Incorporation of Integra in tissue defects: a pilot study in the rat model.

Integra has been shown to be very useful in accelerating the growth of neodermis. It has found extensive use in case of burns as a primary dressing immediately after a burn, after release of contractures and following scar revision. It has been used to achieve cover after the debridement of extensive infective processes involving the skin. Encouraged by these results we have assessed the application of Integra to augment and/or patch defects of the urinary bladder, diaphragm and the abdominal wall in the rat model. This was a pilot study and involved the incorporation of Integra in the diaphragm, the urinary bladder (extramucosal) and the muscle layer of the abdominal wall. Eight adult Wistar rats were given general anaesthesia and Integra was implanted with absorbable sutures at the sites mentioned. The omentum was hitched to the collagen matrix surface to revascularise the graft. The silicone was left in situ. The operative period was covered with antibiotics. The anaesthesia was then reversed. Postoperatively the rats were given analgesia and feeds started immediately. The rats were sacrificed after 3 weeks. The abdominal cavity was examined for adhesions. The Integra implant along with adjacent tissue was harvested and examined histologically. There were no visible intra-abdominal adhesions. The histology revealed good degree of neovascularisation and fibrosis in and adjacent to the implant. This was comparable to the changes seen in the skin. This pilot study has shown that implanting Integra invokes a similar response in deeper tissues and it can develop neovascularisation from the omentum. Hence, this could find some application in treating congenital conditions such as diaphragmatic hernias, abdominal wall defects and for bladders requiring augmentation. Our initial results are quite encouraging and we feel that this field should be further explored.

The incidence and investigation of acute scrotal problems in children.

The true incidence of the various causes of acute scrotum in children is unclear; epididymo-orchitis (EO) is thought to be uncommon. Investigation for underlying urological abnormality in children with EO is recommended. To determine the incidence of the various pathologies in boys presenting to the emergency department with an acute scrotal condition and assess the value of further investigation of the urinary tract in a subgroup of boys with EO, a retrospective review of 100 consecutive patients admitted with a diagnosis of testicular pain was performed. Seventy had torsion of an appendix testis (TAT) and 12 had torsion of the testicle (TT). Ten boys were admitted with 11 episodes of EO; 7 had other pathologies including incarcerated hernia, varicocoele, and idiopathic scrotal oedema. The diagnosis of EO was made at operation in all 11 episodes. Escherichia coli was cultured in 4 patients; none were found to have underlying urinary tract abnormality. TAT was thus commonest causes of the acute scrotum. EO is not rare in infants, the incidence in this study being equal to the of TT. Subsequent urological investigation did not disclose any underlying abnormality. However, based on the current published literature futher investigation is recommended in selected cases.

Gastroschisis: early enteral feeds may improve outcome.

OBJECTIVE: Population-based retrospective review of gastroschisis from 1986 to 1996. METHODS: This was a retrospective review of gastroschisis. Seventy cases were identified from the Birth Defects Registry of Western Australia (WA). Hospital medical records of live-born cases were reviewed. RESULTS: The live-born incidence of gastroschisis in WA was 2.1 per 10,000 live births for the period 1986-96. The incidence in mothers aged less than 20 years was 8.3-fold that of women aged over 30 years (P < 0.0001). The incidence rate for the period 1995-96 was over twice the rate for 1986-88. Age at first enteral feed was significantly related with length of hospital stay and duration of total parental nutrition (TPN). Each day delay in commencing enteral feed was associated with an increase in hospital stay of 1.05 days and an increase in TPN duration of 1.06 days. The method of delivery of the infant, age at repair, length of anaesthetic time, duration of postoperative paralysis and gestational age was not associated with length of stay or TPN duration. The data were divided into two cohorts: (i) 1986-90; and (ii) 1991-96. There was a statistically significant reduction in hospital stay from a geometric mean of 45.7 (1986-90) to 22.9 days (1991-96). CONCLUSIONS: Gastroschisis has a favourable outlook, with 89.7% survival of live births. Over the 10 year period studied, there has been a reduction in length of hospital stay and duration of TPN. The age at which the infant is first fed enteral feeds appears to be important in affecting the length of hospital stay and the duration of TPN, with delays associated with a longer hospital stay and longer TPN duration.

An audit of postoperative analgesia after pyloromyotomy.

Seventy-two cases of pyloric stenosis treated in our institution in the last five years were reviewed in an attempt to determine the need for postoperative analgesia after pyloromyotomy in infants. All children had their wound infiltrated with a mean dose of 2.16+/-1.43 mg x kg(-1) of bupivacaine, and first analgesia was required 9.12+/-8.04 h after surgery. Paracetamol was the main analgesic administered (average of two doses of approximately 20 mg x kg(-1)). Only three patients required postoperative opioids. In conclusion, there was a low consumption of analgesics after pyloromyotomy. Furthermore, infiltration of the wound appeared to be beneficial since time to administration of first postoperative analgesia was delayed.

Fine needle aspiration biopsy in children.

BACKGROUND: Fine needle biopsy (FNB) in children has been slow to gain acceptance compared with the use of the technique in adults where it is regarded as standard clinical practice in screening significant lymphadenopathy and suspicious masses. We report our early experience with FNB in the paediatric population. METHODS: Fifty-two biopsies were performed between June 1991 and June 1993. The age of the children ranged from 6 months to 14 years (median 2 years, mean 5 years). RESULTS: A definite diagnosis on cytology alone was obtained in 67%. The pathologist was certain of malignant or nonmalignant potential in 79% (67% benign and 12% malignant) and unsure in 21% (17% benign and 4% malignant). There were no false positive or false negative diagnoses of malignancy. Surgical excision or biopsy was performed in 33%. Fine needle biopsy assisted in planning surgery in 12%. Surgery was necessary for a definite diagnosis in 21% and FNB assisted 42% of the patients to avoid surgery altogether. CONCLUSIONS: Fine needle biopsy is simple, minimally invasive and useful in the evaluation of children with suspicious lymph nodes and masses.

Acute abdominal pain in children: an analysis of admissions over a three year period.

A quality audit was performed of the case records of 1313 children admitted with acute abdominal pain over a three year period under the care of paediatric surgeons at the Princess Margaret Hospital for Children, Perth. Fifty-four per cent (n = 714) of the patients were discharged without surgical intervention; in this group the most frequent (70%, n = 503) diagnosis was non-specific abdominal pain (NSAP). Of those children having surgery, 74% (n = 443) had appendicitis proven on histopathology; the remaining appendices (n = 134) were reported as normal and no other surgical cause for the patients symptoms were identified. Only 3.7% (n = 22) of children having surgery had another surgical cause for their pain. Of this group, 11 had adnexal pathology, eight had complications of a Meckel's diverticulum and three had torsion of the omentum. There were no deaths in this series, and 39 patients (3%) had wound infections. Based on these results, only 35% of children referred to a surgeon with abdominal pain will actually require surgical intervention, although as a consequence of concern over clinical status an additional 10% will have a laparotomy with normal findings.

Vitamin K coagulation status in surgical newborns and the risk of bleeding.

The vitamin K coagulation status in surgical newborns, who may be at increased risk of developing hypocoagulability and hemorrhage, has not previously been studied. Therefore, we measured the combined activity of the plasma vitamin K-dependent coagulation factors (Thrombotest), total prothrombin, PIVKA II, plasma vitamin K1, fibrinogen, D-Dimer, and platelets in 49 newborns admitted to a neonatal surgical intensive care unit. All infants had significant pathology, and treatment involved surgery in all but two. Twenty-three infants (47%) underwent surgery on two or more occasions. Intravenous or oral antibiotics were used in all patients and many received more than one course. All infants had vitamin K1 prophylaxis at birth. At day 0 (date of birth), the mean Thrombotest and total prothrombin levels were 51% (range, 20% to 100%) and 40% (range, 24% to 59%), respectively. Coagulation activity decreased on day 1 (P > .1) and was followed by a graduate increase in clotting activity, reaching normal adult levels (> 60%) at day 5 for Thrombotest and day 24 for total prothrombin. Only three infants had a Thrombotest less than 20%. PIVKA II was detected in 20 cases (41%). However, levels were within normal limits (< 0.9%) in 17 of these, and between 1.0 and 4.8% in the remaining three infants. There was no relationship between elevated PIVKA levels and coagulation activity in these patients. Plasma vitamin K1 was very high, particularly in the first days of life.(ABSTRACT TRUNCATED AT 250 WORDS)

Central venous catheters in surgical neonates.

Central venous catheters (CVCs) are widely used in neonates, but have significant complication rates. Over a 4-year period, 65 lines were inserted in 55 surgical neonates with a total of 877 catheter days. The mean length of insertion was 13.5 days, with a range of 1 to 35 days. Eighty percent of the surgical diagnoses were of necrotising enterocolitis, diaphragmatic hernia, or gastroschisis. Insertion was almost exclusively via the internal jugular vein. Only two Broviac catheters were used, the other catheters were noncuffed. Fourteen (22%) were inserted in the neonatal unit, with a similar complication rate to those inserted in the surgical theater. Overall, complications occurred with 22 lines (34%), seven of which (11%) were primary catheter sepsis (infection incidence, 1:125 days). One patient died as a result of catheter sepsis. Although the complication rate was similar, the complication incidence per day of catheter usage was higher than comparable reports. It is not clear if this was due to the pathological conditions of the surgical neonate, surgical or nursing technique, or the type of catheter used.

The endoscopic correction of vesico-ureteric reflux.

The traditional surgical treatment of vesico-ureteric reflux has been by open operation, namely that of reimplanting the ureters into the bladder. Endoscopic correction of vesico-ureteric reflux is now possible using a sub-mucosal injection of Teflon paste. The results of injection of 36 ureters over a 12-month period is presented. The procedure is safe, simple and an effective way to correct vesico-ureteric reflux.

Balanitis xerotica obliterans in children.

Balanitis xerotica obliterans was studied in 48 fully developed and 6 early cases in children aged 2-15 years. It occurred in 9% of 100 consecutive circumcisions for all, including religious, reasons and in 19% of 232 other circumcisions for disease of the prepuce and penis. Seven cases developed after surgery for hypospadias. The boys nearly always presented with inability to retract the prepuce; half also had discomfort after micturition, and a quarter had obstructive signs, usually minor. At surgery, half had involvement of glans or meatus, previously considered rare in childhood, 3 requiring meatotomy. The condition, once seen, was easily recognized clinically as well as microscopically. The early cases, characterized by focal narrow hyaline edematous zones in severe diffuse chronic balanitis, suggest that the condition may be an inflammation in which the usual increased permeability of small vessels in inflammatory reaction is accentuated in a loose vascular region.

Carcinoma cuniculatum of the abdominal wall.

A case of carcinoma cuniculatum (verrucous carcinoma of the skin) is reported. The 15 X 16 cm tumour was located on the abdominal wall. We believe this to be the first reported case of carcinoma cuniculatum occurring on the abdominal wall.