Perianal abscess in childhood.

Perianal abscess (PA) is a common condition encountered in childhood, but its optimal primary treatment is uncertain. Treatment of PA by incision and drainage (I & D) alone is associated with an unacceptably high recurrence rate, either as fistula-in-ano (FIA) or as PA. To identify possible causes of recurrence and assess the value of concomitant laying open of a fistulous tract at the time of primary incision and drainage, the case notes of all children who presented to our institution with a PA between January 1992 and January 1997 were reviewed retrospectively. Thirty-three cases were identified (29 boys and 4 girls). A fistulous tract was identified and laid open at the time of primary drainage in 20 cases, whilst 13 were treated by I & D alone. Following primary drainage, there were 7 recurrences (21.2%) (FIA 5 and PA 2). All recurrences had been primarily treated by drainage alone, whilst there were no recurrences in patients who had also undergone fistulotomy at the time of primary drainage. Thus the primary treatment of PA in childhood should involve a careful search for a coexisting fistula and treatment of this by fistulotomy.

Prophylactic gastropexy in the asplenia syndrome.

The asplenia [Ivemark] syndrome (AS) is the association of congenital absence of the spleen with a variety of visceral abnormalities, predominantly of the cardiovascular system. Varying degrees of malrotation and malfixation of the bowel are common in this condition, and the occurrence of catastrophic gastric volvulus due to malfixation of the bowel has been reported. With the improvement in long-term outlook for these patients with modern cardiac surgery and prophylactic antibiotics, the intra-abdominal anomalies have become increasingly significant. This paper draws attention to the prophylactic treatment of gastric malfixation in the AS through the presentation of two cases in which gastropexy was performed.

Oesophageal substitution by jejunal free graft: follow-up data and an evaluation.

We have developed a new technique for oesophageal substitution using a jejunal free graft and now present a 3-5 year follow-up study of five infants who had this procedure performed for long gap oesophageal atresia. Swallowing is excellent in two, good in two and fair in one. We conclude that jejunal interposition, though technically difficult, can produce excellent results and we particularly recommend this technique, when the oesophageal substitute has to reach high in the thorax or to the neck.

Mortality after an antenatal diagnosis of foetal uropathy.

A longitudinal study identified 987 foetal uropathies over a 13-year period. There were 147 deaths. Forty infants died as a result of a lethal uropathy in the presence of associated congenital anomalies. Sixty-six infants with an isolated uropathy died. There were 4 cot deaths, 2 obstetric related deaths, and 34 deaths caused by associated congenital anomalies. There was 1 termination of pregnancy following a false-positive diagnosis of uropathy. Of the 147 deaths, 34 occurred postnatally, 20 within 24 hours. Twenty-nine infants were spontaneously aborted. There were 78 terminations of pregnancy, 43% occurring after 24 weeks of gestation. There was complete concordance in antenatal and postnatal diagnoses in 113 (77%) cases and incomplete concordance in 19 (13%) cases. There were 14 false-negative diagnoses (9.5%). The relative frequency of different lethal congenital uropathies is detailed. Accurate in utero diagnosis of foetal uropathy and hence prediction of outcome is possible. The relatively late gestational age at time of diagnosis remains a constraint when fatal malformations would otherwise prompt termination of pregnancy.

Injury to the common iliac artery during suction rectal biopsy.

A case of injury to the common iliac artery during suction rectal biopsy is described. Factors that might influence the incidence of complications after suction rectal biopsy are considered. Suction rectal biopsy, although invaluable in establishing the diagnosis of Hirschsprung's disease, is a potentially dangerous technique and should not be delegated to an inexperienced operator. In neonates it is unwise to take biopsy specimens more than 4 cm from the anal verge. A posterior approach is likely to be safer than an anterior or lateral one.

Juvenile xanthogranuloma with extra-cutaneous lesions--a case report.

Juvenile xanthogranuloma (JXG) is a rare affliction of early childhood comprising cutaneous and deep-seated lesions. Accurate diagnosis is important as the condition is self-limiting with spontaneous regression over a period of months. A case of congenital JXG is reported and the literature briefly reviewed.

Development of a technique for jejunal interposition in long-gap esophageal atresia.

Primary anastomosis is the treatment of choice in esophageal atresia. There remains a small number of infants in whom establishment of primary esophageal continuity fails or is unrealistic due to a long gap. Esophageal reconstruction then necessitates an interposition/transposition procedure. The most widely used tissues are colon and stomach but each has significant limitations. Jejunum is theoretically the ideal esophageal substitute being of appropriate diameter and having good peristaltic activity. Its use in the past has been limited by the precarious blood supply and restricted length which result from the short mesenteric pedicle. We have attempted to resolve these limitations by using a microvascular anastomosis to augment the blood supply to the proximal jejunum in a series of 5 cases (2 pure atresias, 1 esophageal atresia with proximal fistula, and 2 atresias with distal fistula). In a sixth case (atresia with distal fistula) a free jejunal graft was used. In one case initial surgery was confined to cervical esophagostomy and feeding gastrostomy, in the remaining 5 interposition was necessitated by failure of a primary repair. The age at surgery ranged from 8 to 16 months. The development of the technique and outcome in each patient is described. We conclude that a free jejunal graft is preferable to augmenting the native blood supply and intend to continue with this latter technique.

Risk of neoplasia and malignancy in "dominant" thyroid swellings.

OBJECTIVE: To determine the risk of neoplasia and malignancy in "dominant" thyroid swellings. DESIGN: Prospective analysis during six years. SETTING: Thyroid clinic serving the Grampian region. PATIENTS: 574 consecutive patients presenting with a discrete thyroid swelling, of whom 179 (31%) were classified clinically as having a dominant area of enlargement within a multinodular gland. RESULTS: After clinical and cytological assessment 77 dominant swellings were excised. Of the excised swellings, 45 were non-neoplastic and 32 neoplastic, including 11 malignant lesions. The minimum incidence of neoplasia and malignancy in all 179 dominant swellings was therefore 18% and 6% respectively. CONCLUSION: Dominant thyroid swellings should be regarded with greater clinical suspicion than has been traditional.

DNA aneuploidy in follicular thyroid neoplasia.

The potential value of DNA aneuploidy, in distinguishing benign from malignant follicular thyroid neoplasms, was studied. The nuclear DNA content of 65 follicular thyroid neoplasms (52 adenomas and 13 carcinomas) was determined by flow cytometric analysis of paraffin embedded material; in 58 cases preparations were technically satisfactory. In 22 follicular neoplasms DNA analysis was also performed on fresh material obtained by fine needle aspiration of surgical specimens. Cell cycle analysis was performed on both fresh and fixed specimens. An aneuploid DNA profile was found on analysis of fixed tissue in eight of 45 (18 per cent) follicular adenomas and four of 13 (31 per cent) follicular carcinomas. DNA aneuploidy was also found in six of the 22 (27 per cent) fresh preparations from follicular adenomas. The frequency of DNA aneuploidy in apparently benign and malignant follicular neoplasms was similar. Follicular thyroid neoplasia are best regarded as a single entity with a low incidence of local and distant spread. All follicular neoplasia are therefore best excised.

Management of isolated thyroid swellings: a prospective six year study of fine needle aspiration cytology in diagnosis.

OBJECTIVE: To audit the accuracy and impact on the frequency of operation of fine needle aspiration cytology of isolated thyroid swellings. DESIGN: Prospective analysis over six years of cytological predictions compared with histological findings. SETTING: Thyroid clinic serving the Grampian region. PATIENTS: 395 Consecutive patients presenting with an isolated thyroid swelling, 307 of whom underwent surgical excision. Analysis was confined to a subgroup of 283 patients with satisfactory aspirates who were operated on. RESULTS: The positive predictive value of aspiration cytology for detecting malignant disease was 100% and the sensitivity 83%. The sensitivity for the detection of neoplasia (frank malignancy together with follicular adenomas) was 76%. The specificity was 58% and the overall accuracy 69%. Recalculation of data in previous papers with strict criteria showed the accuracy of aspiration cytology to be variable and lower than is widely accepted. Since the introduction of aspiration cytology 21% fewer operations for isolated thyroid swellings have been performed. CONCLUSIONS: As a basis of selection for surgical excision of isolated thyroid swellings according to prediction of neoplasia fine needle aspiration cytology is less reliable than is widely accepted. It is an adjunct to management rather than a definitive test, and negative cytological results do not exclude neoplastic disease. Further study should take account of the implications of repeated clinic attendances for review and aspiration as these may culminate in delayed surgical treatment.

Comparison of flow cytometry with static densitometry in papillary thyroid carcinoma.

The prognostic accuracy of flow cytometric and static densitometric DNA analysis was compared in 31 patients who had undergone surgery for papillary thyroid carcinoma between 1959 and 1978 (median follow-up 18 years). There were five deaths from papillary thyroid carcinoma. Three of six patients with DNA aneuploid tumours on flow cytometry died (P greater than 0.05, Fisher's exact test) compared with four of eight patients whose tumours were found to be aneuploid by static densitometry (P less than 0.02). When quantitative analysis was applied to the static densitometry data, all five patients who died from papillary carcinoma were distinguished, with no false positives (P less than 0.002). The prognostic accuracy of flow cytometric DNA analysis is less than that of static densitometry in which morphological selection of malignant cells permits quantitative measurements. DNA analysis may add refinement to existing scoring systems in predicting the risk of death from papillary thyroid carcinoma. Such information could provide the basis for controlled prospective evaluation of bilateral resection as opposed to lobectomy in defined high risk patients. At present there is insufficient evidence upon which aneuploidy should be used as a determinant of the extent of operation for papillary thyroid carcinoma.

The resolution of aneuploid DNA stem lines by flow cytometry: limitations imposed by the coefficient of variation and the percentage of aneuploid nuclei.

Factors important in the resolution of cell sub-populations with differing DNA contents were investigated using an EPICS C flow cytometer. Software is available for the EPICS C which permits data from any two histograms to be superimposed or added together before display. Samples of fresh and archival thyroid tissue, stained with propidium iodide, were analysed on the flow cytometer and the peak channel number noted. The photomultiplier (PMT) voltage was increased and the sample analysed again producing a second histogram with a higher peak channel number. The two histograms were added together to simulate a cell suspension with two sub-populations with a different DNA content. By systematically altering the PMT voltage and the number of nuclei included in each analysis, it was possible to examine the importance of DNA index and the percentage of tumor cells with an aneuploid DNA content for both fresh and paraffin-embedded thyroid nuclei. The crucial importance of achieving a low coefficient of variation (CV) was demonstrated and consequently the reservations that pertain when archival material is studied, particularly in tumours where DNA aneuploidy is frequently expressed with a low DNA index.

Cystic change and neoplasia in isolated thyroid swellings.

During a 6-year prospective study of clinically isolated thyroid swellings (ITS), 148 (37 per cent) of 395 swellings were cystic as defined by the aspiration of fluid during fine needle aspiration cytology (FNAC). In the 106 (72 per cent) patients operated upon, 47 per cent of the cystic swellings were neoplastic and 14 per cent were malignant. In men 29 per cent of cystic swellings were malignant and 11 per cent in women. Only twelve cystic ITS were permanently abolished by aspiration and FNAC was inaccurate in predicting neoplasia. The incidence of malignancy in cystic ITS is higher than generally accepted and most cysts not abolished by aspiration should be removed.

Outcome of surgery for Graves' disease re-examined.

The outcome of surgery for Graves' disease in terms of early and late morbidity was studied in 161 patients undergoing subtotal thyroidectomy in the 10-year period 1976-1985. Eighty of these patients had a minimum follow-up of 5 years. There was a low operative morbidity and a zero mortality. The weight of thyroid tissue preserved (in the range 5-10 g) influenced the prevalence of hypothyroidism at one year and at five years. There was a cumulative incidence of hypothyroidism which could not be reliably predicted from biochemical results during the first year. Over 60 per cent of patients with subclinical hypothyroidism at 4 months (63 per cent) or 1 year (70 per cent) did not subsequently need thyroxine replacement within 5 years. Patients remained at risk of developing recurrent toxicity indefinitely and the risk was significantly greater in patients with small goitres (less than 50 g). Our results may be improved by leaving larger remnants (9-10 g) in most patients and smaller remnants (2-4 g) in those with small glands in whom alternative treatment, which is to be preferred, is not acceptable. After subtotal thyroidectomy for Graves' disease lifelong follow-up is necessary.

Polydioxanone or polypropylene for closure of midline abdominal incisions: a prospective comparative clinical trial.

Seven hundred and fifty-seven consecutive patients undergoing a midline abdominal incision were stratified according to age, sex, type of operation and degree of operative contamination and were randomly allocated to mass closure of the abdominal wall with continuous 4 metric polydioxanone (PDX; 374 patients) or continuous 4 metric polypropylene (PPL; 383 patients). Wound infection was less common with PDX (PDX 3.5 per cent; PPL 7.0 per cent; P less than 0.05) and there was one dehiscence in each group. The incidence of defective wounds in patients surviving 1 year was similar (7.7 per cent PDX; 9.7 per cent PPL) but the PPL suture had to be removed because of persisting wound pain or sinus formation in five patients. PDX is the preferred suture material for closure of midline abdominal incisions.