Pneumatosis intestinalis in a cohort of children with neurological impairment: A patient group with a management dilemma.

AIM: Pneumatosis intestinalis (PI) is uncommon in school-age children. We studied a cohort of neurologically impaired school-age children with PI to formulate an optimum management plan. METHODS: We retrospectively studied all school-age children who were referred to paediatric surgeons with radiological evidence of PI identified between 2011 and 2015. We analysed data on patient demographics, medications, feeding, associated comorbidities, presentation, investigations and treatments. RESULTS: Five patients (3F:2M) with a median age of 7 years (range 5-9) were referred for surgical opinion with the evidence of pneumatosis on their abdominal X-rays. Four of them had associated pneumoperitoneum. All children had neurological impairment significant enough to make them unable to communicate clearly. Four patients were gastrostomy fed, one was jejunally fed. Four children had recurrent episodes of pneumatosis. Four patients had surgery at the initial presentation where colonic pneumatosis was detected; however, there was no evidence of bowel ischaemia or perforation despite of the presence of pneumoperitoneum. Recurrent episodes were successfully managed conservatively even in the presence of pneumoperitoneum. CONCLUSION: In neurologically impaired school-age children, the presence of pneumatosis and pneumoperitoneum does not mandate bowel ischaemia or perforation and therefore could be successfully managed conservatively without the need for surgery.

Register based study of anorectal anomalies over 26 years: Associated anomalies, prevalence, and trends.

BACKGROUND: Anorectal anomalies are atresias or stenoses of the anal canal and rectum with or without fistulous connections with the bladder, urethra, perineum, or vestibule. The aim of this study was to describe the epidemiology of anorectal anomalies, including associated anomalies, prevalence, and temporal trends. METHODS: Anorectal anomalies occurring in late miscarriages (>20 gestation weeks), terminations of pregnancy for fetal anomaly (any gestation), stillbirths (≥24 gestation weeks) and live births, delivered from 1985 to 2010, notified to the Northern Congenital Abnormality Survey (NorCAS) were included in this population-based case series. RESULTS: There were 278 cases among 892,194 live births. Twenty (7.2%) cases occurred in twin pregnancies and 24 (8.7%) with chromosomal anomalies/genetic syndromes were excluded. There were 234 cases (total prevalence = 2.7, 95% confidence interval [CI]: 2.4, 3.1 per 10,000 live and stillbirths). There was no evidence of a trend in prevalence over time (Chi(2) test for trend: p = 0.789). There was a male predominance (70.9%). Of the 234 cases, 167 (71.4%) were live born, two (0.9%) were late miscarriages, seven (3.0%) were stillbirths, and 58 (24.8%) were terminations of pregnancy for fetal anomaly. There was no significant association with maternal age at delivery (p = 0.095). 7.2% of isolated cases (cases with no other congenital anomalies) were diagnosed prenatally. CONCLUSION: The prevalence of anorectal anomalies in this study is comparable to other case series. There was no evidence of a temporal increase in prevalence. We confirmed a male predominance of anorectal anomalies and no significant association with maternal age. Birth Defects Research (Part A) 103:597-602, 2015. © 2015 Wiley Periodicals, Inc.

Utility of F-15 diuretic MAG3 renography in assessment of paediatric hydronephrosis.

INTRODUCTION: Diuretic renography is crucial in evaluation of paediatric hydronephrosis. Furosemide is conventionally given 15-20 min after radiolabelled tracer (F+15/F+20 protocol), however this is equivocal in around 15% of patients. Giving furosemide 15 min prior to tracer (F-15 MAG3 protocol) has been suggested as an additional tool in the investigation of patients with suspected upper urinary tract obstruction. However, the role of this method in assessment and management of paediatric hydronephrosis is not widely reported. OBJECTIVE: To investigate utility of F-15 renograms in children with hydronephrosis being assessed for Pelvi-Ureteric Junction Obstruction (PUJO). STUDY DESIGN: Retrospective review of patients <16 years old undergoing F-15 MAG3 renogram between 2018 and 2021 in our tertiary paediatric surgical centre. Data collected included patient demographics, mode of presentation, investigations, management and outcomes. RESULTS: Eighteen patients were included. Median age at F-15 renogram was 7.3 years. Eleven patients presented with antenatal hydronephrosis, 5 with symptoms in childhood and 2 with incidental hydronephrosis on trauma imaging. Fourteen patients were symptomatic. Ten had a prior non-obstructed F+20 renogram but persisting symptoms suggestive of PUJO. Seven had previous equivocal F+20 renograms. One symptomatic patient directly underwent an F-15 renogram. A conclusive result was obtained in 16/18 (89%); 11 patients had obstructed curves and 5 non-obstructed. Two asymptomatic patients' scans were inconclusive. All symptomatic patients had conclusive scans. Of 11 patients with an obstructed F-15, 9 have undergone pyeloplasty to date. All have had post-operative resolution in symptoms and static or improved post-operative ultrasound. One patient with an inconclusive scan underwent pyeloplasty due to persisting hydronephrosis and parent preference. Three patients with non-obstructed F-15 renograms have been discharged. One symptomatic patient with a non-obstructive F-15 had a ureteric stent inserted due to persistent flank pain; 1 continues under surveillance. DISCUSSION: It is known that conventional F+20 MAG3 renograms can give equivocal results. Published experience suggests that F-15 renograms are conclusive in the majority of patients. Routine primary use is, however, discouraged as they can 'over diagnose' obstruction and limit the study of tracer transit under physiological flow rates. This study indicates that the F-15 renogram is a useful adjunct in the assessment of patients with symptoms suggestive of PUJO who have previously had an equivocal or a non-obstructed F+20 renogram. CONCLUSION: F-15 renogram was conclusive in 89% of patients. We recommend using F-15 renograms to aid surgical decision-making in children with equivocal F+20 renograms, especially in the presence of symptoms.

Ureteric Clipping for the Treatment of Urinary Incontinence in Girls With Ectopic Ureters: Predicting Who Is Going to Dilate and Does It Matter?

OBJECTIVE: To assess the effectiveness and midterm follow-up of laparoscopic upper pole ectopic ureteral clipping to treat urinary incontinence in girls with duplex kidneys and non/poorly functioning upper pole moieties. To see if preoperative characteristics increased the likelihood of significant postoperative dilatation and whether this dilation has clinical significance. METHODS: A database review identified children who had undergone ureteric clipping at our institution. Patient details assessed included: age at presentation, age at procedure, significant past medical history, preoperative investigations, operative time, length of stay, postoperative symptoms, postoperative renal tract ultrasound findings and the need for subsequent intervention. RESULTS: Six girls underwent clipping between March 2018 and May 2021. The mean age at presentation and surgery were 77months (39-186) and 86months (44-193), respectively. The mean operative time was 94 minutes (range 66-128 minutes). The median length of stay was 1 day (range 0-3days). All the girls were dry immediately after the procedure. During a mean follow-up of 51months (29-66) all children have remained symptom-free and required no further intervention. Two children have developed significant (>30 mm) but stable ureteric dilatation after clipping but have remained asymptomatic and therefore are continuing on conservative follow-up. Both these children had dilated ureters (>10 mm) preoperatively. CONCLUSION: Ureteric clipping is quick, safe, and effective option in dealing with incontinence due to ectopic upper pole ureters in girls. Children with preoperative ureteric dilation seem to be at increased risk of postoperative dilation. However, as they remain asymptomatic, the clinical significance of this dilatation is unclear.

Impacted urethral stone presenting as urinary retention in a child.

A seven-year-old boy was referred to our Accident and Emergency department with a history of urinary retention secondary to urinary tract infection and an inability to pass a urethral catheter. He had been treated a month before for suspected pyelonephritis by the referring hospital. Attempts at urethral catheterisation failed, and he was taken to theatre for cystourethroscopy and catheter placement. At this time, an impacted urethral stone was discovered. Because it could not be dislodged, a suprapubic catheter was placed, and the child was brought back at a later date for definitive management. Investigations revealed a pure calcium oxalate stone that was secondary in origin. There has been no recurrence during a follow-up period of 6 months.This illustrates that while rare, urethral stones do occur in children and should be considered in children presenting with urinary retention, haematuria and/or abdominal pain.

Diagnosing and treating occult vesicoureteric reflux using PIC cystography: Is it influenced by abnormalities on DMSA?

BACKGROUND: Positioning the Instillation of Contrast cystography (PICc) is used to identify occult vesicoureteric reflux (VUR) in patients with recurrent urinary tract infections (UTI) despite optimized bladder and bowel function and without VUR demonstrated on conventional imaging. AIM: To determine the incidence of finding occult VUR in such patients usingPICc and the benefit, if any, of treating it. We also assessed if this was influenced by abnormalities on the pre-operative DMSA. PATIENTS AND METHODS: This was a retrospective review of PICc in our hospital between 2016 and 2018 and involved three paediatric urologists. The primary indication for PICc was two or more culture proven UTIs despite optimized bladder and bowel function and no reflux on voiding cystourethrography (VCUG) or indirect radionuclide cystography (I-RNC). All children had a preoperative DMSA scan to document any abnormalities. PICc was performed in a standardized way to each ureteric orifice. If occult reflux was found, it was treated concomitantly by cystoscopic injection of Deflux®. To assess the influence of the pre-operative DMSA status, the cohort was subdivided into two groups based on the DMSA scan: Group 1-abnormal DMSA, Group 2-normal DMSA. The median follow-up was 26 months (range 3-39 months). RESULTS: PICc was performed in 25 patients [23 females and 2 males; median age: 7 years (range 2-16 years; IQR = 4)]; 17 from Group 1 and 8 from Group 2. Occult VUR was identified in 22 patients (88%); 15/17 (88.2%) in Group 1 and 7/8 (87.5%) in Group 2 (p = 0.9). After cystoscopic treatment, 21/25 (84%) became infection free and this was not influenced by the preoperative DMSA status (p = 0.6). Fig 1. DISCUSSION: In this challenging group of patients, looking for and treating occult reflux appears to be clinically useful and beneficial. The ability to test and treat at the same sitting is an added advantage of PICc. The DMSA results did not influence the diagnostic or therapeutic aspect of the process. Our results concur with other published literature. CONCLUSION: There is a high incidence of finding occult reflux using PICc in this cohort of patients. Concomitant cystoscopic treatment led to 84% of children becoming infection free on follow up. Abnormalities on DMSA did not influence either the likelihood of finding occult reflux or the likelihood of successful treatment.

Are PEGJs a Risk Factor for the Buried Bumper Syndrome?

AIM: Percutaneous endoscopic gastrostomies (PEGs) with or without a jejunal extension (PEGJs) are a well-accepted method of enteral feeding. They are associated with a number of complications, including the buried bumper syndrome (BBS). We aimed to identify risk factors for BBS, our current management strategies, and optimal timing for surgical treatment. METHODS: Hospital coding and a database compiled by our specialist nutrition nurse were used to identify all cases of buried bumpers from January 2012 to December 2014 as well as all PEG/PEGJ devices inserted during this time. A retrospective case note review was performed for each patient with BBS to identify risk factors, management strategies, and outcomes. RESULTS: Two hundred twelve PEGs and 22 PEGJs were inserted. Nine patients were identified with BBS. Patients with PEGJ tubes were significantly more likely to develop BBS (7/22, 32%) than those with PEG tubes (2/212, 0.9%) P<0.01. There was one death in the study group because of abdominal sepsis associated with an intraperitoneal PEG bumper 33days after BBS was diagnosed and before removal was attempted. All other patients underwent laparotomy to remove the bumper. Mean hospital stay was 22days postoperatively. CONCLUSIONS: Buried bumper syndrome is a serious condition which warrants urgent intervention. We have demonstrated a higher than expected rate of BBS associated with PEGJ tubes. We hypothesize that this may be related to the jejunal extensions leading to difficulty in the usual maintenance regimen that all carers are taught after PEG/PEGJ insertion.

Jejunogastric intussusception presenting with outlet obstruction.

A 77-year-old man presented with sudden-onset epigastric pain and bilious vomiting following a light breakfast. Vagotomy and gastrojejunostomy for bleeding duodenal ulcer had been done 22 years ago. Barium meal study suggested jejunogastric intussusception. At laparotomy, a retrograde type II jejunogastric intussusception was confirmed and managed by reduction of the intussusception, disconnection of gastrojejunostomy and resection of the jejunum. Postoperative recovery was uneventful.

Polyorchidism: a torted right-sided supernumerary testis.

Polyorchidism is a rare congenital anomaly defined by the presence of more than two histologically proven testes. The commonest variant is triorchidism, the supernumerary testis being commonly reported on the left side. Most cases of polyorchidism are found incidentally in association with undescended testis, hydrocele, hernia or torsion. We report a right-sided triorchidism in a 15-year-old boy found at time of groin exploration for an irreducible right inguinal hernia.