Endoscopic findings in children born with oesophageal atresia in an academic unit in South Africa.

BACKGROUND: Oesophageal atresia (OA) is one of the most common congenital gastrointestinal (GI) abnormalities. Due to advances in multidisciplinary care, early prognosis has improved with emphasis shifting to the long-term impact of this disease. Literature suggests a higher incidence of Barrett's and eosinophilic oesophagitis in these children, with an increased risk of oesophageal carcinoma. Guidelines for adults born with OA include routine endoscopy and lifelong screening of the upper gastrointestinal tract (GIT). Despite this, uncertainty remains regarding the necessity and frequency of endoscopic surveillance for children born with OA. We describe our endoscopic findings in children born with OA. METHODS: A prospective analytic cohort study was undertaken, which included all children born with OA, that were followed-up in our unit between 2020 and 2022. History regarding feeding and GI symptoms were documented after which an endoscopy was performed. RESULTS: During the study period, 37 endoscopies were performed in patients born with OA at a median age of 25 months. The most common clinical appearance on endoscopy was anastomotic strictures followed by oesophagitis. Twelve patients had biopsies taken, with abnormal histology in all but one patient. The most common histological finding was oesophagitis with lymphocytes and chronic gastritis. Two patients had Helicobacter Pylori infection, and one had findings suggestive of eosinophilic oesophagitis. CONCLUSION: All patients with a clinical indication for an endoscopy had abnormal clinical or histological findings, thus concurring with the literature in highlighting the need for regular endoscopy. We recommend regular clinical follow-up and endoscopic surveillance if clinically indicated for children born with OA.

The impact of the COVID-19 pandemic on presentation of surgical disease in paediatric patients at a tertiary centre in Cape Town, South Africa.

BACKGROUND: Children are less susceptible to infection with SARS-CoV-2 and subsequent severe disease, yet especially vulnerable to the indirect effects of the pandemic. A constrained healthcare service, combined with the societal and behavioural changes observed during the pandemic, is likely to have altered the presentation of paediatric surgical disease. The objective was to investigate the impact of the COVID-19 pandemic on the volume of paediatric surgical admissions, the severity of disease and the type of surgical pathology treated at our centre. METHODS: A retrospective cohort study compared paediatric surgical admissions in an eleven-month period before COVID-19 to the same period during the pandemic. Comparisons in volume and diagnoses were based on the number of admissions. Predetermined criteria for severity of disease using triage scores, intraoperative findings and intensive care admissions were compared. RESULTS: A total of 1 810 admissions were recorded, 1061 in the pre-COVID group and 749 during COVID. Emergency admissions reduced by 9.2%, most notably due to a reduction in trauma, caustic ingestions and constipation. There was an increase in incarcerated inguinal hernias and helminth-related pathologies. Significantly more intussusceptions failed pneumatic reduction requiring surgical intervention with bowel resection. There was a two-fold increase in patients requiring emergency intensive care. CONCLUSION: Paediatric surgical volumes at our centre decreased during the COVID-19 pandemic. There was evidence of more advanced disease on presentation of inguinal hernias and intussusception and a generalised increased demand for emergency ICU admission.

The impact of the COVID-19 pandemic on presentation of surgical disease in paediatric patients at a tertiary centre in Cape Town, South Africa.

BACKGROUND: Children are less susceptible to infection with SARS-CoV-2 and subsequent severe disease, yet especially vulnerable to the indirect effects of the pandemic. A constrained healthcare service, combined with the societal and behavioural changes observed during the pandemic, is likely to have altered the presentation of paediatric surgical disease. The objective was to investigate the impact of the COVID-19 pandemic on the volume of paediatric surgical admissions, the severity of disease and the type of surgical pathology treated at our centre. METHODS: A retrospective cohort study compared paediatric surgical admissions in an eleven-month period before COVID-19 to the same period during the pandemic. Comparisons in volume and diagnoses were based on the number of admissions. Predetermined criteria for severity of disease using triage scores, intraoperative findings and intensive care admissions were compared. RESULTS: A total of 1 810 admissions were recorded, 1061 in the pre-COVID group and 749 during COVID. Emergency admissions reduced by 9.2%, most notably due to a reduction in trauma, caustic ingestions and constipation. There was an increase in incarcerated inguinal hernias and helminth-related pathologies. Significantly more intussusceptions failed pneumatic reduction requiring surgical intervention with bowel resection. There was a two-fold increase in patients requiring emergency intensive care. CONCLUSION: Paediatric surgical volumes at our centre decreased during the COVID-19 pandemic. There was evidence of more advanced disease on presentation of inguinal hernias and intussusception and a generalised increased demand for emergency ICU admission.

Anorectal atresia with gross terminal colonic distension in Africa.

UNLABELLED: Anorectal malformation (ARM) is a group of significant birth defects with geographic variation in incidence, individual phenotypes and regional geographic subtypes occurring in approximately 1:5,000 live births. Anorectal atresia with gross terminal colonic distension in the presence of an absent anal canal has also been known as 'pouch colon' which is mainly associated with the Indian subcontinent. Its prevalence is unknown but it is rare, possibly representing a fraction of 1 % of ARM. The problem seems to revolve around the gross terminal distension of the distal pouch which remains a significant surgical challenge to surgeons resulting in poorer postoperative continence in many instances. AIM: This study set out to collate data on ARM patients with gross terminal distension of the distal pouch from Africa to evaluate its epidemiology and outcome in African patients. METHODS: Fifteen African paediatric surgical centres (7 South African and 8 African centres) were polled on the occurrence of anorectal atresia with gross terminal distension of the terminal bowel, an ARM variant. Data included ethnic group, age, gender as well as the anatomical pathology, classification and presence or absence of associated anomalies. RESULTS: Of 12 respondents, 8 (67 %) responded and sufficient data to classify and analyse were obtained from six of the eight positive replies (7 new cases). Abdominal X-ray showed a grossly dilated terminal portion of the colon in the presence of an imperforate anus. A colovesical fistula was observed in four (three males and one female cloaca). Three were associated with a colonic atresia, of which two were in the transverse colon and one in the sigmoid colon. Surgical corrective procedures were carried out in six, but one patient, with a cloaca, died prior to surgical correction. CONCLUSIONS: In this survey of 15 African centres, we have attempted to document the occurrence and presentation of anorectal atresia with gross terminal distension in Africa and report seven additional new cases. A possible association with associated conditions like colonic atresia requires further investigation.

Retrospective surveillance of intussusception in South Africa, 1998-2003.

BACKGROUND: Intussusception is a common gastrointestinal emergency in children and appears to have a somewhat different clinical spectrum in developing countries. Its etiology is still unclear, but a link to infective agents and viruses has been highlighted. This study aimed to assess the clinical spectrum and prevalence of intussusception in children from the diverse South African population. METHODS: Retrospective data were obtained from 9 participating pediatric referral units on the occurrence of intussusception in South African children (<14 years old) during a 6-year period (1998-2003). Results were correlated with national population statistics. Intussusception was anatomically classified into ileoileal, ileocolic, and colocolic types. The clinical features, management, outcome, and possible causes were examined. RESULTS: We reviewed the occurrence and clinical spectrum of intussusception in 423 children (age, 0-14 years) presenting with acute intussusception to 9 pediatric surgical centers. The mean duration of symptoms was 1.5 days, but a delayed presentation was common (median delay, 2.3 days). Intussusception occurred throughout the year, with a peak in the summer months. The majority of patients (89%) were <2 years old, and 78% presented at age 3-18 months of age. Crude population estimates indicate an occurrence of 1 case per 3123 population <2 years old. Only 11% of patients presented after 2 years of age, and the age at presentation was significantly lower (P < .05) in black African patients. All ethnic groups were affected. In 84% of patients, intussusception occurred at the ileocolic region junction, in 7% it was ileoileal, and in 9% it was colocolic. Colocolic intussusception appeared more common in black African patients, and associated pathologic conditions (polyps and Burkitt's lymphoma) occurred mainly in older children. Surgical intervention was required in 81% of patients and involved resection of gangrenous bowel in 40%. CONCLUSION: Intussusception appears to be a relatively frequent occurrence in children in South Africa. Although the clinical spectrum appears to vary, there is an apparent link to intestinal infection, which requires further investigation. A collaborative approach is required to ascertain the relationship of intussusception to preventable infections and to improve its diagnosis and management.

Optimal time for neonatal circumcision: an observation-based study.

OBJECTIVE: A detailed observation-based study to determine the ideal age for neonatal circumcision. PATIENTS AND METHODS: A prospective study of 583 neonatal circumcisions was carried out over a 3-year period (December 2005-December 2008). First a penile ring block was performed with 1% lignocaine solution, injected with a 26G needle. Formula milk, expressed breast milk or 20% sucrose solution was given to the child ad libitum as a further soothing agent. Circumcision was performed utilizing the Gomco sutureless clamp technique. Neonatal/Infant Pain Scale (NIPS) was used to score the severity of pain. NIPS > or =2 was taken to imply a painful procedure. RESULTS: Only 6.5% of neonates under 1 week of age scored NIPS > or =2 during the procedure, but this reached 100% by the 4th week of life. There were 2 minor complications in this cohort. CONCLUSION: Despite current controversy over whether it is ethical for parents to consent to a non-therapeutic neonatal circumcision, it remains a widely practiced procedure. Therefore it is important for pediatric surgeons/urologists to perform circumcision safely with minimal trauma to the neonate. This study shows that painless circumcision is possible in almost all newborns if it is performed during the first week after birth.

The spectrum of anorectal malformations in Africa.

Anorectal malformations (ARM) remain a significant birth defect with geographic variation in incidence, individual phenotypes and regional geographic subtypes. Although early studies indicated a low incidence in Black patients, there is a great paucity of knowledge as to the types, frequency and incidence of ARMs encountered in the African continent and their associated anomalies. Current evidence suggests a significant clinical load. This study set out to evaluate ARM in Southern and other parts of Africa to define the clinical load of ARM. We retrospectively collected data on 1,401 ARM patients from six South African Paediatric Surgical units plus representative samples from five other African countries from West, Central and Southern Africa. Data included ethnic group, age, gender as well as the anatomical pathology, classification and presence or absence of associated anomalies. ARM lesions classified by the Wingspread classification plus an analysis of fistula position was carried out in evaluable cases for purposes of comparison. South African centres reported a higher prevalence of cloacae and vestibular fistulae, whereas rectovaginal, recto prostatic and anorectal malformation without fistula were more prevalent in the Northern African group. 76% of 1,401 patients were ethnically Black African [gender ratio = 2 (vs gender ratio 1.38 overall)] and 49.8% were "low" lesions (Wingspread classification). High or intermediate lesions were mostly males (72%). Anal stenosis was most prevalent in black males and non-Black females. Fistulae were identified in 95% with 682 (52%) being low (perineal/covered anus/vestibular) fistulae. Perineal fistulae had a male predilection (n = 260; 20%), whereas vestibular fistulas (n = 416; 32%) was strikingly frequent in black females (55%). Of the remainder, 15 fistulae were rectovesical (1.2%), 544 recto-urethral or prostatic (42%), 16 recto-vaginal (1.2%). In addition, there were 43 cloacal lesions (3.3%). Isolated rare ARM anomalies included "Pouch" colon (2) and H-type fistula (2). Isolated lesions occurred in 81% but 163 associated anomalies were identified in 114 patients. These included chromosomal lesions (10), genito-urinary anomalies (50), genital (16), cardiac (31), skeletal anomalies (33), gastro-intestinal malformations (28). Other anomalies included CNS anomalies (14), anterior abdominal wall defects (2) and facial (8) abnormalities and neuroblastoma (1). The ARM is not uncommon in Black African populations and constitutes a significant clinical load to surgical practice in Africa. Ethnic differences appear to exist and vestibular fistulae predominate in black females. Cloaca (3.3%) did appear to be more prevalent. Isolated lesions are frequent but the types of associated anomalies appear similar to other series except chromosomal syndromes. This study illustrates the need for more objective data from developing countries to assess geographical differences.

A simplified technique for giant inguinal hernia repair in infants.

Repair of giant inguino-scrotal hernia (GISH) in male infants is a difficult operation, even in experienced hands. It requires an immaculate technique to avoid known complications such as tearing of the sac, injury to delicate testicular vessels and dividing of vas deferens. Moreover, a recurrence rate of 9% is noted in a number of reports. This article describes a new surgical maneuver to simplify the procedure. All GISH repaired by the author, over a 5-year period (October 2001-September 2006), were reviewed retrospectively. In total, 89 infants with 106 GISH underwent uni- or bilateral herniotomies. A standard inguinal incision is made and Scarpa's fascia is sharply opened; the external inguinal ring and the cord is identified. By gentle manipulation and blunt dissection, the spermatic cord together with the testis is exteriorized. The assistant applies gentle traction to the cord, which allows for easy identification of the inguinal sac and its subsequent separation from vas and vessels. Testis is replaced in the scrotum, hernial sac suture ligated at its base and the wound closed in layers. All cases were managed with the above approach. The average length of the procedure was 11 min for unilateral and 19 min for bilateral cases. Except for minimal scrotal swelling post-operatively, no other surgery-related complications were noted during or immediately after the operation. Testicular atrophy or iatrogenic undescended testes were not encountered in the follow-up period. Ipsilateral recurrent hernia was noted in one infant after 6 months which required re-operation with the same technique. In cases of GISH; dislocating the testis into the wound and applying a gentle stretch on the cord allows for a safe dissection of the hernial sac and subsequent herniotomy. This maneuver converts a difficult procedure into a relatively simple one.

Respiratory pressure monitoring as an indirect method of intra-abdominal pressure measurement in gastroschisis closure.

AIM OF STUDY: Abdominal compartment syndrome (ACS) is a rare but potentially fatal complication of gastroschisis closure. The liberal use of a staged reduction technique has become a well-established method of avoiding this problem. Unfortunately the use of silos is associated with a high rate of sepsis, prolonged ileus, and ventilation. A method of predicting an impending ACS would help surgeons to decide more objectively which patients would benefit from a staged reduction. A new simple method is presented here which predicts intra-abdominal pressure based on airway pressure readings. METHOD: Over a four-year period, 34 neonates with gastroschisis underwent measurement of Pplateau respiratory pressures and simultaneous intra-vesical pressures. RESULT: The Pplateau pressures were approximately 10 cmH2O higher than any concurrent intra-vesical pressure readings. ACS occurred, in one patient, when pressure measurements were above 15 cmH2O (intra-vesical) or 25 cmH2O (Pplateau). CONCLUSION: By measuring Pplateau pressures, it is possible to predict the intra-abdominal pressure and hence avoid the development of an abdominal compartment syndrome on closing the abdominal wall in gastroschisis.

Laparoscopic evaluation of testicular mobility as a guide to management of intra-abdominal testes.

The optimal management of intra-abdominal testes is the subject of an ongoing debate as the result of widespread use of laparoscopy since early 1990's. A simple laparoscopic technique uses cord mobility to act as a guide to cord length and therefore predict the success of a conventional orchidopexy in cases of true intra-abdominal testes. In the technique described, the testis is displaced by stretching the testes to overly the opposite internal inguinal ring. Over a 3-year period, a total of 36 boys with 38 intra-abdominal testes, confirmed laparoscopically, were prospectively assessed. The reported "stretching maneuver" was carried out in all cases. Successful conventional orchidopexy as predicted by a positive stretch maneuver was carried out in 20 testes. When the stretch maneuver failed, conventional 2-stage open operation was done in 3 patients and Fowler-Stephens orchidopexies for the remaining 13 children. A simple test determining testicular mobility assessed during laparoscopic evaluation of intra-abdominal testes provides information of significant importance upon which the correct surgical approach can be based.

Guidelines for the successful treatment of lymphangioma with OK-432.

BACKGROUND/PURPOSE: Cystic hygroma or lymphangioma (LA) is a disfiguring benign lesion commonly seen in the neck and face regions in children. Extensive neck/face resectional surgery is frequently performed for this condition, often with disappointing results. An attractive alternative to surgery is injection, sclerosing therapy. OK-432 injection therapy has been characterised as a novel treatment of LA since 1987. Since this first report, there have been a number of articles from different institutions reporting variable success rates with its use. This has resulted in uncertainty and confusion among physicians, surgeons and parents alike as to in whom, when, and how to treat patients with this modality. METHOD: A prospective study over a five-year period. Thirty-five patients were injected with this agent, 1 to 4 times, depending on response. RESULT: In patients with macrocystic LA, complete regression was achieved in 96 %. Patients with microcystic LA responded poorly or not at all. CONCLUSION: The anatomical appearance of the malformation on computerised tomography (or sonar) scan is crucial in determining the treatment strategy taken; macrocystic lesions respond almost universally to OK-432 injections, whereas patients with microcystic disease generally do not respond and should therefore not be injected with this agent.

Antegrade continence enema and its application in Africa.

BACKGROUND: Antegrade continent enema (ACE) procedure has been accepted worldwide as the salvage procedure for intractable constipation and faecal incontinence after anorectal malformation surgery. Its application only has been reported from the developed countries. METHODS: The authors performed four such operations on incontinent children in a poor socioeconomic group in South Africa. RESULTS: Three patients had previous surgery for anorectal malformation, and one had intractable encopresis. The patients kept clean with water washouts only, starting 1 week after the operation. CONCLUSIONS: The ACE procedure can be used easily by patients in disadvantaged communities of Africa, and its use requires minimal but sympathetic supervision only. The authors recommend that all pediatric surgeons dealing with these unfortunate children should perform this procedure after a trial period of medical treatment. This is also the first report of the ACE procedure performed for an encopretic child.

Surgical management of uterine prolapse in an infant.

Neonatal uterine prolapse has been rarely described in the literature. Most cases have an underlying cause, usually spinal cord malformations. Conservative treatment has been advocated for this condition in the neonates. We would like to present the late presentation of a child with complete uterine prolapse which was treated with classical uterine ventrisuspension.