Routine urine microscopy and culture in paediatric surgical outpatients: is it necessary?

Midstream urine culture has been the gold standard for diagnosing a urinary tract infection. But sample collection in children can be time-consuming and frustrating. In our department, a urine sample is routinely collected by the nursing staff prior to the outpatient consultation. We therefore reviewed our practice with respect to correlation with symptoms, change in management occurring as a result of the culture, and financial implications. Case notes of 109 children attending paediatric nephrourology clinics over a three-month period were retrospectively reviewed. Data collected included underlying diagnosis, symptomatology, urine culture results at current and previous outpatient visits, and change in management that occurred as a direct result of the culture. A pure growth of >10(5 )colony-forming units/ml was considered to be a positive result. Of 783 urine samples, only 23 were positive in 15 patients, nine of which required change in management. All of these nine patients were symptomatic at or just preceding the clinic visit. None of the remaining patients in the group had symptoms of a urinary tract infection at the time of the outpatient visit. Change in management therefore occurred in 8.3% of patients, all symptomatic, based on the results of 1.1% of urine samples. At a cost of pound 3.00 per sample during working hours, the cost of processing 783 samples was pound 2349.00. We conclude that urine samples from paediatric surgical outpatients should not be sent routinely unless the patients are symptomatic or a change in management is anticipated. Other techniques to screen for urine samples needing culture may be considered.

Laparoscopic splenectomy: a suitable technique for children and adults

Aims: Splenectomy retains an important role in the management of certain haematological conditions that fail to respond to conventional medical therapy, and has traditionally been performed through a midline or left subcostal incision with patients requiring 5-7 days in hospital. The well recognized benefits of laparoscopic surgery should also apply to splenectomy. This study aimed to develop a safe and effective technique suitable for all age ranges and without the requirement for expensive stapling devices. METHODS: An operative technique evolved over the 5-year period from 1994, from an initial six-port approach with the patient supine, to a four-port approach in a modified right lateral position, with locking surgical clips applied down a 5-mm port to vessels in the hilum, and removal of the spleen within a retrieval bag through a 4-6-cm Pfannanstiel incision. Data were collected prospectively for all patients undergoing laparoscopic splenectomy at Leicester Royal Infirmary, including demographic details, indication for surgery, duration of surgery, length of inpatient stay, transfusion requirement, postoperative complications and the response of the original condition to surgical intervention. RESULTS: A total of 40 patients underwent laparoscopic splenectomy (14 children, 26 adults) for a variety of conditions (idiopathic thrombocytopenia (ITP) (n = 24), haemolytic anaemia (n = 9) or malignancy (n = 7)) with a median operating time of 180 min for the first 20 patients and 100 min for the second 20 (P < 0.0001), and median inpatient stay of 3 days for the first 20 patients and 2 days for the second 20 (P < 0.0003). None of the operations was converted to open surgery, five patients required blood and/or platelet transfusion perioperatively, none of the patients had major postoperative complications, 23 of the 24 patients with ITP developed normal platelet counts after operation, and all nine patients with haemolytic anaemia maintained a normal haemoglobin concentration after operation. CONCLUSION: Laparoscopic splenectomy can be performed safely and effectively in adults and children without the need for stapling devices.

Gastrostomy complications in infants and children.

Thirty children have had percutaneous endoscopic gastrostomy (PEG) inserted for feeding purposes. During a follow-up period of 5-45 months (mean 24 months), complications were recorded in 13 patients. Some patients had more than one complication. Complications included colocutaneous fistula, gastro-oesophageal reflux, wound infection, granulation tissue formation, tube leakage, tube blockage and bleeding. The authors present a retrospective review of the results and discuss the management of these complications.

Is the incidence of acute appendicitis really falling?

To determine if there has been a genuine fall in the incidence of acute appendicitis, an epidemiological study using HAA and Korner datasets for the years 1975-1994 was carried out to identify those children and young adults undergoing appendicectomy for acute appendicitis. The overall incidence of acute appendicitis fell from 1.84/1000 to 1.17/1000. This fall was statistically significant (R2 = 0.74, P < 0.01). The decrease was significant in both males (overall reduction, 34%) and females (overall reduction, 40%). No significant reduction was observed in either males or females between 15 and 19 years of age. The overall reduction remains essentially unexplained, but may have implications for health planning and provision of services.

The diagnostic value of symptoms and signs in childhood abdominal pain.

The assessment and diagnosis of abdominal pain in childhood continues to be a clinical challenge. We audited the presenting symptoms and signs in a consecutive series of 447 children presenting to a paediatric surgical unit in an attempt to quantify the value of particular symptoms and signs in differentiating acute appendicitis (AA) from non-specific abdominal pain (NSAP). The onset of pain in the centre of the abdomen and radiation of pain was not sufficient to differentiate between NSAP and AA. Progression of pain, nausea, vomiting, anorexia and diarrhoea were significantly more common in children with AA (P < 0.01). Similarly, facial flushing, tachycardia (pulse > 100 beats/min), guarding and rebound tenderness were significantly more common in children with AA (P < 0.001). Knowledge of this quantitative data could help clinicians adjust the weighting given to the presence of a particular symptom or sign in children with acute abdominal pain.

Anal dilatation in the management of painful defaecation in children.

Painful defaecation is a common and distressing problem in children. A retrospective study has been made of 27 such children who underwent examination under anaesthetic and anal dilatation as part of their overall management. At operation, fifteen were found to have perianal skin inflammation and fissuring. Follow-up was continued where possible until symptoms resolved. The length of follow-up ranged from 1 to 18 months (mean 7 months). At discharge, 21 of the children were cured or substantially better. The author concludes that anal dilatation may help in the management of these children but only as part of an overall strategy of medical care.

Splenectomy for haematological disease.

The role of splenectomy in haematological disease appears to be changing. This single centre, retrospective study was carried out to document the indications for splenectomy and its outcome over a 7-year period and to compare it with the preceding 7-year period. Sixty-four patients underwent splenectomy in the study period, the main indication being idiopathic thrombocytopenic purpura. There was one post-operative death and morbidity was seen in 40 (63%) patients. Splenectomy was successful in achieving the desired aim in 51 (80%) patients. Approximately 40% fewer patients underwent splenectomy in the study period compared with the preceding 7 years despite there being an overall increase of 123 (633 vs. 540) patients treated for haematological disease in this period. The reason for this observation was the fall in the number of splenectomies performed for Hodgkin's disease and auto-immune haemolytic anaemia.

Laparoscopic Nissen fundoplication in children.

Laparoscopic surgery for the definitive treatment of gastroesophageal reflux (GOR) has become an accepted alternative to conventional techniques in adults. Although relatively rare, GOR in children represents an important clinical entity with symptoms including failure to thrive, nocturnal dyspnea, and vomiting. This paper details our experience in eight children who have undergone a laparoscopic Nissen fundoplication for failed medical treatment of severe GOR. Particular attention is paid to technical aspects of the procedure and the differences between adult and pediatric techniques are emphasized. The preliminary results suggest that a laparoscopic Nissen fundoplication is a safe procedure which significantly improves reflux symptoms in children and that these results are comparable to those obtained with conventional surgery.

Atypical mycobacterial lymphadenopathy in children--is it underdiagnosed?

Lymphadenitis due to atypical mycobacteria occurs primarily in the neck region of children, the most common organisms isolated are the Mycobacterium avium intracellulare (MAIS) group and M. malmoense. The nodes are unilateral and may be hot or cold. The infection is benign. There is little or no systemic upset and it is usually the preschool child who is affected. Routine haematological investigations are unhelpful, chest X-ray is clear and the Mantoux test may be positive or negative. Cultures are necessary to prove the diagnosis. The ideal treatment is total excision of the affected nodes and antituberculosis chemotherapy is not indicated.

Pancreatic function following partial pancreatectomy and anastomosis of the pancreatic duct to the stomach or duodenum in dogs.

The effects of pancreatic duct anastomosis to stomach (stomach group) or duodenum (duodenal group) on pancreatic function were examined in dogs following two thirds pancreatectomy. Normal fasting blood glucose concentrations were maintained in both groups despite significant reductions in glucose tolerance in the stomach group, and reductions in fasting insulin and insulin peak response in both groups. Pancreatic exocrine function was significantly decreased in both groups, though plasma p-aminobenzoic acid (PABA) concentrations were generally higher in the duodenal group. A correlation was found between plasma trypsin-like immunoreactivity (TLI) and pancreatic weight. These results indicate that anastomosis of the pancreas to bowel can be undertaken with minimal postoperative complications and that the site of the anastomosis influences pancreatic function. They suggest that preservation of more than one third of the pancreas is required for optimal function. The complementary information provided by the PABA and TLI tests suggests their dual application will be clinically useful for the detection and characterisation of naturally occurring pancreatic diseases.

Psychological effects of day case surgery compared with inpatient surgery.

Short term psychological disturbance in 70 children undergoing minor surgery was compared in two randomly allocated groups by means of questionnaires answered by their parents. Significantly less psychological disturbance was reported in children undergoing day case surgery compared with children admitted on the day before and discharged on the day after surgery. Children who had day case surgery were less often reported to require extra attention in the first week after discharge home, and at three months after operation these children were less often said to be still affected by their hospital stay. It is concluded that a reduced psychological upset can now be added to the other arguments in favour of day case surgery in children.

Elective splenectomy in haematological disorders.

We report on 106 elective splenectomies performed for haematological disorders between March 1979 and January 1986. The most common indications were immune thrombocytopenic purpura (30 patients) and Hodgkin's disease (19 patients). However, staging laparotomy is no longer performed routinely for patients with Hodgkin's disease and the reasons for this are discussed. Other indications for splenectomy included splenic pain (13 patients), autoimmune haemolytic anaemia (12 patients), hereditary spherocytosis (11 patients) and hypersplenism (9 patients). The overall morbidity and mortality was 48% and 5% respectively. The most common postoperative complication was thrombocytosis (defined as a platelet count greater than 800 X 10(9)/l) and occurred in 26 patients. This review confirms that splenectomy continues to have an important role in the management of certain haematological disorders.

Orchidopexy: the effect of changing patterns of referral and treatment on outcome.

One-hundred and twenty-eight orchidopexies performed between 1979 and 1981 were reviewed in 1985, and the results compared with the results of operations performed in 1972. The age of referral has been determined for 1972, 1979-1981 and 1985. The number of unsatisfactory results has decreased from 35 per cent in 1972 to 9.4 per cent between 1979 and 1981. Five cases of the 'ascending testicle' were discovered, confirming the importance of this phenomenon. We suggest that the optimum age for orchidopexy is during the second year of life; however, during 1985, only 20 per cent of boys referred for orchidopexy were under 3 years of age. Doctors performing neonatal examinations should consider the possibility of cryptorchidism and ensure that affected neonates are reviewed at 1 year. The potential theoretical advantages of orchidopexy at an early age will only be converted into clinical benefit if the operation is performed by an experienced surgeon who has developed an expertise in this area of surgery.