Bipolar circumcision: A new technique for an old procedure with quantified cosmetic outcome.

BACKGROUND: Circumcision using bipolar diathermy is well established and used widely. It seems to be superior in terms of post operative complications. The cosmetic outcome of the procedure has never been quantitatively described though. AIMS: To describe a modification to performing circumcision with bipolar that involves applying four clamps to the foreskin as it is being amputated with the bipolar so that a consistent length of the mucosal cuff can be obtained with a single almost bloodless cut. METHODS: Prospective case series of all patients circumcised using the 4 clamps traction and bipolar cut technique. The cosmetic outcome was assessed in terms of the length of the mucosal cuff in absolute numbers and in proportion to the penile and glanular length. RESULTS: Seventy four patients were recruited with a median age of 3.5 months. No complications were encountered. The average length of the penis was 40 ± 13 mm and the glans 12 ± 3.6 mm. The average length of the mucosal cuff was 8.4 ± 2.9 mm, and the proportion to total penile length was 21.1% ± 4.7% and to glans length 72% ± 24.1%. CONCLUSION: The four clamp traction method with bipolar circumcision is safe and has a satisfactory cosmetic outcome.

The "Silk Road": A novel method for inserting transpyloric feeding tubes in low resource settings.

INTRODUCTION: Transpyloric tube (TPT) feeding is used in a multitude of conditions including gastroesophageal reflux disease. We here describe a new simple method to insert TPTs. METHODS: 6 French feeding tube is premeasured nose to xiphisternum, and then another 7cm of length is added and 3-5 silk (4-0) ties are applied to the end of the tube spaced 0.5-1cm apart. The knots are placed in different radial directions, and multiple throws are placed on each knot so as to add bulkiness. The tube is then inserted transnasally to the premeasured length and secured. The child is given a single dose of metoclopramide and placed on his right side for 4h. A plain abdominal x-ray is then performed to confirm adequate TP placement. Following correct placement the patient is tube fed with small volumes every 15-20min. Descriptive data was prospectively collected. RESULTS: 34 patients were recruited, median age 3.5months. All presented with vomiting, and 26 had failure to thrive. 24had successful TP tube placement from the first attempt, 6 from the second attempt, 2 on third attempt, and in 2 placement was unsuccessful. In 28 patients vomiting almost stopped completely. 9 patients had fundoplication, and 1 had gastrostomy placement. 3 patients died during the study because of unknown reasons. CONCLUSION: The silk tie technique is a safe and simple way to treat persistent vomiting and may prove useful in low resourced environments. LEVEL OF EVIDENCE: IV.