Latent vitellointestinal duct sinus presenting with massive lower gastrointestinal bleeding in an adolescent.

A 12-year-old boy with a history, at birth, of a weeping pink fleshy lesion after his umbilical cord detached, requiring repeated chemical cauterisation, presented with massive lower gastrointestinal bleeding and required resuscitation and blood transfusion. Augmented Tc99m nuclear medicine scan confirmed ectopic gastric mucosa. The lateral view suggested its attachment behind the umbilicus. At exploration, a latent vitellointestinal duct sinus with ectopic gastric mucosal mass was found. Segmental resection of the sinus and mass excision with primary anastomosis and incidental appendicectomy was curative. Pink fleshy mass discharging coloured fluid at the umbilicus following detachment of umbilical cord should be considered a remnant of vitellointestinal duct unless proved otherwise. A pink lesion with yellowish discharge resistant to chemical cauterisation should raise the suspicion of embryonic structures. Latent vitellointestinal sinus is a new lesion in the spectrum of umbilical anomalies. Lateral view of the nuclear medicine scan is helpful in locating the site.

Paediatric giant cervicomediastinal thymolipoma.

We report a case of a 11-year-old boy who presented with a massive soft tissue right cervical painless and progressive lesion displacing trachea to the left and extending into the anteriosuperior mediastinum which was diagnosed to be a lipomatous mass on chest CT scan. Subsequent biopsy and total excision proved it to be a giant cervicomediastinal thymolipoma. It was successfully excised with excellent prognosis and long-term results. A giant paediatric cervicomediastinal thymolipoma is a rare, benign, mediastinal mass of thymic origin. It may remain asymptomatic despite massive size and up to 50% in some series are associated with autoimmune disease. CT scan gives fat density and encapsulated benign nature and biopsy usually establishes the diagnosis. Preoperative tissue diagnosis is important as now the availability of thoracoscopic option is best suited to reduce morbidity. Treatment of choice is total excision using open surgical, minimal invasive techniques or robotic surgery and the prognosis is excellent.

The role of maternal stress in early pregnancy in the aetiology of gastroschisis: an incident case control study.

OBJECTIVE: The incidence of gastroschisis, a congenital anomaly where the infant abdominal wall is defective and intestines protrude from the abdominal cavity, is increasing in many countries. The role of maternal stress in some adverse birth outcomes is now well established. We tested the hypothesis that major stressful life events in the first trimester are risk factors for gastroschisis, and social support protective, in a case-control study in the United Kingdom. METHODS: Gastroschisis cases and three controls per case (matched for maternal age) were identified at routine 18-20 week fetal anomaly ultrasound scan, in 2007-2010. Face to face questionnaire interviews were carried out during the antenatal period (median 24 weeks gestation) asking about serious stressful events and social support in the first trimester. Data were analysed using conditional logistic regression. RESULTS: Two or more stressful life events in the first trimester (adjusted OR 4.9; 95% CI 1.2-19.4), and moving address in the first trimester (aOR 4.9; 95% CI 1.7-13.9) were strongly associated with risk of gastroschisis, independent of behavioural risk factors including smoking, alcohol, and poor diet. Perceived availability of social support was not associated with reduced risk of gastroschisis (aOR 0.8; 95% CI 0.2-3.1). CONCLUSIONS: Stressful maternal life events in the first trimester of pregnancy including change of address were strongly associated with a substantial increase in the risk of gastroschisis, independent of stress related high risk behaviours such as smoking, alcohol consumption and poor diet. This suggests that stress pathways are involved in the aetiology of gastroschisis.

Cultural bias in the AAP's 2012 Technical Report and Policy Statement on male circumcision.

The American Academy of Pediatrics recently released its new Technical Report and Policy Statement on male circumcision, concluding that current evidence indicates that the health benefits of newborn male circumcision outweigh the risks. The technical report is based on the scrutiny of a large number of complex scientific articles. Therefore, while striving for objectivity, the conclusions drawn by the 8 task force members reflect what these individual physicians perceived as trustworthy evidence. Seen from the outside, cultural bias reflecting the normality of nontherapeutic male circumcision in the United States seems obvious, and the report's conclusions are different from those reached by physicians in other parts of the Western world, including Europe, Canada, and Australia. In this commentary, a different view is presented by non-US-based physicians and representatives of general medical associations and societies for pediatrics, pediatric surgery, and pediatric urology in Northern Europe. To these authors, only 1 of the arguments put forward by the American Academy of Pediatrics has some theoretical relevance in relation to infant male circumcision; namely, the possible protection against urinary tract infections in infant boys, which can easily be treated with antibiotics without tissue loss. The other claimed health benefits, including protection against HIV/AIDS, genital herpes, genital warts, and penile cancer, are questionable, weak, and likely to have little public health relevance in a Western context, and they do not represent compelling reasons for surgery before boys are old enough to decide for themselves.

The role of maternal nutrition in the aetiology of gastroschisis: an incident case-control study.

BACKGROUND: Gastroschisis, a congenital anomaly involving a defect in the fetal abdominal wall, has increased in prevalence in many countries, but the aetiology is uncertain. We tested the hypothesis that high maternal alcohol consumption and poor diet in the first trimester are risk factors in a case-control study in the UK (1 July 2007 to 28 February 2010). METHODS: Gastroschisis cases and three controls per case (matched for maternal age) were identified at 18- to 20-week routine anomaly screening ultrasound scan (USS). Interviews were carried out during the antenatal period (median 24 weeks' gestation) using a piloted questionnaire. Conditional logistic regression was used to describe the associations between exposure variables and gastroschisis, adjusted for known confounding variables. RESULTS: The response rate was 73% for cases (n = 91) and 70% for controls (n = 217). High consumption of fruits and vegetables during the first trimester (aOR 0.2; 95% CI 0.04-0.6), taking folic acid for at least 6 weeks during the first trimester (aOR 0.3; 95% CI 0.1-0.7) and increasing body fat percentage of total maternal body weight (aOR 0.9; 95% CI 0.8-0.9 per 1% increase) were independently associated with reduced risk. Cigarette smoking (aOR 2.7; 95% CI 1.1-6.8) was an independent risk factor. CONCLUSION: We report for the first time that higher intake of fruits and vegetables during the first trimester, longer duration of folic acid supplementation and higher body fat percentage are associated with reduced risk of fetal gastroschisis, independent of cigarette smoking. The increased risk of cigarette smoking is greatest in older women and in high socio-economic groups.

The unidirectional testicular tunneller: a simple, safe and novel device for orchidopexy in patients with palpable undescended testes.

PURPOSE: Inguinal orchidopexy is already considered a safe procedure, this paper describes a simple new surgical instrument designed to make the operation easier, simpler and quicker, whilst reducing tissue trauma, in particular to the deep ring. The result of its use in two centres is presented. METHODS: A unidirectional testicular tunneller has been developed comprising a head, shaft and eye. At operation, following testicular mobilisation, the tunneller is passed through the groin incision into the scrotum and a dartos pouch created by cutting against the head of the instrument. This allows more of a "no-touch" technique with less back and forth movement through the inguinal canal. The testis is attached to the eye of the instrument and pulled into the scrotum before fixation. RESULTS: From November 2000 to December 2011, two surgeons operated on 592 boys using the instrument. 93 procedures were bilateral. All operations proceeded without incident and a healthy testis was safely and permanently placed in the scrotum. There were no complications related to the use of the tunneller. All were treated as day cases. CONCLUSION: The instrument described in this paper simplifies inguinal orchidopexy, improves procedural safety and is felt to reduce surgical trauma. In view of these advantages and the absence of complications related to this instrument, its use in inguinal orchidopexy is recommended.

Autoimmune thyrotoxicosis with achalasia cardia.

We report a case of autoimmune thyrotoxocosis in an 11-year-old boy with achalasia cardia. This case explores autoimmunity as an etiological factor for achalasia based on several autoimmune conditions that have been associated with it.

Duplicated proctodeum.

A 3-month-old female infant was noted to have two near mirror image anal openings: an anterior, normally sited, anus and a posterior duplicated proctodeum. Ultrasound and X-rays were normal. Contrast X-ray showed 2-cm long non-communicating proctodeal duplication. She underwent EUA, proctoscopy, stimulation of sphincter and transproctodeal excision of the duplication and external sphincter reconstruction with excellent cosmetic and functional results.

Mature and immature extracranial teratomas in children: the UK Children's Cancer Study Group Experience.

PURPOSE: The purpose of this article is to describe the features, treatment, and risk factors for relapse of children with mature teratoma (MT) and immature teratoma (IT) to assist future treatment plans. PATIENTS AND METHODS: Patients were younger than 16 years of age and referred to the UK Children's Cancer Study Group centers with biopsy-proven extracranial MT and IT and no prior chemotherapy. Complete excision, with the coccyx in sacrococcygeal patients, and follow-up, including serum alpha-fetoprotein monitoring for early detection of malignant yolk sac tumor (YST) recurrence, were recommended. Carboplatin, etoposide, and bleomycin (JEB) were given for YST relapse, whereas relapsed MT and IT were treated at clinicians' discretion, usually surgically. Pathology was reviewed and treatments, outcome, and prognostic features assessed. RESULTS: There were 351 patients, 227 with MT, 124 with IT. Tumor sites were: testis (n = 53), ovary (n = 130), sacrococcygeal region (n = 98), thorax (n = 23), and other (n = 47). Surgical resection was incomplete in 26% of MT and 40% of IT patients; 5-year event-free survival was 92.2% and 85.9%, respectively, and 5-year overall survival was 99% and 95.1%. Poorer outcome occurred with incomplete resection, tumor rupture, nongonadal site (particularly sacrococcygeal), young age, higher stage and grade, and gliomatosis peritonei, but not with cyst fluid aspiration/spillage, tumor enucleation, nodal gliomatosis, or microfoci of YST in the tumor (Heifetz lesions). JEB was effective for YST recurrence, but not for MT or IT. CONCLUSION: Treatment remains primarily surgical, with JEB chemotherapy for YST relapse. No definite response followed JEB for pure MT and IT. Adjuvant chemotherapy after surgery for sacrococcygeal patients is not advocated.