Synthetic Cannabinoids and Their Effects on the Cardiovascular System.

BACKGROUND: In the past couple of years, there has been an outbreak of synthetic cannabinoid (SC) use in major cities in the United States. Patients can present with various symptoms affecting the central nervous and cardiovascular systems. The effects of endocannabinoid on contractility and Ca(2+) signaling have been shown through both cannabinoid receptors and a direct effect on ion channels. These effects result in abnormalities in ionotropy, chronotropy, and conduction. CASE REPORT: Here we report on two cases of SC abuse and abnormalities in the cardiovascular system. These cases raise concerns about the adverse effects of SCs and the possibility of QTc prolongation and subsequent complications when using antipsychotic medication in the presence of SC abuse. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Given the rise in SC use and the potential effect on the cardiovascular system, physicians need to be mindful of potential cardiac complications, such as QTc prolongation and torsade de pointe, especially when administering medications that have the potential to cause QTc prolongation.

Successful treatment of recurrent rectal prolapse using three Thiersch sutures in children.

Many techniques are described to manage recurrent rectal prolapse in children, including repeated Thiersch stitch, phenol injections, Delorme and Altemeier procedures, and rectopexy. We describe a case of successful treatment of rectal prolapse by placing three Thiersch sutures circumferentially along the anal canal--a simple and novel modification of a well-known procedure. An 8-year-old boy with full-thickness rectal prolapse was treated with laxatives to no avail. He was subsequently treated with phenol-in-almond-oil injection and insertion of a 1/0PDS Thiersch suture. The effects were temporary with recurrence 3 months later. A further phenol-in-almond-oil injection was given and a 1/0PDS Thiersch suture placed, and the patient was discharged on laxatives. Recurrence occurred again at 3 months. This was treated with three circumferential Thiersch sutures along the anal canal--one Prolene 2/0 and two 1/0PDS. There has been no recurrence at follow-up. Placement of three sequential Thiersch sutures along the rectum is effective in treating recurrent rectal prolapse and a good alternative to major rectopexy.

Spontaneous resolution of a recurrent axillary cystic hygroma following acute infection.

We report a case of spontaneous resolution of a recurrent axillary cystic hygroma in a 4-year-old boy. He presented with a 1-year history of a cystic lump in the left axilla, which intermittently changed in size. Ultrasound suggested it was a lipoma, with raised suspicions of vascular malformation. Scans were discussed in a multidisciplinary meeting and provisional diagnosis of lymphocele or slow flow lymphovascular malformation was made. It was surgically excised and histology confirmed the lesion to be a cystic hygroma. However, it recurred within 3 weeks. The patient was booked for aspiration and treatment with sclerotic agent OK 432. He developed acute infection in the cystic hygroma a week before surgical intervention and was treated with antibiotics for 5 days by his general practitioner. Acute infection led to complete spontaneous resolution of the cystic hygroma within a week. There are no other reported cases in which recurrent cystic hygroma has resolved after a week of acute infection.

Extensive Necrotising Enterocolitis: Objective Evaluation of the Role of Second-Look Laparotomy in Bowel Salvage and Survival.

AIM: We investigated the role and outcome of a planned second-look laparotomy (SLL) in preserving bowel in extensive necrotizing enterocolitis (NEC). METHODS: Extensive NECs managed surgically in a tertiary centre in 2006-2009 were retrospectively studied to include patients planned for an SLL. End points were bowel salvage rate and survival outcomes. Results were median (ranges), and statistical significance was P < 0.05. MAIN RESULTS: In 4 years, 34 NECs required a laparotomy, and 9 extensive NECs who required an SLL were included. The gestation at birth was 27 (24-38) weeks, birth weight was 1120 (580-2835) g, and first laparotomy performed on day 34 (2-77) of life, with SLL performed 2 (1-3) days after initial laparotomy. Commonest indications for SLL were doubtful bowel viability and physiological instability. 3 died before SLL. Patients who survived to have an SLL (n = 6) had remaining small bowel length of 41 (25-70) cm, overall small bowel salvage rate 51 % (0-100 %), and 30-day survival 5/6 (83 %). Four patients survived for 1 year, their length of NICU stay was 114 (76-120) postoperative days, time on PN was 84 postoperative days (71 days-17 months), including one patient with short bowel syndrome who achieved enteral autonomy at 17 months; one late mortality had short bowel syndrome after further bowel resection for bowel obstruction, developed intestinal failure associated liver disease, and died before 1 year of life following liver transplant. CONCLUSION: SLL is a viable approach for extensive NEC. It offered bowel salvage rate of 51 % and long-term PN-free survival of 44 %, in the patient group who would have had significant risk of mortality and major morbidity.

Management of necrotising appendicitis associated with widespread necrotising enterocolitis of the small and large bowel and perforated duodenal ulcer.

A 7-year-old boy presented in septic shock secondary to appendicitis with generalised peritonitis. Following crystalloid resuscitation, he underwent surgery. Faecopurulent contamination and free air were found. This was secondary to a perforated and gangrenous appendix, multiple large and small bowel segments with perforations, patches of necrosis, interspersed with healthy bowel and segments of questionable viability. There was also a perforated duodenal ulcer. Necrotic segments were resected using a 'clip-and-drop' technique to shorten operative duration and guide resection to preserve bowel length. After six laparotomies and multiple bowel resections, the child was discharged home with an ileostomy that was subsequently reversed. He is currently on a normal diet and pursuing all activities appropriate for his age. Perforated appendicitis can be associated with widespread bowel necrosis and multiple perforations. A conservative damage limitation approach using the 'clip-and-drop' technique and relook laparotomies is useful in the management of extensive bowel necrosis in children.

Peristeen (ⓒ) transanal irrigation system for paediatric faecal incontinence: a single centre experience.

Aim. To evaluate the efficacy of the Peristeen (Ⓒ) transanal irrigation system when treating faecal incontinence in children due to chronic idiopathic constipation. Methods. A retrospective study was conducted of the first cohort of patients affected with faecal incontinence and referred to our centre for Peristeen (Ⓒ) transanal irrigation treatment between January 2010 and December 2012. Patients with neurogenic bowel disturbance were excluded. A previously described and validated faecal continence scoring system was used to assess bowel function and social problems before and after treatment with Peristeen (Ⓒ) . Results. 13 patients were referred for Peristeen (Ⓒ) transanal irrigation during the study period. Mean time of using Peristeen (Ⓒ) was 12.6 months (±0.6 months) and mean length of follow-up was 21.2 months (±0.9 months). All patients were noted to have an improvement in their faecal continence score, with a mean improvement from 9.7 ± 1.4 to 14.8 ± 2.7 (P = 0.0008) and a reduction in episodes of soiling and increasing in quality of life scores. Conclusion. In this initial study, Peristeen (Ⓒ) appears to be a safe and effective bowel management system, which improves bowel function and quality of life in children affected with faecal incontinence as a result of chronic idiopathic constipation, Hirschsprung's disease, and anorectal malformations.

Experience of the MACE procedure at a regional pediatric surgical unit: a 15-year retrospective review.

INTRODUCTION: The Malone antegrade continence enema (MACE) procedure is an established treatment option for children with constipation or fecal incontinence. This study retrospectively analyses the management and outcomes of children who underwent MACE procedures at a regional pediatric surgery unit. PATIENTS AND METHODS: Children who underwent a MACE procedure in our unit between 1998 and 2012 were identified. Demographic and clinical data were obtained from contemporaneous records. Using the continence scale described by Malone, overall outcomes were categorized as full, partial, or failure (full: totally clean or minor rectal leakage on night of washout; partial: clean but significant stoma or rectal leakage, occasional major leak and/or still wearing protection but perceived by child or parent to be an improvement; failure: regular soiling or constipation persisted, no perceived improvement, procedure was abandoned). Data entry and statistical analysis were performed using Excel and SPSS (IBM Corp., Armonk, New York, United States). RESULTS: A total of 40 children (29 male) were identified for inclusion. Underlying diagnoses were idiopathic constipation (16), anorectal anomalies (14) and Hirschprung's disease (10). The MACE procedure was performed laparoscopically in 26 cases and using an open technique in 14 cases. Mean age at the time of surgery was 8.9 years (range, 3-19 years) and mean follow-up time was 6.5 years (range, 1-10 years). Outcomes categorized as full were 62.5% for chronic idiopathic constipation (CIC), 71.4% for anorectal malformation (ARM), and 70% for Hirschsprung disease (HD). Overall success rates (full and partial outcomes combined) were 87.5% for CIC, 92.8% for ARM, 100% for HD, and 92.5% for all diagnoses taken together. Eleven MACE procedures (27.5%) were reversed, in seven (17.5%) due to the return of spontaneous and regular bowel movements and in four (10%) due to stomal problems. CONCLUSION: This study identified a high success rate (combining full and partial outcomes) of 92.5% for MACE procedures within our unit. An encouraging finding is that the procedure was reversed in a significant proportion of patients following the return of normal bowel habits.

Scrotal fixation in the management of low undescended testes.

AIMS: Scrotal fixation (SF) is a known technique for the management of low undescended testes (UDT). SF assumes that most low UDT have no patent processus vaginalis (PPV) and can be managed via scrotal mobilization alone. We report our experience of the role of SF in the management of low UDT. MATERIALS AND METHODS: A retrospective review of all palpable UDT operated on by the senior author between 1998 and 2008 was undertaken. Children diagnosed with palpable UDT were examined under general anesthesia; if the whole testis could be manipulated into the upper part of the scrotum, low UDT was assumed and SF was performed. Attempts to identify a PPV intraoperatively were made in all and, if found, the procedure was converted to standard inguinal incision orchidopexy. RESULTS: One hundred and thirteen children with 134 UDT were identified. SF was performed in 55 testes; inguinal orchidopexy (IO) in 75 and four testes were excised. The median (IQR) age at SF was 5.5 [4.7-6.3] years. Three SF were converted to an IO when a PPV was discovered. The complications in SF were scrotal hematoma (n = 1) and superficial wound infection (n = 1). No post-operative herniae or atrophied testis were seen and none required a redo operation. The mean (SD) operative times for SF and IO were 29.5 (18.1) and 42.7 (16.6) min, respectively (P = 0.04). CONCLUSION: In our study, 52 of 55 (94.5%) patients with low UDT lacked a hernial sac and were successfully fixed by SF. SF is a viable, simple, quick and safe alternative to IO in the management of low UDT.

Oblique anastomosis in Soave endoanal pullthrough for Hirschsprung's disease--a way of reducing strictures?

The Soave endorectal pullthrough is a commonly performed procedure for the definitive management of children with Hirschsprung's disease (HD). Anastomotic stricture is a recognised complication of this procedure. There are multiple causes for these strictures, circular anastomosis being one of them. There are techniques described which alter the shape of the anastomosis of the pulled through bowel to decrease the incidence of strictures. These are oblique and heart-shaped anastomoses. We describe a new technique of oblique anastomosis where the pulled through bowel is anastomosed posteriorly 0.5 cm from the dentate line, and anteriorly 1.5 cm above this point. This oblique anastomosis is designed to lower the stricture rate. If a stricture does occur, an anastomosis near the anocutaneous junction on the posterior aspect also faciltates Y-V anoplasty. We present our experience using this technique. Seventeen consecutive children underwent the procedure at our institution between 2003 and 2006. Only one child developed an anastomotic stricture requiring anal dilatation.

Validity of 13C octanoic acid breath test for measurement of solid meal gastric emptying time in children.

BACKGROUND/PURPOSE: It is important to establish a physiologic range of gastric emptying (GE) in children. Gastric emptying time measured with (99)Tc-labeled solid meal (GE(Tc)) is the gold standard. Large-scale studies with GE(Tc) are ideal but not feasible because of radiation exposure. The (13)C-labeled octanoic acid breath test (GE(13C)) does not involve radiation and is suitable for large studies. The aim of this study was to validate GE(13C) with GE(Tc) and to explore whether GE(13C) could be used to establish a physiologic range of GE in children. METHOD: Twenty-five healthy children underwent simultaneous GE(Tc) and GE(13C) using a standardized solid test meal. The time taken for the stomach to empty half its content (T(1/2)(13C)) and solid lag phase (lag(13C)) for GE(13C) were computed from the fractional excretion of (13)C in expired air. T(1/2)(13C) and lag(13C) were compared with corresponding values obtained by GE(Tc). RESULT: Correlation coefficient between T(1/2)(13C) and T(1/2)(Tc) was 0.69 (P < .01; r = 0.92 if 3 outliers were omitted). Correlation coefficient between lag(13C) and lag(Tc) was 0.39 (P < .05). There was good agreement between the methods by the Bland Altman method. CONCLUSION: There is good agreement between GE(13C) and GE(Tc). GE(13C) can be safely used to establish the reference range of GE in healthy children.

Gastric emptying of solids in normal children--a preliminary report.

OBJECTIVE: The physiological range of gastric emptying in healthy children has not previously been documented. The aim of this study was to establish the range of normal gastric emptying in children aged between 5 and 10 years with a Tc 99m-labelled solid meal acceptable to most of the children. METHODS: A list of 7 child-friendly foods was compiled. Thirty-one children aged 5 to 10 years completed a questionnaire, ranking their favourite food choices. A volume survey, to decide the weight of solid meal for the study, was carried out in 20 children. After ethical approval, gastric emptying was monitored in healthy children aged 5 to 10 years with a 99mTc-labelled solid meal selected by the methodology given hereinabove. Geometric mean counts were obtained from anterior and posterior gamma camera images, and data were used to produce normal emptying curves. In each case, a T1/2 gastric emptying time (time taken to empty half the stomach contents) was calculated. RESULTS: The overall preference was a chocolate Technecrispy cake, and the volume survey suggested a 30-g weight for the study. Twenty-four subjects consumed the meal and completed the study. The mean T1/2 gastric emptying time was 107.2 minutes (2 SD; range, 54.6-159.8 minutes). CONCLUSIONS: Chocolate Technecrispy cake was acceptable to most healthy children between 5 and 10 years of age and gave mean T1/2 gastric emptying time of 107.2 minutes. This meal can now be used for paediatric patients with transit problems.

Use of pelvic ultrasound in the diagnosis of megarectum in children with constipation.

PURPOSE: It has not been possible so far to differentiate slow transit constipation from functional fecal retention because the existing medical literature lacks data on rectal dimensions for healthy children or children with chronic idiopathic constipation (CIC). We, for the first time, describe the use of pelvic ultrasound (US) to achieve this. METHODS: A pelvic US was carried out on 82 children with a full or partially full bladder and with no history of bowel problems and on 95 children with CIC. The rectal crescent seen behind the bladder was measured. All children also had documentation of their age, weight, and height. RESULTS: The median age, weight, and height for the healthy children were comparable with those of the children with CIC. The median rectal crescent size in children with constipation was 3.4 cm (range, 2.10-7.0; IQR, 1.0), as compared with 2.4 cm (range, 1.3-4.2; IQR, 0.72) in the healthy children, and this difference is statistically significant on multiple regressions of log for rectal diameter, adjusted for height, weight, and age (P value< .001). CONCLUSION: Pelvic US is a quick child-friendly investigation, which can be used to document the presence of megarectum. It should be the first line investigation for all the children with CIC.

Denis Browne's thoracotomy revised.

The three main issues involved in thoracotomy technique for the repair of oesophageal atresia (OA) are: (1) prevention of chest wall deformities; (2) adequate surgical exposure; and (3) the cosmetic appearance of the skin scar. Adequate surgical exposure should be the first priority. The technique described is an endeavour to address all the above concerns, a modification of the technique described by Denis Browne that eliminates the risk of injury to the long thoracic nerve (LTN). A retrospective analysis from case notes of 70 children (1974-1997) with OA from a single surgeon's practice was performed. Data collected included the presence of complications such as wound problems, chest-wall deformities, and evidence of nerve palsies including winged scapula. A uniform technique of a vertical skin incision in the mid-axillary line, preservation of the latissimus dorsi, and division of the serratus anterior muscle anterior to its nerve was followed in all cases. No wound infection, breakdown, or seroma formation was seen in any case. On long-term followup (range 1-22 years, mean 10.5 years) no chest wall deformities or nerve palsies were observed. This modification gives excellent exposure, avoids injury to the LTN, does not lead to chest-wall deformity, and gives a pleasing cosmetic result. The scar is hardly noticeable with the arm by the side of the body.