PAPSA). The basis of the argument for the formation of PAPSA was that paediatric surgeons from Africa have a wealth of experience and special knowledge of diseases affecting children in the African continent which differ substantially from those encountered in other regions of the world. This historical account is mainly from documentation by 2 of the organisations founding members.

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.

Adherence to Referral Criteria at Admission and Patient Management at a Specialized Burns Centre: The Case of the Red Cross War Memorial Children's Hospital in Cape Town, South Africa.

Referral guidelines for burn care are meant to assist in decision-making as regards patient transfer and admissions to specialized units. Little is known, however, concerning how closely they are followed and whether they are linked to patient care. This is the object of the current study, focused on the paediatric burns centre of the Red Cross War Memorial Children's Hospital in Cape Town, South Africa. All patients admitted to the centre during the winters of 2011-2015 (n = 1165) were included. The patient files were scrutinized to clarify whether the referral criteria in place were identified (seven in total) and to compile data on patient and injury characteristics. A case was defined as adherent to the criteria when at least one criterion was fulfilled and adherence was expressed as a percentage with 95% confidence intervals, for all years aggregated as well as by year and by patient or injury characteristics. The association between adherence to any individual criterion and hospital care (surgery or longer length of stay) was measured using logistic regressions. The overall adherence was 93.4% (100% among children under 2 years of age and 86% among the others) and it did not vary remarkably over time. The two criteria of "injury sustained at a specific anatomical site" (85.2%) and "young age" (51.9%) were those most often identified. Children aged 2 years or older were more likely to undergo surgery or to stay longer than those of young age (although a referral criterion) and so were those with higher injury severity (a referral criterion). In this specialized paediatric burns centre, children are admitted mainly according to the guidelines. However, given the high prevalence of paediatric burns in the region and the limited resources at the burns centre, adherence to the guidelines need to be further studied at all healthcare levels in the province.

'Getting under our skin': Introducing banked allograft skin to burn surgery in South Africa.

Deceased donor skin possesses many of the properties of the ideal biological dressing, and a well-stocked skin bank has become a critically important asset for the modern burn surgeon. Without it, managing patients with extensive burns and wounds becomes far more challenging, and outcomes are significantly worse. With the recent establishment of such a bank in South Africa, the challenge facing the medical fraternity is to facilitate tissue donation so that allograft skin supply can match the enormous demand.

Acticoat™ stimulates inflammation, but does not delay healing, in acute full-thickness excisional wounds.

Acticoat™ has antimicrobial and anti-inflammatory effects which aid wound healing. However, in vitro studies indicate that Acticoat™ is cytotoxic and clinical and in vivo studies suggest that it may delay healing in acute wounds. Therefore, this study investigated the effects of Acticoat™ on healing in acute full-thickness excisional wounds. Using a porcine model, healing was assessed on days 3, 6, 9 and 15 post-wounding. Five wounds dressed with Acticoat™ and five wounds dressed with polyurethane film (control) were assessed per day (n = 40 wounds). The rate of healing, inflammatory response, restoration of the epithelium and blood vessel and collagen formation were evaluated. No difference was found in the rate of healing between wounds treated with Acticoat™ and the control wounds. Inflammation was increased in Acticoat™-treated wounds on day 3 post-wounding compared to the control wounds. However, by day 15 post-wounding, the epithelium of the Acticoat™-treated wounds closely resembled normal epithelium. Acticoat™-treated wounds also contained a higher proportion of mature blood vessels, and differences in collagen deposition were apparent. Despite inducing an inflammatory response, Acticoat™ did not delay healing in acute wounds. Conversely, the improved quality of the epithelium and blood vessels within Acticoat™-treated wounds indicates that Acticoat™ has a beneficial effect on healing.

Pseudomonas aeruginosa burn wound infection in a dedicated paediatric burns unit.

BACKGROUND: Pseudomonas aeruginosa infection is a major cause of morbidity in burns patients. There is a paucity of publications dealing with this infection in the paediatric population. We describe the incidence, microbiology and impact of P. aeruginosa infection in a dedicated paediatric burns unit. METHODS: A retrospective review of patients with clinically significant P. aeruginosa infection between April 2007 and January 2010 in the burns unit at Red Cross War Memorial Children's Hospital in Cape Town, South Africa, was performed. RESULTS: During the 36-month study period, 2 632 patients were admitted. Of 2 791 bacteriology samples sent for microscopy, culture and sensitivity, 406 (14.5%) were positive for P. aeruginosa. Thirty-four patients had clinically significant P. aeruginosa wound infection, giving an incidence of 1.3%. Three patients had loss of Biobrane or allografts, and 23 cases of skin graft loss occurred in 18 patients. An average of 12 dressing days was needed to obtain negative swabs. All isolates were sensitive to chlorhexidine, whereas 92.5% were resistant to povidone-iodine. Piperacillin-tazobactam was the systemic antimicrobial to which there was most resistance (36.1%), and tobramycin had least resistance (3.3%). CONCLUSIONS: The incidence of clinically significant burn wound infection is low in our unit, yet the morbidity due to debridement and re-grafting is significant. We observed very high resistance to topical povidone-iodine. Resistance to systemic antimicrobials is lower than that reported from other burns units.

Our surgical heritage: the role of the Department of Paediatric Surgery in the development of paediatric surgery in Cape Town, in Africa, and around the world.

The Department of Paediatric Surgery at the University of Cape Town has made a remarkable contribution to the academic body of knowledge of Paediatric Surgery both in South Africa and around the world. It has played a key role in the development of the specialty in South Africa and through the South African diaspora has trained many paediatric surgeons who have made their mark internationally. More recently it has become a major focus of teaching and training for African paediatric surgeons. This article traces this legacy through its origins in the early 1920s to its current prominent position in the world paediatric surgical community.

Training and practice of pediatric surgery in Africa: past, present, and future.

The evolution and recognition of pediatric surgery as a specialty in Africa can be divided into 4 distinct phases, starting from early 1920s till the present. The pace of development has been quite variable in different parts of Africa. Despite all recent developments, the practice of pediatric surgery in Africa continues to face multiple challenges, including limited facilities, manpower shortages, the large number of sick children, disease patterns specific to the region, late presentation and advanced pathology, lack of pediatric surgeons outside the tertiary hospitals, and inadequate governmental support. Standardization of pediatric surgery training across the continent is advocated. Collaboration with well-established pediatric surgical training centers in Africa and other developed countries is necessary. The problems of delivery of pediatric surgical services need to be addressed urgently, if the African child is to have access to essential pediatric surgical services like his or her counterpart in the high-income parts of the world.

Pediatric trauma care in Africa: the evolution and challenges.

Childhood trauma is one of the major health problems in the world. Although pediatric trauma is a global phenomenon in low- and middle-income countries, sub-Saharan countries are disproportionally affected. We reviewed the available literature relevant to pediatric trauma in Africa using the MEDLINE database, local libraries, and personal contacts. A critical review of all cited sources was performed with an emphasis on the progress made over the past decades as well as the ongoing challenges in the prevention and management of childhood trauma. After discussing the epidemiology and spectrum of pediatric trauma, we focus on the way forward to reduce the burden of childhood injuries and improve the management and outcome of injured children in Africa.

Urethroplasty and vaginoplasty by a single small bowel interposition graft: a novel technique for cloacal reconstruction.

Despite the advances in surgical management of anorectal malformations, repair of cloacal malformations remains a challenging condition for many pediatric surgeons. Posterior cloaca is present where urogenital sinus deviates posteriorly to form a cloaca with rectum. Often, achieving adequate urethral and vaginal length can be challenging. We describe a novel technique where a loop of small bowel on a single mesenteric blood supply could be constructed in 2 functional tubular structures: one for urethral and the other for vaginal replacement.

Long-term urological outcomes in six sets of conjoined twins.

AIM: To review the long-term urological outcomes of six sets of ischiopagus and pygopagus conjoined twins. Emphasis is placed on the particular genitourinary challenges of separation, reconstruction and monitoring of these patients. PATIENTS AND METHODS: We performed a longitudinal, retrospective analysis of six sets of conjoined twins who presented to a single center and describe their long-term urological outcomes. RESULTS: Six sets of ischiopagus (4) and pygopagus (2) conjoined twins presented from 1993 to 2003 and have been followed up for a mean of 12 years (range 7-17 years). Separation was achieved in 5/6 cases; the remaining one died of intestinal perforation and resultant sepsis. One further child died of malaria after separation. Patterns of genitourinary anatomy found in these conjoined twins are described. Urinary continence was achieved in 2/6 ischiopagus and 3/4 pygopagus twins. Renal failure has developed in one child. Urinary tract infections have been common. Secondary urological surgery has been required in 3/6 ischiopagus twins, usually to perform an incontinent urinary diversion. CONCLUSION: Complex urological problems occur in ischiopagus and pygopagus conjoined twins. Beyond the challenge of surgical separation, they continue to provide management challenges requiring secondary reconstructive surgery and close urological monitoring.

The Ventral V-plasty: a simple procedure for the reconstruction of a congenital megaprepuce.

A buried penis secondary to a megaprepuce is defined clinically by a phimosis, failure of the corporal bodies to inhabit a variably deficient penile shaft skin and a basal hemispheric ballooning of the penis during micturition. Anatomically, it describes a condition in which a normal phallus is trapped within normal prepubic connective tissue by the excessive skin of a megaprepuce and a variable abundance of dartos fascia. Many surgical procedures have been described to correct this deformity, suggesting that no single method has a clear advantage. Most of them rely on relatively complex skin flaps or on the abnormal megapreputial tissue for reconstruction of the deficient ventral shaft skin. Herein, the authors describe an alternative technique for ventral skin coverage, the Ventral V-plasty. This surgical procedure allowed for the favorable reconstruction of 10 consecutive children with a buried penis secondary to a megaprepuce. This technique is distinguished by its simplicity and consistent, pleasing cosmetic results.

Fetal extraperitoneal rectal perforation: a rare neonatal emergency.

PURPOSE: Intraperitoneal bowel perforation may occur in utero as a result of a variety of abnormalities and typically results in sterile meconium ascites, pseudocysts, and/or calcification in the fetus. On the other hand, extraperitoneal bowel perforation in intrauterine life is extremely rare. The object of this report is to present our experience of prenatal extraperitoneal rectal perforation, defining the clinical presentation, management, and progress. METHODS AND MATERIALS: Nine babies who were identified from 2 centers in the Republic of South Africa with fetal extraperitoneal rectal perforation are presented. The details of these babies were obtained retrospectively from the case notes. RESULTS: All patients presented at or shortly after birth with air and meconium tracking below the pelvic floor manifesting as either an expanding, meconium-stained aerocele or with perirectal spreading sepsis. Where abdominal signs were present, laparotomy confirmed the extension of the meconium perforation into the peritoneal cavity. Management was by diverting colostomy, drainage of the perineal collection, and supportive therapy. A posterior approach to the rectum and excision of a fibrotic section of the lower rectal wall was performed in one case. One case developed rectal stenosis that was treated by dilatation before colostomy closure. In all the other cases, digital examination performed before colostomy closure ruled out significant narrowing. There was no mortality, and the site of the rectal perforation healed in all cases to leave good anorectal function after treatment. CONCLUSIONS: Fetal extraperitoneal perforation is extremely rare, but the clinical features are easily recognizable, and when appropriate therapy is instituted, the outcome is likely to be good with normal anorectal function to be expected in the long-term. The exact cause of the condition is unknown.

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.

Situs inversus abdominalis and duodenal atresia: a case report and review of the literature.

Fewer than 20 patients born with situs inversus and duodenal atresia have been reported in the literature. We present a patient with this condition. A newborn baby presented shortly after birth with persistent bilious vomiting. An abdominal radiograph showed a right-sided stomach bubble and a second bubble on the left - typical of duodenal atresia but with mirror image configuration. Laparotomy confirmed the diagnosis of situs inversus abdominalis, which was also demonstrated by contrast studies and ultrasound. Duodenoduodenostomy was performed and the patient discharged on day 8 postoperatively. Situs inversus is associated with other congenital malformations including splenic malformations, left-sided liver and cardiac abnormalities; it is rarely associated with duodenal atresia. Duodenal obstruction in the presence of situs inversus has been described, including obstruction due to a web, stenosis, pre-duodenal portal vein and complete atresia. The patient presented in this paper had a duodenal web in the second part of the duodenum. Before undertaking surgery it is important to establish the presence of associated gastrointestinal and cardiac abnormalities.

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.

Laparoscopic insertion with tip suturing, omentectomy, and ovariopexy improves lifespan of peritoneal dialysis catheters in children.

UNLABELLED: Over the past two decades, chronic peritoneal dialysis (PD) has emerged as the first choice pediatric dialysis modality. A recent study visually identified the cause of malfunction of PD catheters at the Red Cross Children's Hospital in Cape Town. The reasons that could be found, lead to changed Tenckhoff insertion-techniques from open to laparoscopic. This included suturing of the tip, omentectomy and ovarian-pexy by laparoscopy. In the present paper we prospectively analyzed, if changed insertion technique lead to an improved outcome. PATIENTS AND METHODS: 26 Patients required 36 laparoscopic Tenckhoff insertions during the period August of 2003 and July of 2006. Overall a total number of 222.5 catheter-months have been observed. Laparoscopic insertion technique required 3 port placements. The tip of the catheter was sutured to pelvic peritoneum, omentectomy performed through a port site and ovariopexy done when required. RESULTS: The mean lifespan of all Tenckhoff's was 6.4 +/- 6.3 months. The tip of the catheter was sutured 20 times, omentectomy done in 9 cases and 6 patients underwent ovarian pexy. In the group where the tip was sutured to the pelvic peritoneum catheter life was 8.4 months compared to the non-sutured group which was only 4.1. Omentectomy lead to an overall catheter survival of 8.0 months compared to the no omentectomy group, which had a survival of 5.8 months. The complication-rate concerning early problems and malfunctions in the sutured and omentectomy groups was also lower. Patients who underwent both, suturing of the tip and omentectomy had no malfunctions at all. CONCLUSION: Omentectomy and suturing the tip can lower the complication-rate and prolong catheter survival. Using these procedures could decrease costs and morbidity and prevent patients from having further operations.

Management of traumatic complete pancreatic fracture in a child: case report and review of literature.

UNLABELLED: Blunt abdominal trauma is the most common cause of pancreatic injury in children. Laparoscopic distal pancreatectomy in a child with complete duct disruption has not been reported in the literature in children, although it has been well described in adults. METHODS: In this paper report a case of a 7-year-old male, with grade 4 pancreatic trauma, who was treated nonoperatively in the acute phase and subsequently by laparoscopic distal pancreatectomy 3 months after the trauma. DISCUSSION: Although in adults the surgical management of grade 3-4 pancreatic traumatic injury is well described, including the laparoscopic approach, no report of laparoscopic distal pancreatectomy was found in the literature. We would like to emphasize the importance of using a conservative management in the acute phase of pancreatic injury, including grade 4 injuries. After this phase, the use of the high-definition computed tomography scan and endoscopic retrograde pancreatography were fundamental. CONCLUSION: Magnification of laparoscopic technique allowed us to identify the structures much better than open surgery.

Adverse reactions to the Bacillus Calmette-Guerin vaccine in HIV-positive infants.

BACKGROUND: The Bacillus Calmette-Guerin (BCG) vaccine is routinely administered to newborn infants in South Africa. In 2000, a new vaccine, the Danish 1331 strain, was introduced into the Western Cape region. Red Cross Children's Hospital subsequently documented an increase in the number of complications arising from the new vaccine. Since 2004, HIV-positive infants have been treated with highly active antiretroviral therapy (HAART). Coinciding with the roll out of HAART there has been a significant and apparently paradoxical worsening of the complications of the BCG vaccine. METHODS: A retrospective analysis of all HIV-positive infants referred to the surgical department for management of BCG vaccine complications. RESULTS: Fifteen infants were included in this study; they were all HIV-positive. Fourteen infants received HAART. In 10 patients, the implementation of HAART predated the complications of the BCG vaccine by an average of 1.4 months. CONCLUSION: We believe this to be the first description of BCG-associated immune reconstitution inflammatory syndrome. The implications for the operating surgeon are the unique management strategies that should be applied to this disease process and the ongoing research to determine which of these strategies is the most effective.