Adherence to General Medical Council guidance regarding disclosure of alternative treatments during the consent process.

INTRODUCTION: General Medical Council (GMC) guidelines dictate that reasonable alternatives to treatment should be disclosed during the consent process. We aimed to determine whether GMC guidelines on disclosure of alternatives during consent are being followed in a real-world example which is disclosure of non-operative management as an alternative to appendicectomy in uncomplicated paediatric appendicitis. METHODS: We undertook a retrospective single-centre observational study and national consultant specialist paediatric surgeon survey. Two groups of 50 consecutively treated children (<16 years) with acute uncomplicated appendicitis were included in the observational study during two periods. UK-based consultant surgeons who treat appendicitis were included in the national survey. The main outcomes were disclosure and use of non-operative management (NOM) as an alternative to appendicectomy. RESULTS: Overall, in the observational study, NOM was disclosed in 30 (30%) children and 77% (23/30) opted for this treatment method when it was disclosed. There were 83 survey respondents representing all 25 eligible specialist paediatric surgery centres. Ten (12%) consultants reported routinely offering NOM, 39 (47%) offer it in select circumstances, and 34 (41%) never offer NOM. Only 25 (30%) respondents always disclose NOM as an alternative to appendicectomy, whereas 22 (27%) never do. Consultants who never disclose NOM are more likely to prefer appendicectomy over NOM compared with those who always disclose it (p<0.001). CONCLUSION: In this illustrative clinical scenario, observed and reported practice regarding disclosure of alternative treatments during the consent process do not meet GMC guidance. This risks depriving children and caregivers of a choice that they are entitled to.

Scope and feasibility of operating on the neonatal intensive care unit: 312 cases in 10 years.

PURPOSE: To report the scope, feasibility and learning experience of operating on neonates on the neonatal intensive care unit (NICU). METHODS: (1) Review of all NICU operations performed by general neonatal surgeons over 10 years; (2) 6-month prospective comparison of procedures performed in NICU or operating room; (3) structured interviews with five surgeons with 1-13 years experience of operating on NICU. RESULTS: 312 operations were performed in 249 infants. Median birth weight was 1,494 g (range 415-4,365), gestational age 29 weeks (22-42), and age at operation 25 days (0-163). Nearly half (147) were laparotomy for acute abdominal pathology in preterm, very low birth-weight infants There were no surgical adverse events related to location of surgery. Surgeon satisfaction with operating on NICU for this population was high (5/5). Several factors contribute to making this process a success. CONCLUSIONS: This is the largest reported series of general neonatal surgical procedures performed on NICU. Operating on NICU is feasible and safe, and a full range of neonatal operations can be performed. It removes risks associated with neonatal transfer and is likely to reduce physiological instability. We recommend this approach for all ventilated neonates and urge neonatal surgeons to operate at the cotside of unstable infants.

Checking pregnancy status in adolescent girls before procedures under general anaesthesia.

OBJECTIVE: Surgery, ionising radiation and anaesthesia in the presence of an undetected pregnancy could be harmful. British guidelines state that female patients of 'childbearing age' should have their pregnancy status established before surgery. Approaching this topic with an adolescent girl can be challenging. DESIGN: The authors conducted an observational study and a survey in their institution and a national survey of Association of Paediatric Anaesthetists (APA) linkmen. SETTING: Local: Southampton. National: UK. RESULTS: Both surveys demonstrate widespread concerns about inconsistent and informal practices. Only 45% of respondents in the authors' institution stated they ask adolescent girls if they could be pregnant. 40% of APA linkmen were unaware of national guidelines. CONCLUSIONS: This work illustrates the need for consistent national guidance. We propose that all girls who have reached menarche should be routinely offered a urine pregnancy test before any procedure under general anaesthesia.

A new intraperitoneal technique for safe repair of incarcerated inguinal hernias: a novel technique to consider.

INTRODUCTION: Inguinal herniotomy is one of the most common operations performed by paediatric surgeons. Most procedures are elective operations but occasionally the hernia is incarcerated. Complications after emergency repair of an incarcerated hernia repair are higher than those associated with elective surgery because of congestion of the sac. Operative techniques described so far include low, high, preperitoneal and laparoscopic approaches. We describe here an open intraperitoneal technique. METHODS: 6 boys aged between 4-40 weeks were taken urgently to the operating room for incarcerated inguinal hernia repair. All boys were operated on using an open intraperitoneal technique. In this technique, the congested sac does not need to be separated from the adherent vas and vessels within the inguinal canal, the reduced bowel can be inspected with 3D visualisation and resected if necessary, and the peritoneum can be easily incised and sutured through a single skin incision, reducing the risk of complications and providing superior cosmesis. RESULTS: All patients had very good postoperative outcomes with no complications. CONCLUSIONS: The technique can be used not only for incarcerated inguinal hernia repair but also for problematic repairs of recurrent hernias. Disadvantages include postoperative hydrocele formation and failure to inspect the testicle.

Trans-anastomotic tubes reduce the need for central venous access and parenteral nutrition in infants with congenital duodenal obstruction.

PURPOSE: To determine the effect of trans-anastomotic tube (TAT) feeding on outcome following repair of congenital duodenal obstruction (CDO). METHODS: Retrospective comparative study of all infants with CDO over 10 years. Data are median (range). Mann-Whitney U test and Fisher's exact test were used. RESULTS: Of 55 infants with CDO (48 atresia, 7 stenosis), 17 were managed with a TAT, 38 without. Enteral feeds were commenced earlier in infants with a TAT compared to those without (TAT 2 days post-repair [1-4] vs. no-TAT 3 days post-repair [1-7]; p = 0.006). Infants with a TAT achieved full enteral feeds significantly sooner than those without (TAT 6 days post-repair [2-12] vs. no-TAT 9 days post-repair [3-36]; p = 0.005). Significantly fewer infants in the TAT group required central venous catheter (CVC) placement and parenteral nutrition (PN) than in the no-TAT group (TAT 2/17 vs. no-TAT 28/38, p < 0.0001). There were six CVC-related complications (5 infections, 1 PN extravasation) and four TATs became displaced and were removed before achieving full enteral feeds. One infant with a TAT with trisomy 21 and undiagnosed Hirschsprung disease developed an anastomotic leak and jejunal perforation requiring re-operation. CONCLUSIONS: A TAT significantly shortens time to full enteral feeds in infants with CDO significantly reducing the need for central venous access and PN.

Consent: luck or law?

INTRODUCTION: The aim of this study was to identify whether clinicians are obtaining a valid consent for surgery, and ascertain the parents' perception of parental responsibility when giving consent for their children. PATIENTS AND METHODS: Adults consenting for 100 children were questioned about the possession of parental responsibility, and their understanding of the concept. RESULTS: Only 4 children had surgery without valid consent, these forms being signed by fathers without parental responsibility. However, only 5% of the sample stated that parental responsibility was required. More than 80% believed that cohabitation was a sufficient qualification to provide consent; fewer than 15% recognising any influence of marital status. It seems that, although 96% of consenters had parental responsibility, the validity of their consent was a product more of luck than of lawful behaviour. CONCLUSIONS: The results demonstrate a wide gulf between the standards set by the Children Act 1989 and common practice, as perceived by parents. Furthermore, this reveals a significant disparity between the principles behind the statute, and the role that parents believe that they play in the 21st century.

Diversion procto-colitis: response to treatment with short-chain fatty acids.

BACKGROUND/PURPOSE: Diversion procto-colitis (DPC) results from a deficiency of luminal short-chain fatty acids (SCFAs). Endoscopic and histopathologic features of the disorder are almost universally present in defunctioned bowel, but symptomatic DPC is less common. METHODS: Five children with symptomatic DPC underwent endoscopy and rectosigmoid biopsies. An endoscopic index (EI) was used to quantify disease severity. An SCFA mixture was administered into the defunctioned bowel. RESULTS: A good clinical response and improvement in the endoscopic index occurred in all children. Undiversion or rectal excision was carried out in 4 and was curative in each case. One child is awaiting a redo pull through. CONCLUSIONS: DPC should be considered in children with a defunctioned colon presenting with evidence of colitis. Histopathology provides supportive evidence and SCFAs may provide effective relief of symptoms. Stoma reversal or rectal excision is curative.

Unexpected nitrosyl-group bending in six-coordinate [M(NO)](6) sigma-bonded aryl(iron) and -(ruthenium) porphyrins.

The six-coordinate nitrosyl sigma-bonded aryl(iron) and -(ruthenium) porphyrin complexes (OEP)Fe(NO)(p-C(6)H(4)F) and (OEP)Ru(NO)(p-C(6)H(4)F) (OEP = octaethylporphyrinato dianion) have been synthesized and characterized. Single-crystal X-ray structure determinations reveal an unprecedented bending and tilting of the MNO group for both [MNO](6) species as well as significant lengthening of trans axial bond distances. In (OEP)Fe(NO)(p-C(6)H(4)F) the Fe-N-O angle is 157.4(2) degrees, the nitrosyl nitrogen atom is tilted off of the normal to the heme plane by 9.2 degrees, Fe-N(NO) = 1.728(2) A, and Fe-C(aryl) = 2.040(3) A. In (OEP)Ru(NO)(p-C(6)H(4)F) the Ru-N-O angle is 154.9(3) degrees, the nitrosyl nitrogen atom is tilted off of the heme normal by 10.8 degrees, Ru-N(NO) = 1.807(3) A, and Ru-C(aryl) = 2.111(3) A. We show that these structural features are intrinsic to the molecules and are imposed by the strongly sigma-donating aryl ligand trans to the nitrosyl. Density functional-based calculations reproduce the structural distortions observed in the parent (OEP)Fe(NO)(p-C(6)H(4)F) and, combined with the results of extended Hückel calculations, show that the observed bending and tilting of the FeNO group indeed represent a low-energy conformation. We have identified specific orbital interactions that favor the unexpected bending and tilting of the FeNO group. The aryl ligand also affects the Fe-NO pi-bonding as measured by infrared and (57)Fe Mössbauer spectroscopies. The solid-state nitrosyl stretching frequencies for the iron complex (1791 cm(-)(1)) and the ruthenium complex (1773 cm(-)(1)) are significantly reduced compared to their respective [MNO](6) counterparts. The Mössbauer data for (OEP)Fe(NO)(p-C(6)H(4)F) yield the quadrupole splitting parameter +0.57 mm/s and the isomer shift 0.14 mm/s at 4.2 K. The results of our study show, for the first time, that bent Fe-N-O linkages are possible in formally ferric nitrosyl porphyrins.

Does duodenal atresia and stenosis prevent midgut volvulus in malrotation?

Thirty-six of the 64 (56%) neonates with duodenal atresia and stenosis who were retrospectively reviewed had associated malrotation. A volvulus neonatorum (age: <28 days) was not encountered among these patients. Can the duodenal atresia and stenosis act as a flood gate mechanism, in the prevention of volvulus in these children?

Opsite skin closure in day case paediatric surgery: is a subcuticular suture necessary?

Opsite skin closure without skin suture was compared with subcuticular Vicryl in a randomized trial in children undergoing day-case surgery for hernia, hydrocele or undescended testis. Ninety-nine groin closures were randomized, 47 to Opsite and 52 to subcuticular Vicryl. There was no difference in the duration of operation or in the cosmetic appearance of the wounds. Complications were all minor and similar in both groups. Opsite alone is suitable as a skin closure for the groin wounds in children.

Use of the appendix in reconstructive surgery: a case against incidental appendicectomy.

Ignored for years, the appendix is once again being promoted as having useful surgical potential, notably in the management of incontinence. Incidental and prophylactic appendicectomy with their established complications become less easy to justify as the incidence of appendicitis declines. The role of the appendix in reconstructive surgery is reviewed, with particular reference to urinary reconstruction and to the treatment of chronically constipated or faecally incontinent children by use of the antegrade continence enema.

Urea production and recycling in neonates.

Urea represents 15% of the nitrogen in breast milk, but its functional significance is unclear. We have proposed that the urea may be utilised as a valuable source of nitrogen in neonates. We report the first measurements of urea kinetics in newborn, full-term infants. Six neonates received a continuous nasogastric infusion of 15N15N-urea over 24 hours. Urine was collected every 2 hours and the isotopic enrichment in urea was measured by mass spectrometry. Urea kinetics were calculated by the method of Jackson. The urea production rate was 17.3 mmol/kg/d (range, 15.6 to 19.2), but the urinary urea excretion rate, 3.5 mmol/kg/d (range, 1.2 to 4.9), was only 20% of production. Hence, 80% of urea produced was hydrolysed in the colon and the nitrogen made available for further metabolism. These data show that urinary urea excretion is a poor indication of urea production in the newborn and that there is substantial salvaging of urea nitrogen by the colon.

Surgical presentation of Kawasaki disease (mucocutaneous lymph node syndrome).

Five patients with Kawasaki disease (mucocutaneous lymph node syndrome) are reported whose varied presentations included acute abdominal pain, peripheral arterial aneurysms, digital gangrene and sterile pyuria and whose presenting pathology ranged from hydrops of the gallbladder to enteric pseudo-obstruction. As the complications of the disease can usually be managed without resort to surgery, which is associated with a mortality rate of up to 25 per cent, the recognition of Kawasaki disease will prevent hazardous and unnecessary laparotomy.

Life-threatening complications during anaesthesia in a patient with a ventriculo-atrial shunt and pulmonary hypertension.

A 6-year-old patient with hydrocephalus who underwent revision of a ventriculo-atrial shunt is described. Anaesthesia was complicated by the occurrence of systemic hypertension and arterial hypoxaemia. The patient was subsequently found to have pulmonary hypertension secondary to recurrent pulmonary thromboembolism. The pathophysiological mechanisms for the patient's deterioration are discussed and the anaesthetic management of children with pulmonary hypertension is outlined. It is concluded that patients with a ventriculo-atrial shunt who present for surgery should be screened carefully for the presence of pulmonary hypertension.

Feeding regimens after pyloromyotomy.

In a prospective randomized study three different feeding regimens after operation were compared in 74 babies with infantile hypertrophic pyloric stenosis: gradual regarding of feeds over 48 h (regimen 1), rapid regarding of feeds over 16 h (regimen 2), and initial starvation followed by full normal feeds at 24 h (regimen 3). No significant difference between the treatment groups was found either in episodes of vomiting after operation (regimen 1, 2.9 episodes in 21 patients; regimen 2, 3.6 episodes in 28 patients; regimen 3, 3.6 episodes in 25 patients) or in the mean duration of postoperative hospital stay (regimen 1, 59.3 h; regimen 2, 47.8 h; regimen 3, 56.7 h). We conclude that vomiting following pyloromyotomy is self-limiting and independent of the timetable or composition of the postoperative dietary regimen.

Gastric neurofibroma in an adolescent.

A 14-year-old white girl with a large, bleeding, ulcerated mass of the stomach was treated with surgical excision. Histologically, the mass was a plexiform neurofibroma. These tumors are uncommon, especially in the pediatric age group, and are best treated by surgical resection.