Inguinal hernia in children

Two hundred and seventy one cases of inguinal hernias and hydrocoels in children treated at the University Hospital of the West Indies over a five-year period have been reviewed. The dominance of the boys and the right side is borne out. The younger infant has the highest risk of incarceration which is more common in boys and in right-sided hernias. Females with inguinal hernias were screened for testiculaar feminization and none was found. There were three girls with hydeocoels of the Canal of Nuck. The incidence of metachronous presentations of contralateral hernia occurred only in 6.6 por ciento of cases. When routine explorartion of the contralateral side was undertaken in 5.2 por ciento of cases, a hernia sac was found only in less than half of them. These findings support the present policy of not routinely exploring the opposite side in unilateral inguinal hernias. Herniotomy was adequate for 92.6 por ciento of cases. Herniorrhaphy was seen in only one case. One testicular atrophy occurred following incarceration. Eighty-six per cent of these children were managed as day cases. Inpatient management was required when the hernia was complicated or when there were associated other medical conditions.

Anorectal manometry in hirschsprung's disease - abstract

Normal anorectal reflexes are a relaxation of the internal anal sphincter and a simultaneous contraction of the external anal sphincter, in response to rectal distension. The internal anal sphincter (involuntary, smooth muscle sphincter) relaxation is mediated via a local reflex arc involving the ganglion cells in the bowel wall. Whereas the external sphincter (voluntary, striated muscle) contraction involves a spinal relex arc with afferent limb through the hypogastric nerves, efferent limb through the pudendal nerves and the neurons in the sacral segment of the spinal cord. Hence the study of the response of the anal sphincters to rectal distension, i.e. anorectal manometry, provides information about the functional state of the muscle and the integrity of the reflex arcs. This forms the basis for its apllication in the diagnosis of congenital aganglionic megacolon (hirschsprung's disease) (AU)

Inguinal hernia in children

Two hundred and seventy one cases of inguinal hernias and hydrocoels in children treated at the University Hospital of the West Indies over a five-year period have been reviewed. The dominance of the boys and the right side is borne out. The younger infant has the highest risk of incarceration which is more common in boys and in right-sided hernias. Females with inguinal hernias were screened for testiculaar feminization and none was found. There were three girls with hydeocoels of the Canal of Nuck. The incidence of metachronous presentations of contralateral hernia occurred only in 6.6 percent of cases. When routine explorartion of the contralateral side was undertaken in 5.2 percent of cases, a hernia sac was found only in less than half of them. These findings support the present policy of not routinely exploring the opposite side in unilateral inguinal hernias. Herniotomy was adequate for 92.6 percent of cases. Herniorrhaphy was seen in only one case. One testicular atrophy occurred following incarceration. Eighty-six per cent of these children were managed as day cases. Inpatient management was required when the hernia was complicated or when there were associated other medical conditions. (AU)

Segmental dilation of the colon and the Stilling-Turk-Duane retraction syndrome

A case of a 3-year and 9-month-old girl with segmental dilation of the colon and the Duane Retraction Syndrome is reported. The dilated hypertrophied segment of the colon had no taenia coli. Dysfunction of this segment was demonstrated both radiologically and clinically by a non-functioning clostomy placed at the apparent distal transition zone. The proximal and distal colonic segments were normal and a resection of the dilated segment was curative. The relevant literature is reviewed (AU)

Paediatric day-care surgery: parental attitudes

Sixty per cent of the paediatric surgical procedures at the University Hospital of the West Indies are performed as day cases, without any significant complications. This allows better utilization of the available bed space, increased turnover and improved cosy efficiency. Parents of one hundred consecutive day-care paediatric surgical patients were asked to answer a questionnaire during their post-operative follow-up visit in order to ascertain their opinion regarding the procedure and to obtain a socio-economic profile of the group. Forty per cent of the children were with single parents or other guardians. Twenty-five per cent were unemployed and, of those employed, the majority were blue collarworkers. In spite of these adverse socio-economic conditions, ninety-six per cent of the parents opted to accept the day-care procedure again or recommend it for another child without any modification. Pain was a significant post-operative complaint, and improved post-operative analgesia would make it even more acceptable. Day-care surgery is not only medically and economically attractive but also well accepted by the parents (AU)

Necrotising enterocolitis at the University of the West Indies, Jamaica - abstract

Necrotising enterocolitis (NEC) is the commonest abdominal surgical emergency in the newborn. A retrospective ten-year survey of newborn babies admitted to the University Hospital of the West Indies was carried out to identify the disease patterns in Jamaican patients and to assess the results of treatment. Adequate data for analysis were obtained in 77 cases. These were divided into two groups. In group A patients, the diagnosis was based on the clinical findings. Group B patients also had characteristic radiological, operative or post mortem findings. Of the babies reviewed, 63 percent were born at term and 73 percent weighed more than 2,000 grams. There were twelve deaths, all in Group B patients. Nine of these were less than 36 weeks' gestation. Eight patients required operation, seven for intestinal perforation and one patient for intestinal stricture. Seven of the eight patients died. From this study, two recommendations can be made. Firstly, there should be a more aggressive approach to necrotic bowel prior to perforation. Secondly, peritoneal drainage employed in unstable perforated neonates should be followed by laparatomy within 12 hours (AU)

Parental attitudes to day-care surgery - abstract

Sixty per cent of the Paediatric surgical procedures at the UHWI are performed as day cases, without any significant complications. This allows better utilisation of the available bed space, increased turnover and improved cost-efficiency. Parents of one hundred consecutive day-care Paediatric surgical patients were asked to answer a questionnaire during their post-operative follow-up visit in order to ascertain their opinion regarding the procedure and to obtain a socio-economic profile of the group. Forty-seven per cent of the children were with single parents or other guardians. Twenty-five per cent of the parents were unemployed and of those employed the majority were blue-collar workers. In spite of the adverse socio-economic background, 96 percent of the parents opted to accept the day-care procedure again or recommend it for other children without any modifications. Pain was a significant post-operative complaint and improved post-operative analgesia would make day-care surgery even more acceptable. Day-care surgery is not only medically and economically attractive but also well accepted by the parents (AU)

Hirschsprung's disease at the University Hospital of the West Indies - abstract

From 1958 to 1979, 55 children with Hirschsprung's disease have been treated at the University Hospital of the West Indies. Delay in passage of meconium, abdominal distension, vomiting and constipation, were the main symptoms. Bowel obstruction (28) and chronic constipation (27) were the common modes of presentation. Although symptoms had their onset within the first six months in 43 children, the diagnosis was established before six months in only 18. Barium Enema failed to demonstrate a narrow segment in 21 cases often leading to delay in establishing the correct diagnosis. It was also misleading in the assessment of the extent of the aganglionosis, only one out of eight long segment types being identified radiologically. Rectal biopsy by punch technique was successfully employed in 41 cases to establish the diagnosis. Forty-four children had pull-through operations (31 Duhamel, 10 Modified Soave, 3 Swenson). Four had posterior excisional anorectal myectomies, while three are awaiting definitive surgery following colostomy. Eleven of the definitive procedures were done in one stage while six were done in two stages and 27 in three stages. Stenosis (10) cases pelvic abscesses (7) persistent septa (6) and cuff revision of pull-through. There were eight deaths of which three were before surgery, one after colostomy and four after definitive surgery. Three of these four post pull-through deaths were in one stage procedures. Thirty children have been followed up for periods of one year to ten years. Seventeen have excellent results with normal continence, growth and development. Eleven have fair results with five of them requiring laxatives and six having soiling. Two have poor results. Of the seven children followed up for more than five years after surgery, six have excellent results. With early diagnosis and adequate staged definitive surgery, the long term results for Hirschsprung's disease are excellent (AU)

The low frequency of reflux in Jamaican children

Fifty consecutive micturating cystourethrograms (MCUG) performed at the UHWI between June 1989 and December 1991 were reviewed. There were forty boys and ten girls. Infants under the age of one year accounted for 58 percent Urinary tract infection was the commonest presenting feature (72 percent), voiding difficulties (10 percent) and associated malformations (14 percent) were the other reasons for doing the MCUG. Only 10 percent of the children revealed vesico-ureteral reflux (VUR) which supports the view that reflux is less common in the noncaucasian population. In our population, the yield from MCUG is low. However, when detected, the reflux was of significant degree as to warrant active therapy. All but one of the VU refluxes diagnosed by MCUG had ultrasonographic abnormalities. Black children with single uriniary infections have a low likelihood of VUR. A clear history of pyelonephritis and abnormalities on ultrasound or radionuclide cystogram may be use as criteria to select those whom MCUG will be useful (AU)

Paratesticular neuroblastoma

A case of paratesticular neuroblastoma in a 2-year old boy is described. The tumour appears to be a primary lesion rather than a metastasis. No previously reported cases of this unusual condition could be found in the literature. Possible explanation for the occurrence of the tumour in the scrotum is given (AU)

Polysplenia and reversed rotation of the midgut

A 3-week-old female infant with polysplenia syndrome and partial situs inversus with reversed rotation of the intestinal tract who presented with subacute bowel obstruction at the University Hospital of the West Indies is reported. The absence of associated cardiovascular anomalies is notable. A modified Ladd's procedure was successful in relieving the obstruction. The clinical and diagnostic features of polysplenia syndrome are discussed. When complex cardiovascular anomalies, which usually account for the high mortality rate, are absent, normal growth and development can be expected. (AU)

Acid ingestion causing pyloric obstruction

A case of gastric outlet obstruction following acid ingestion in a 21/2-year-old child is reported. The characteristic features of this injury are minor injury to the mouth, pharynx and oesophagus, and major injury to the stomach. A small amount of acid can produce considerable damage to the stomach. Therefore all patients require admission to hospital. Early barium meal examination and, if available, flexible endoscopy, will identify the extent of damage so as to avoid early discharge of patients when gastric performation is likely. Emphasis is placed on the need for public education in the prevention of ingestion of corrosive substances by children (AU)

Omental cyst masquerading as ascites

This report describes a three-year-old girl with an omental cyst masquerading as ascites. A review of the literature has shown that large omental cysts are frequently misdiagnosed as ascites. Ultrasonography is a valuable aid in the diagnosis (AU)

The management of perforated necrotizing enterocolitis - abstract

Fourteen patients with perforated, necrotizing enterocolitis (NEC) managed at the University Hospital of the West Indies are reviewed. Seven patients had peritoneal drains sited under local anaesthesia as a resuscitative measure in preparation for laparotomy. Six demised, five within 24 hours of siting drains and one soon after laparotomy. The single survivor after peritoneal drainage responded well enough not to require laparotomy. Four patients had immediate exploration, leading to death in one. Two patients had localized perforation, resulting in abscess formation. Both were drained but were complicated by intestinal stricture. Of these two patients, one survived. Perforated NEC was diagnosed at post-mortem in one patient. We conclude that a high index of suspicion is required for the early detection of NEC perforation. Peritoneal drains have limited application in this condition: only in low birth weight and in unstable, perforated neonates under 1,500 gm. Intestinal resection and stoma formation is the recommended operative approach but primary anastomosis is justified for fit, well-resuscitated neonates (AU)

Abscess - to incise or aspirate? - abstract

A randomized prospective study of 82 patients attending the Paediatric Emergency Department with soft tissue abscesses was undertaken to compare the efficacy of aspiration versus incision and drainage as the method of treatment. Forty patients belonged to the aspiration group and 42 to the incision and drainage as the method of treatment. Forty patients belonged to the aspiration group and 42 to the incision and drainage group. The groups were comparable for age distribution, size and location of abscess and usage of antibiotics. Three complications were noted resulting in minor morbidity but no major complications were encountered. In comparable groups of patients, aspiration alone achieved resolution of the abscess with no significant risks or complications. We conclude that aspiration is an adequate method of treating soft tissue abscesses (AU)

Biliary ascariasis

Biliary ascariasis complicated by cholangitis is reported in a 23-year-old woman. Removal of a worm and cholecytostomy were performed. Residual worms were found in the bile ducts by post-operative cholecysto-cholangiography. These were successfully eradicated with oral antihelminthic therapy (AU)

Prognosis of neuroblastic tumours in children

A retrospective analysis of 26 children with neuroblastic tumours treated at the University Hospital of the West Indies (UHWI) between 1970 and 1991 was undertaken to evaluate factors affecting prognosis. The peak incidence was between 48 months and 60 months of age, and 75//of the deaths occurred in children older than 3 years. The abdomen was the most common site of the tumours 79//of which were from the adrenal gland and carried a dismal outcome. Other sites were thoracic, pelvic and cervical. Extra-adrenal tumours have a good outcome even when the histology is unfavourable; 92//of the tumours were in Stages III or IV at the time of initial presentation. Stage IV disease accounted for all but one of the deaths. Of the 8 children with favourable histology (ganglioneuroma or well-differentiated ganglioneuroblastoma), only one (12.5//) died, whereas of the remaining 18 cases with unfavourable histology (neuroblastoma and undifferentiated ganglioneuroblastoma), eleven (61//) died. When managed by surgery alone or with adjuvant chemo- and/or radio-therapy, only 36.4//succumbed while all 4 children with chemotherapy only died. Ten children are alive without disease for more than three years post-therapy. A scoring system was designed which takes into account the factors influencing the outcome in neuroblastic tumours, namely, age, location, stage and histological types of the tumours and therapy. All the children with a score of 21 or less survived, whereas all those with scores of 22 or above succumbed. This underlines the multifactorial influences on the final outcome of neuroblastic tumours

Outcome of solid renal tumours in children at the University Hospital of the West Indies

Of the twenty-nine children with solid tumours treated at the University Hospital of the West Indies (UHWI) between January, 1972 and December, 1991, there were twenty-eight cases of nephroblastoma and one of mesoblastic nephroma. Peak incidence was between the ages of two and four years. Twenty-five children had radical nephrectomy while one had bilateral partial nephrectomy. In thirteen cases, pre-operative chemotherapy and radiotherapy was used. Post-operative chemotherapy and radiotherapy were used in 24 and 13 cases, respectively. Stage of the tumour was the most decisive factor influencing the outcome. Whereas there was 100 per cent cure rate in Stages I and II, Stage III had only a 55.5 per cent survival rate and non of the Stage IV survived. Bilateral (Stage V) tumours are curable if individual tumours are localised, as in one of the two cases. The benign mesoblastic nephroma, in a one-month-old infant, was cured by nephrectomy alone. While the present therapy of radical nephrectomy along with combination chemotherapy is satisfactory for early stages, more aggressive adjuvant therapy is needed for improving the results in Stages III and IV

Childhood portal hypertension in Jamaica

Portal hypertension and bleeding from oesophageal varices in children remain a difficult medical problem. The clinical course and management of children with portal hypertension seen over a 14-year period was reviewed. There were 5 females and 2 males with a mean age of 3.6 years at presentation. Five patients presented with severe upper gastrointestinal bleeding and two with severe hypersplenism. All patients had extra-hepatic portal hypertension. Five patients were treated with endoscopic sclerotherapy, including one who had bleeding five years post-splenectomy. A mean of 9 sclerotherapy sessions was performed in each patient. Complete obliteration of varices was not achived in any patient and a single rebleeding episode occurred in four. Three children underwent operative management consisting of splenectomy in two and splenectomy and central spleno-renal shunt in one. There was no mortality in either group after a mean follow-up of 4.3 years. Sclerotherapy may not be totally successful in long-term management of childhood portal hypertension. Surgical therapy or a combination of sclerotherapy and surgery may be the best approach

Dumping syndrome in a young Jamaican child

The dumping syndrome in childhood is an uncommon complication of gastro-oesophageal surgery, principally Nissen fundoplication. A Jamaican child developed the syndrome after fundoplication and pyloroplasty to relieve gastro-oesophageal reflux complicating the repair of a congenital tracheo-oesophageal fistula. He developed marasmus and failed to gain weight on the standard remedial milk-based high energy diet. An oral glucose tolerance test confirmed the diagnosis of dumping syndrome. A low sugar low milk diet based on adult type meals with continous nibbling of fried dumplings relieved his diarrhoea and hypoglycaemia and he gained weight. This is a cheaper and more practical dietary therapy than the regimens described previously(AU)