Diagnosis, management and outcome of splenic torsion; a systematic review of published studies.

INTRODUCTION: Splenic torsion is a rare condition but one that many surgeons will encounter once in their career. Management options are varied but due to the rarity of the condition there are no contemporary evidence-based summaries to inform a treating clinician. We aim to describe patterns of presentation and provide an evidence-based guide to the management. METHODS: A PRISMA structured meta-analysis was conducted of all published cases of splenic torsion and a recent case added from our institution. RESULTS: 408 cases were identified between 1888 and 2021 and a single case added from our institution, 312 cases were sourced from case reports and 96 from 40 case series. 8% of patients had a co-existing congenital anomaly and 28% an identified risk factor for splenic torsion. 82% required emergency surgery. A preoperative diagnosis is becoming more common, reaching 80% in 2020's. While spleen conserving surgery is feasible using a variety of techniques. splenectomy was the definitive management for the majority (82%). On histopatholy no occult disease was identified and a significant number of resected spleens were potentially viable; 32% were reported to be normal or congested and 14% demonstrated only partial or focal necrosis. DISCUSSION: Despite the significant publication bias implied by the methodology this is a large dataset in a rare condition. Splenic torsion frequently occurs in a premorbid population. The presence of a palpable mass in the context of abdominal pain should increase suspicion and trigger cross sectional imaging. Conservation of the spleen, using the techniques discussed, should be seriously considered.

At risk child: a contemporary analysis of injured children in London and the South East of England: a prospective, multicentre cohort study.

Background: Injury is a leading health burden in children yet relatively little is reported about the contemporary risks they face. Current national registry data may under-represent the true burden of injury to children. We aim to analyse contemporary patterns of paediatric trauma and identify current factors putting children at risk of injury. Methods: A 3-month prospective multicentre cohort evaluation of injured children across the London Major Trauma System was performed. All children receiving a trauma team activation; meeting National Institute for Health and Care Excellence CT head criteria; or admitted/transferred out due to trauma were included. Data were collected on demographics, mechanism and location of injury, and body region injured. The primary outcome was in-hospital mortality and secondary outcome was safeguarding concerns. Results: 659 children were included. Young children were more likely to be injured at home (0-5 years old: 70.8%, n=167 vs adolescents: 15.6%, n=31). Adolescents were more likely to be injured in the street (42.7%, n=85). Head trauma caused over half of injuries in 0-5 years old (51.9%, n=121). Falls were common and increasingly prevalent in younger children, causing 56.6% (n=372) of injuries. In adolescents, penetrating violence caused more than one in five injuries (21.9%, n=50). Most injured children survived (99.8%, n=658), however, one in four (26.1%, n=172) had safeguarding concerns and a quarter of adolescents had police, third sector or external agency involvement (23.2%, n=53). Conclusions: This study describes modern-day paediatric trauma and highlights the variance in injury patterns in young children and adolescents. Importantly, it highlights differences in actual rates of injuries compared with those reported from current national registry data. We must understand real risks facing 21st century children to effectively safeguard future generations. The results provide an opportunity to reassess the current approach to injury prevention, child and adolescent safeguarding, and public health campaigns for child safety.

Megarectum: systematic histopathological evaluation of 35 patients and new common pathways in chronic rectal dilatation.

AIMS: Megarectum is well described in the surgical literature but few contemporary pathological studies have been undertaken. There is uncertainty whether 'idiopathic' megarectum is a primary neuromuscular disorder or whether chronic dilatation leads to previously reported and unreported pathological changes. We sought to answer this question. METHODS: Systematic histopathological evaluation (in accord with international guidance) of 35 consecutive patients undergoing rectal excision surgery for megarectum (primary: n=24) or megarectum following surgical correction of anorectal malformation (secondary: n=11) in a UK university hospital with adult/paediatric surgical and gastrointestinal neuropathology expertise. RESULTS: We confirmed some previously reported observations, notably hypertrophy of the muscularis propria (27 of 35, 77.1% of patients) and extensive fibrosis (30 of 35, 85.7% of patients). We also observed unique and previously unreported features including elastosis (19 of 33, 57.6%) and the presence of polyglucosan bodies (15 of 32, 46.9% of patients). In contrast to previous literature, few patients had any strong evidence of specific forms of visceral neuropathy (5 of 35, including 3 plexus duplications) or myopathy (6 of 35, including 3 muscle duplications). All major pathological findings were common to both primary and secondary forms of the disease, implying that these may be a response to chronic rectal distension rather than of primary aetiology. CONCLUSIONS: In the largest case series reported to date, we challenge the current perception of idiopathic megarectum as a primary neuromuscular disease and propose a cellular pathway model for the features present. The severe morphological changes account for some of the irreversibility of the condition and reinforce the need to prevent ongoing rectal distension when first identified.

Optimal management of gastrojejunal tube in the ENFit era - Interventions that changed practice.

BACKGROUND: We experienced a high incidence of jejunal tube (JEJ) displacement in children who underwent percutaneous endoscopic transgastric jejunostomy (PEGJ), ever since the introduction of ENFit connector (2017). METHODS: Two interventions were introduced in 2018 - fixative suture to PEGJ ENFit connector, and conversion to balloon transgastric-jejunal feeding device (Balloon GJ) whenever possible. Children receiving PEGJ and Balloon GJ in 2.8 years were categorized into 3 eras: 2016 (pre-ENFit), 2017 (ENFit) and 2018 (interventional), for comparison of complications and sequelae. Kaplan-Meier survival curves with log-rank test (P < 0.05) were applied. RESULTS: 100 children underwent 323 JEJ insertions - PEGJ (n = 237), Balloon GJ (n = 86). Complications occurred in 188 JEJs (58%), more frequently with PEGJ than Balloon GJ (69% vs. 29%, P < 0.0005). PEGJ had higher complication/1000-tube-days (6 vs. 0, P < 0.0005). In 2018, complication rate reduced from 76% to 30% (P < 0.0005) owing to effectiveness of PEGJ connector suture application (P = 0.019), and increased utilization of Balloon GJ (16% to 44%, P = 0.005). Balloon GJ showed better JEJ survival (P = 0.019), less morbidity (emergency attendance, X-ray) and greater cost-effectiveness than PEGJ. CONCLUSIONS: Balloon GJ had better overall outcomes than PEGJ. Suture application to connector successfully reduced JEJ internal displacement in PEGJ; however, conversion to Balloon GJ should be strongly considered. LEVEL OF EVIDENCE: II.

Anorectal manometry in pediatric settings: A systematic review of 227 studies.

BACKGROUND: There is wide variation in the clinical use of diagnostic tools for children with chronic constipation and functional/structural fecal incontinence (CCFSFI). Anorectal manometry (ARM) is a well-recognized technique to assess the function of the anorectum. PURPOSE: Our aim was to perform an up-to-date review on ARM in pediatric patients with CCFSFI, with specific focus on the indication of use and protocol. Variation of its use in pediatrics will be explored. METHODS: A systematic search was conducted for empirical studies utilizing ARM with a pediatric sample. A keyword search of literature published in English before July 2018 was conducted and updated to October 2019. Data on demographics, clinical information, study aims, ARM parameters and use of sedation/anesthesia were collected. KEY RESULTS: A total of 227 studies were included in this systematic review. The age of study participants at the time of ARM ranged from birth to 18 years. ARM was most commonly used in patients with organic conditions (65%) compared to functional constipation (41%). In almost half [108/227 (48%)] of the studies, ARM was performed awake. The ARM parameters most frequently assessed were the rectoanal inhibitory reflex, which was evaluated in 198/227 studies (87%) and the anal resting pressure [166/227 studies (73%)]. CONCLUSIONS AND INFERENCES: This systematic review has highlighted the vast variation of ARM use within pediatrics and the need to strive toward standardization and use of consensus guidelines. We anticipate this will further advance our understanding of the pathophysiological mechanisms involved in children with defecation disorders.

Treatment of megarectum in anorectal malformation with emphasis on preventive aspects: 17 years experience.

PURPOSE: Megarectum in anorectal malformation (ARM) causes severe morbidity. To compare conservative management (CM) of megarectum with excision (EX), to propose a new classification and to analyse management strategies. METHODS: Between 2000-2016, we reviewed all ARM to identify megarectum, defined by radiological recto-pelvic ratio > 0.61. A new classification was proposed: primary megarectum (PM) pre-anorectoplasty, and secondary megarectum (SM) post-anorectoplasty, with sub-types. Complications and Krickenbeck bowel function were compared between CM and EX. RESULTS: Of 124 ARM, 22 (18%) developed megarectum; of these, 7 underwent EX. There was no difference in functional outcomes when comparing CM vs EX-voluntary bowel movement (both 86%), soiling (40% vs. 57%) and constipation (both 86%). However, EX was associated with major complications (43%) and the requirement for invasive bowel management, compared to CM (85% vs. 27%, P = 0.02). 6/7 EX needed antegrade continence enema (ACE), one of these has a permanent ileostomy. With strategic changes, incidence of megarectum reduced from 20/77 (26%) to 2/47 (4%) after 2013 (P = 0.002). CONCLUSION: EX did not confer benefit in the functional outcome but carried a high risk of complications, often needing ACE or stoma. By adhering to strategies discussed, we reduced the incidence of megarectum and have avoided EX since 2013.

Anorectal manometry in children with defecation disorders BSPGHAN Motility Working Group consensus statement.

Defecatory disorders in children, including chronic constipation (CC) and fecal incontinence (FI), are common conditions worldwide and have a significant impact on children, their families, and the healthcare system. Anorectal manometry (ARM) and high-resolution anorectal manometry (HRAM) are relatively novel tools for the assessment of anal sphincter function and rectal sensation and have contributed significantly to improving the understanding of the anorectum as a functional unit. ARM has been recognized as the investigation of choice for adults with symptoms of defecation disorders, including fecal incontinence (FI), evacuation difficulties, and constipation. Although it is the gold standard tool in adults, it has yet to be formally accepted as a standardized diagnostic tool in the pediatric age, with limited knowledge regarding indications, protocol, and normal values. ARM/HRAM is slowly becoming recognized among pediatricians, but given that there are currently no agreed guidelines there is a risk that will lead to diversity in practice. The British Society of Paediatric Gastroenterology, Hepatology and Nutrition (BSPGHAN)-Motility Working Group (MWG) therefore has taken the opportunity to provide guidance on the use of ARM/HRAM in children with CC and/or FI.

Scientific solution to a complex problem: physiology and multidisciplinary team improve understanding and outcome in chronic constipation and faecal incontinence.

PURPOSE: There is a lack of diagnostic credibility to direct focused management for children with chronic constipation (CC) and faecal incontinence (FI). The aim is to assess the impact of an innovative Children's Anorectal Physiology Service (CAPS) focusing on improving outcomes in children with CC/FI. METHODS: Prospective data: demographics, bowel and quality of life (QoL)/risk of distress questionnaires. Diagnostics: awake high-resolution anorectal manometry (AHRAM), endoanal ultrasound and transit marker studies (TMS). RESULTS: Total patients: 112; 66 males (59%); median 9 years (17 months to 16 years). Patient groups included: 89 (79%) had functional CC/FI; 9 (8%), Hirschsprung's disease; 12 (11%), anorectal malformations and 2 (2%), trauma. St Marks Incontinence score (SMIS) abnormal in 91 (81%) and Cleveland Constipation Score (CCS) in 101 (90%) patients. Anorectal manometry: 94 (84%) awake and 18 (17%) under anaesthesia. Play specialist input 37 (33%) patients. AHRAM abnormal 65 (58%): sphincter dysfunction 36 (32%) and altered rectal sensation: hyposensitive 22% (20/91); 21% (19/91) hypersensitive. TMS normal in 64 (57%), 17 (15%) slow transit and 27 (24%) rectal evacuatory disorder. Risk of distress in 38% and poor QoL in 55% patients which correlated with abnormal SMIS (p = 0.02). Patient/parent satisfaction improved significantly (p < 0.05). CONCLUSIONS: Scientific investigations combined with multidisciplinary team improve patient satisfaction and reduces patient self-report illness severity. A complex problem requires a scientific solution.

Head, heart or checklist? How self-reported decision-making strategies change according to speciality and grade: a cross-sectional survey of doctors.

PURPOSE: To identify and analyse variations in self-reported decision-making strategies between medical professionals of different specialty and grade. STUDY DESIGN: We conducted a cross-sectional survey of doctors of different specialities and grades at St. George's Hospital, London, UK. We administered 226 questionnaires asking participants to assign proportions of their clinical decision-making behaviour to four strategies: intuitive, analytical, rule-based and creative. RESULTS: We found that physicians said they used rule-based decision-making significantly more than did surgeons and anaesthetists (p = 0.025) and analytical decision-making strategies significantly less (p = 0.003). In addition, we found that both intuitive (p = 0.0005) and analytical (p = 0.0005) decision-making had positive associations with increasing experience, whereas rule-based decision-making was negatively associated with greater experience (p = 0.0005). CONCLUSIONS: Decision-making strategies may evolve with increasing clinical experience from a predominant use of rule-based approaches towards greater use of intuitive or analytical methods depending on the familiarity and acuity of the clinical situation. Rule-based strategies remain important for delivering evidence-based care, particularly for less experienced clinicians, and for physicians more than surgeons, possibly due to the greater availability and applicability of guidelines for medical problems. Anaesthetists and intensivists tend towards more analytical decision-making than physicians; an observation which might be attributable to the greater availability and use of objective data in the care environment. As part of broader training in non-technical skills and human factors, increasing awareness among trainees of medical decision-making models and their potential pitfalls might contribute to reducing the burden of medical error in terms of morbidity, mortality and litigation.

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.

How long will I have my ACE? The natural history of the antegrade continence enema stoma in idiopathic constipation.

PURPOSE: We aim to determine the natural history of the ACE in idiopathic constipation and factors predictive of closure. METHODS: A retrospective case-note review of all patients undergo ACE formation for idiopathic constipation Jan 2003-Mar 2016. Kaplan-Meier analysis was used to determine ACE survival and Cox's proportional hazard models to examine potential predictors of closure. RESULTS: 29/84 (35%) ACEs were closed: 21/84 due to success and 8/84 due to failure. Median age of closure was 15.5 years (3.5-23.6). Median ACE survival was 77.0 months (95% CI 58.0-96.0). An ACE survival curve was derived from which we estimate that 5-year post-ACE, one-third of patients can expect to have had their ACE closed. Younger age at ACE was predictive of earlier closure (p = 0.023) and closure for success (p < 0.001). Neither patient sex (p = 0.546) nor presence of psychological comorbidities (p = 0.769) predicted likelihood of closure. Incontinence 6-week post-ACE was also associated with increased likelihood of closure (p = 0.042). CONCLUSION: The ACE survival curve estimates the proportion of patients with idiopathic constipation who can expect closure (either due to success or failure) at certain timepoints. This may be useful for patient counseling. Younger age at ACE was associated with earlier closure (for success).

Post-operative strictures in anorectal malformation: trends over 15 years.

AIM: For decades, paediatric surgeons have employed the standard posterior sagittal anorectoplasty (PSARP) approach to deal with patients with anorectal malformations (ARM). In recent years, we noted an apparent increase in the incidence of anal stricture after surgical repair of ARM following the introduction of laparoscopic pull-through and techniques aiming to preserve the internal sphincter-the internal sphincter sparing approach (ISSA). We decided to analyse our data to find out if these new trends had added to the problem of post-operative strictures. METHODS: All patients with ARM at our institution from January 2000 to December 2015 were identified. A retrospective case note review was carried out. Data collected included patient demographics, type of ARM, operative details, and post-operative outcomes. RESULTS: 114 patients were identified. Ten patients were excluded. Of the remaining 104 children, 48 (46%) were female. Median age was 8.3 (range 1.2-16.8) years. Types of ARM were as follows: perineal fistula (15 patients), anterior stenotic anus (12), imperforate anus without fistula (10), vestibular fistula (32), rectourethral (bulbar) fistula (11), rectourethral (prostatic) fistula (14), rectovesical fistula (7), and cloaca (3). Twenty-seven patients with a perineal fistula or anterior stenotic anus underwent perineal procedures that were variably described by the different operating surgeons. The majority (15 patients) had an anoplasty, 5 had anal transposition, 5 had limited PSARP, and 2 patients had ISSA. Two patients with a cloacal anomaly underwent open cloacal reconstruction. Of the remaining 75 patients, 45 had a PSARP approach, 6 had a laparoscopic-assisted pull-through, and 18 had ISSA. Four girls with vestibular fistula had anal transposition and two boys with imperforate anus without fistula had anoplasty. 15 (14%) children developed anal stricture. Stricture incidence differed according to operation type. PSARP was the most commonly performed procedure, with only 6% developing a stricture. In contrast, 30% of ISSA patients and 50% of children who had laparoscopic pull-through developed a stricture. Strictures also occurred in 11 and 12% of children having anal transposition and anoplasty, respectively. CONCLUSION: The laparoscopic-assisted pull-through involves tunnelling the sphincter muscle complex. We found that often the tunnels were not wide enough, resulting in narrowing not just at the ano-cutaneous junction but also at the deeper level. 50% developed strictures. We have modified our technique by ensuring that the tunnels are generous enough to allow the rectum to be pulled through without any resistance. ISSA unfortunately resulted in 30% of our patients developing strictures. This approach, started in 2004, was, therefore, abandoned in 2013. The standard Pena's PSARP, with or without a laparotomy, has stood the test of time. Any modification of this approach must be carefully thought through and audited meticulously. Strictures can cause significant morbidity, which may need several revisions, and the resulting redo anoplasties run the risk of sphincter damage, ironically which the newer modifications of ISSA were trying to conserve.

Screening and Treatment of Intestinal Rotational Abnormalities in Heterotaxy: A Systematic Review and Meta-Analysis.

OBJECTIVE: To assess the role of screening and prophylactic surgery for intestinal rotational abnormalities (IRAs) in asymptomatic patients with heterotaxy. STUDY DESIGN: PubMed, Embase, and Cinahl were searched electronically to determine the overall incidence of IRAs in heterotaxy; the detection rate of IRAs associated with screening; the incidence of midgut volvulus in patients without screening; and the incidence of morbidity and mortality after prophylactic and emergency Ladd procedures. Relevant data were computed with a meta-analysis of proportions. Between-study heterogeneity was assessed with the I(2) statistic. RESULTS: From 276 papers identified, 24 studies with a total of 1433 patients with heterotaxy were included for systematic review. No randomized study was identified. True incidence of IRA in heterotaxy could not be ascertained through meta-analysis. In patients who underwent screening, the incidence of IRA was 58%. Acute midgut volvulus occurred in 5.8% of those who did not undergo screening. Postoperative mortality after Ladd procedure mainly was associated with cardiac insufficiency, and overall it was significantly greater in the emergency group compared with the prophylactic group (18% vs 5.6%). The complication rate also was greater in case of emergency vs prophylactic abdominal surgery (27% vs 16%); adhesional small bowel obstruction was the most common complication overall (6%). CONCLUSION: The screen-detected incidences of IRA and acute midgut volvulus were significantly greater in heterotaxy than the normal population. Prophylactic Ladd procedure was associated with less morbidity and mortality compared with emergency surgery. A long-term prospective randomized trial is needed to define the indication for screening and prophylactic treatment of IRA in heterotaxy.

Contemporary pediatric surgical training in the UK.

INTRODUCTION: Pediatric surgical trainees worldwide face pressures from expansion of programs and training positions, subspecialization, regionalization, restrictions of working hours, and rigid training criteria. The era of apprenticeship training has long gone, and surgical education needs to be responsive and adapt to newer challenges. The aim of this study was to examine the teaching provision component of pediatric surgical training in the UK. METHOD: A national teaching survey was sent to UK pediatric surgery trainees in 2010 and compared to results of a repeat survey in 2015. Analysis was carried out to compare type of teaching, trends in teaching delivery, quality, and attendance over time. RESULTS: Regional variability was noted in teaching programs. Both provision of educational activities and ability to attend teaching improved between 2010 and 2015. Despite this, overall trainee satisfaction remained low, with 50% and 52% of respondents describing their teaching as "good" or "excellent" in 2010 and 2015, respectively (P=0.84). Seventy-five percent of centers provided simulation training, and 25% of respondents had regional teaching provided. Survey response rate was comparable between 2010 and 2015. CONCLUSION: Variability in national educational provision was observed. We suggest regular national audit of educational activity and responsive adaption to external pressures on training if competent surgeons are to be the product of contemporary pediatric surgery training programs.

Transanal irrigation for intractable faecal incontinence and constipation: outcomes, quality of life and predicting non-adopters.

PURPOSE: Intractable faecal incontinence (FI) and constipation is a challenging condition to manage in children. Transanal irrigation (TAI) is a non-operative treatment option. This study presents our experience with TAI with the aim of finding predictive factors of non-compliance. METHODS: This is an outcome and quality of life (QoL) study of a prospectively maintained database of patients < 17 years old commenced on TAI for intractable FI/constipation between 2008 and 2014. Outcome measures were: (1) compliance-classified as non-adopter (use of TAI stopped within 1 month after commencement) or adopter; (2) functional outcome-classified as responder (totally continent or occasional soiling) or non-responder; (3) Rintala score; and (4) QoL score (PedsQL™ 4.0 Generic Core Scale). Analysis to determine predictive factors was also performed. RESULTS: 42 patients were started on TAI [74% male, median age of commencement was 7 (3-16) years]. Underlying diagnoses were: idiopathic constipation (62%), anorectal malformation (26%), Hirschsprung disease (5%), spina bifida (5%) and gastroschisis (2%). Median follow-up period was 14 (3-78) months. 24% were non-adopters. 84% of the adopters responded to treatment. Rintala scores (mean ± SD) pre- and post-TAI were 6.7 ± 3.5 and 11.2 ± 4.8, respectively (P < 0.001). QoL scores pre- and post-TAI were 55.6 ± 24.1 and 65.5 ± 23.7, respectively (P < 0.001). Median age at which TAI was commenced in the non-adopter and adopter group were 6 (IQR 4.5-8.25) and 8 (IQR 7-12), respectively (P = 0.008). CONCLUSION: TAI is a safe and effective treatment for intractable constipation/FI in children. If tolerated, it can significantly improve quality of life. Age and underlying diagnosis are important factors when recommending TAI to children with intractable FI/constipation.

Botulinum toxin use in paediatric colorectal surgery.

PURPOSE: To evaluate outcomes of intrasphincteric botulinum toxin injection (ISBTI) in children with intractable constipation. METHODS: Retrospective case-note review of patients ≤ 16 years of age undergoing ISBTI between January 2010 and February 2014. Data collected included patient demographics, diagnosis, complications, follow-up duration and functional outcomes. Successful outcome was defined as resolution/improvement in symptoms and failed when there was no change in symptoms. Statistical analyses were performed using PRISM (GraphPad, CA, USA). p values <0.05 were considered as significant. RESULTS: 43 patients [male 29, median age 5 years 9 months (range 13 months-13 years 5 months)] underwent 86 ISBTIs. Underlying diagnoses were idiopathic constipation (67 %), Hirschsprung disease (26 %), anorectal malformation (5 %), gastrointestinal dysmotility (2 %). 72 % (31/43) reported improvement in symptoms after the first ISBTI. 39 % of patients had recurrence of symptoms at 12-month median follow-up. 10 patients non-responsive to ISBTI required an antegrade continence enema or stoma. There was no correlation between age (p = 0.3), gender (p = 0.7), diagnosis (p = 0.84), or number of ISBTIs (p = 0.17) with successful outcome. CONCLUSION: Successful outcomes occurred in 72 % patients after the first ISBTI. 25 % required further surgical management of their symptoms. Further work is required to help predict which patients will benefit from ISBTI.

Immunohistochemical confirmation of the presence of smooth muscle in the normal neonatal anorectum and in neonates with anorectal malformations.

AIM: To evaluate the presence of smooth muscle in relation to the anorectum in neonates that are normal and in neonates with anorectal malformations using immunohistochemical staining of antibodies specific to smooth muscle actin (SMA). METHODS: Research ethics committee approval was obtained to study historical neonatal tissue sections. 7-15-µ thickness, sagittal sections of both normal anorectums (NA) and neonates with anorectal malformations (ARM) were available to study. The fragile tissue predates the development of charged glass microscope slides that are inherent to contemporary immunohistochemistry (IHC). Normal appendix sections on non-charged slides were used to establish and optimise a novel, steam generated heat, antigen retrieval protocol. This technique of "gentle" antigen retrieval allows preservation of tissue architecture whilst maintaining adequate staining of tissue on non-charged glass microscope slides. NA and ARM tissue was stained and compared to control NA and ARM sections. RESULTS: SMA staining was observed in sagittal sections of both normal neonatal anorectums and neonates with anorectal malformations, confirming the presence of smooth muscle. CONCLUSION: This preliminary work confirms the presence of smooth muscle in the anorectum of neonates that are normal and in neonates with anorectal malformations. It is likely that the smooth muscle complex demonstrated represents the internal anal sphincter in the normal anorectum. It is postulated that the smooth muscle complex seen in anorectal malformations may represent a similar internal anal sphincter complex which maybe of functional significance. Further IHC of tissue sections will allow reconstruction of the exact three-dimensional smooth muscle structure of the anorectum in neonates that are normal and neonates with anorectal malformations.

Attitudes to consent--a national survey.

PURPOSE: The medicolegal case of Chester v Afshar (October 2004) raises important questions with regard to the consent process in medicine and surgery. If consent has to involve disclosure of all serious risks, regardless of frequency, how does a surgeon ensure the thoroughness of the consent procedure and minimise the risk of such litigation? Procedure-specific consent forms (PSCFs)--detailing all serious risks--are a possible solution. The aim of our study was to establish the frequency of the use of such consent forms throughout the UK. METHODS: A postal questionnaire of UK consultant British Association of Pediatric Surgery (BAPS) members was conducted. Members were asked if they used PSCFs for 4 commonly performed procedures in paediatric surgery: central venous access, inguinal herniotomy, orchidopexy, and pyloromyotomy. RESULTS: The response rate was 89% (108/122). We obtained at least one response from every centre involved in paediatric surgery (38/38) in the UK. Seventy-nine percent (85/108) of respondents do not use PSCFs, 19% (21/108) do use PSCFs, and 2% (2/108) forms were returned blank. Thirty-one percent (33/108) of respondents included comments regarding PSCFs. CONCLUSION: A medical negligence claim will succeed if the practitioner owes the patient a duty of care, there has been a breach of this duty, and that the breach caused a loss (causation). Our duty to the patient may now need to include disclosure of all risk regardless of frequency. PSCFs allow accurate and reproducible information for families about procedures. PSCFs currently have a low uptake amongst paediatric surgeons in the UK. The use of PSCFs for 4 procedures is currently under trial in our unit. It remains to be seen whether the success of further claims leads to an increase in their use nationally.