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).

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.

Ileal atresia secondary to antenatal strangulation of Littre's hernia in an exomphalos minor.

We describe an unusual case of ileal atresia, resulting from antenatal strangulation of a Meckel's diverticulum in an exomphalos minor. This is a rare antenatal complication of Littre's hernia, which has not been previously described. A small exomphalos minor at the base of umbilical cord and late onset vascular accident at the narrow defect leading to ileal atresia may be missed in the prenatal diagnosis. The triad of exomphalos minor, Meckel's diverticulum and terminal ileal atresia secondary to antenatal strangulation of Littre's hernia is very rare to find in the same patient. A small exomphalos minor at the base of the umbilical cord can be missed even in the postnatal period. Our case lends direct evidence of vascular accident as a cause of ileal atresia and supports vascular theory. Whenever possible umbilicus should be preserved naturally and exomphalos sac should be opened higher up for excellent cosmetic results.

Peritoneal drainage does not stabilize extremely low birth weight infants with perforated bowel: data from the NET Trial.

INTRODUCTION: Proponents of peritoneal drainage (PD) hypothesize that it allows stabilization before laparotomy. We examined this hypothesis by comparing clinical status before and after either PD or primary laparotomy (LAP). METHODS: In an ethically approved, international, prospective randomized controlled trial (2002-2006), extremely low birth weight (<1000 g) infants with pneumoperitoneum received primary PD (n = 35) or LAP (n = 34). Physiologic data were collected prospectively and organ failure scores calculated and compared between preprocedure and day 1 after procedure. Data, expressed as mean +/- SD or median (range), were analyzed using appropriate statistical tests. RESULTS: There was no postprocedure improvement in either PD or LAP group comparing heart rate (PD, P = 1.0; LAP, P = .6), blood pressure (PD, P = .6; LAP, P = .8), inotrope requirement (PD, P = .2; LAP, P = .3), or Arterial partial pressure of oxygen/fraction of inspired oxygen ratio (PD, P = .1; LAP, P = .5). Infants managed with PD had a worsening cardiovascular status (P = .05). There were no differences in total organ failure score in either group (PD, P = .5; LAP, P = 1). Only 4 infants survived with PD alone with no difference between preprocedure and postprocedure organ failure score (P = .4). CONCLUSIONS: Peritoneal drainage does not immediately improve clinical status in extremely low birth weight infants with bowel perforation. The use of PD as a stabilizing or temporizing measure is not supported by these results.