Small bowel volvulus due to giant mesenteric lipoma.

We report on a 14-year-old girl with acute intestinal obstruction due to volvulus of the small bowel caused by a giant mesenteric lipoma. To the best of our knowledge, this presentation of a mesenteric lipoma is unknown in the previous paediatric literature.

Congenital small bowel diverticulosis and intestinal atresia: a rare association.

An unusual case of multiple intestinal atresias with multiple small bowel diverticulae is presented. To the best of our knowledge this is the first reported case of its kind in the literature.

Dual pH probe monitoring versus single pH probe monitoring in infants on milk feeds: the impact on diagnosis.

OBJECTIVES: Oesophageal pH monitoring is the gold standard technique for the detection of gastro-oesophageal reflux in adults and children. A standard parameter used to define "abnormal" reflux is the percentage of recording time for which the gastric pH is < 4. This study investigated the relevance of this measure in infants on regular milk feeds whose gastric contents and refluxate will be neutral for most of the recording time. METHODS: Simultaneous oesophageal and gastric pH monitoring was carried out on all infants who were milk fed exclusively and admitted to hospital for suspected gastro-oesophageal reflux. In vitro studies were performed to establish the buffering capacities of the fruit juice, Dioralyte (a glucose electrolyte solution), breast milk, and milk formula feeds available on the paediatric wards. RESULTS: Complete sets of data were obtained from 30 babies with a mean age of 4 months. Gastric pH was 4 increased this value to 17.81 (2. 46)%. Using a cut off point of 10%, 11 of the 30 babies would have been diagnosed positive for reflux using the conventional method; however, recalculation by ignoring the time for which gastric pH was high doubled this to 22 positive for reflux. CONCLUSION: Combined oesophageal and gastric pH monitoring greatly increases the number of positive results from tests in infants on regular milk feeds.

Wilms' tumor: a 25-year review of the role of preoperative chemotherapy.

PURPOSE: This 25-year population based, single institution review was conducted to investigate the impact of preoperative chemotherapy on surgical and histological staging in patients with Wilms' tumors. RESULTS: Forty-nine patients under the age of 15 years were identified from case notes to have had histologically verified Wilms' tumors over the 25-year period from January 1972 to December 1996. Twenty-six patients were treated initially with preoperative chemotherapy, 23 with immediate surgery. Eleven had treatment randomized within the UKCCSG WT9101 trial (UKWT3), and the remainder received initial treatment according to unit policy. Surgical stages in the two groups (preoperative chemotherapy and immediate surgery) were respectively, stage 1:14(28.5%) and 11 (22.5%), stage II: one (2%) and eight (16.3%), stage III: 11 (22.5%) and four (8.2%). Seven patients had clinical stage IV disease at presentation. Histology results were favorable in 45 patients and unfavorable in four. All patients received chemotherapy during treatment, whereas 25 (51%) also received radiotherapy. No significant difference was evident in the two groups with respect to treatment-related morbidity. Five patients relapsed, three of whom died within the period of review, but a fourth has since died. CONCLUSIONS: This study suggests that the use of preoperative chemotherapy does not put the patient at increased risk of postoperative morbidity or reduced survival. The distribution of surgical stages suggests that limited tumor downstaging may have occurred as a result of preoperative chemotherapy.

Scrotal fixation: a different surgical approach in the management of the low undescended testes.

OBJECTIVES: To evaluate the feasibility of using the scrotal approach in patients with undescended testes. METHODS: Over an 18-month period, 165 patients were diagnosed to have 208 undescended testes. Of these, 28 were nonpalpable. RESULTS: At exploration, 7 testes were abdominal, 33 were canalicular, 165 were in the region of the external ring/pubic tubercle, and 1 was perineal. There were 2 cases of unilateral monorchism. The operative procedure performed was as follows: orchiectomy for 6 abnormal testes, orchiopexy for 142, and scrotal fixation (SF) for 58. (In this series, 9 patients were converted from SF to an orchiopexy at the time of the initial operative procedure.) SF involves a scrotal incision extending down to the tunica vaginalus. The cord is then mobilized from below, after which the testis is placed in an extra-dartos pouch. CONCLUSIONS: Our study has shown that there are a significant number of undescended testes that lie in the region of the pubic tubercle, lack a hernial sac, and can be managed by a scrotal mobilization alone. Based on our experience with SF, we have used a simple classification of undescended testis that has therapeutic and prognostic justifications.

Acute appendicitis in the under-5 year old.

During a 10-year period we operated on 816 children with a diagnosis of acute appendicitis. Of these, 36 (4.5%) were under 5 years of age. A retrospective analysis was made of these 36 cases to assess the natural history, management and outcome in these children. Abdominal pain was the commonest symptom but was not invariable, being present in only 32 of the 36 children while vomiting was present in 28 children. Localized tenderness in the right iliac fossa was present in 21 children and generalized in 10. In 5 children there was a delay in diagnosis in excess of 18 h. The overall perforation rate was 50% as assessed macroscopically and was inversely proportional to the child's age. There was no mortality and the wound sepsis rate was 16.6%. The low incidence of acute appendicitis in very young children means that it is often overlooked. A high index of suspicion may contribute to earlier diagnosis and thereby reduce morbidity.

Paediatric gastro-oesophageal reflux: prognostic indicators from pH monitoring.

The original diagnostic 24 hour pH monitoring data in 57 children with gastro-oesophageal reflux (GOR) were retrospectively reviewed after a minimum of one year follow up. The tracings of children who responded to medical treatment were compared with those who failed to respond and required a fundoplication. Children with GOR secondary to oesophageal atresia/tracheo-oesophageal fistula and neurological conditions (n = 12) were analysed separately from those with primary GOR (n = 45). Children with primary GOR requiring a fundoplication (n = 9) had increased daytime reflux. The percentage time pH < 4 was the best discriminator (21% v 7%) with a threshold of 18% giving a 92% specificity and a 70% sensitivity. For children with secondary GOR the percentage time pH < 4 at night was significantly higher (29% v 3.7%) in those requiring a fundoplication (n = 5). A threshold of 18% gave an 80% specificity and an 86% sensitivity. These results show that both daytime and night time pH monitoring data can be of prognostic value in different subgroups of children with GOR. A percentage time pH < 4 of greater than 18% was a useful threshold to apply when evaluating the pH monitoring data.

Complications of circumcision.

Circumcision remains a common operation, with over 30,000 procedures performed annually in the UK, mostly on children. The British Medical Association has recommended that circumcision should be performed only for medical reasons. Despite this, controversy exists over whether too many circumcisions are being performed. Are patients being exposed to an unnecessary operation? It may be argued that in doubtful cases it is easier to proceed to circumcision on the assumption that the attendant risks are low, but the operation is associated with a definite morbidity and rare deaths have been reported. This review considers the spectrum of complications that may result from circumcision and discusses the possible aetiological mechanisms.

Biliary and anorectal atresia.

This is a report of a unique case of biliary and rectal atresia.

Short-bowel syndrome: a collective review.

Neonates can now be expected to survive with very short lengths of bowel because of advances in pediatric neonatal care and in parenteral and enteral nutrition. Most pediatric surgeons have only a few patients with this problem under their care, so individual experience is limited. This collective survey, carried out by postal questionnaires to pediatric surgeons in the British Association of Paediatric Surgeons in the United Kingdom with an interest in the gastrointestinal tract, documents current techniques of management, the complications encountered, and reviews the clinical and economic consequences of prolonged total parenteral nutrition. We conclude that within the limitations of resources and our understanding of prognosis, neonates, especially if less than 35 weeks' gestation, with remaining jejunoileal segment of greater than 20 cm with an intact ileocecal valve (ICV) or greater than 30 cm without an ICV, should be considered salvageable.

Esophageal pH monitoring for gastroesophageal reflux: a United Kingdom study.

Esophageal pH monitoring is the accepted standard for the investigation of gastroesophageal reflux (GER) in adults. A postal questionnaire was sent to 912 United Kingdom paediatric physicians & surgeons. Five hundred forty-seven (61%) replied, with 124 (22.7%) currently using the technique, mostly in conjunction with barium swallow and/or esophagoscopy. The use of pH monitoring to quantify GER was also accepted in principal as being the best determinant of reflux by a further 186 (34%), but as yet was unavailable in their hospitals. Pediatricians were also questioned as to their management of children with GER. The majority were treated medically with a variety of antireflux medication, with only 237 (42%) referring cases for surgery.

Measurement of testicular blood flow at orchiopexy with a solid state laser.

We have evaluated the solid state laser as a means of determining testicular blood flow at operation. A solid state laser was used to measure blood flow before mobilization of cryptorchid testes, and subsequently after mobilization and placement within a subcutaneous scrotal pouch. Testicular volume was calculated. The median blood flow (ml/100 gm/min) before mobilization was 8.96 (range, 3.43 to 27.2). After mobilization a modest rise to 9.39 (range, 1.82 to 23.75) occurred, which was not statistically significant. However, heterogeneity existed in the response; 11 testes showed a median fall of 8.07 (range, 1.59 to 15.36), which was significant compared to the initial value; 16 testes showed a variable degree of hyperemia with a rise of 2.57 (range, 0.1 to 12.7), which was also significant compared to the initial value; two testes showed no change. The testes that showed a fall in blood flow were all high abdominal testes, which required the most mobilization. The mean testicular volume was 0.38 cc (SEM, 0.03 cc). No difference was noted in size between testes with a net rise in blood flow (mean volume, 0.38 cc) and testes with a net fall in blood flow (mean volume, 0.375 cc). No relationship was noted between testicular size and blood flow. We conclude that the solid state laser is a simple means of measuring testicular blood flow at orchiopexy and may provide a method of deciding which testes should undergo microvascular replantation on the basis of inadequate perfusion per-operatively.

Acute pancreatitis and gastric volvulus occurring in a congenital diaphragmatic hernia.

Many complications are known to occur in association with congenital diaphragmatic hernia. Acute pancreatitis in this situation is very rare. A case is reported and guidelines are given for the management of this complication.

Second primary tumour following retinoblastoma.

Reported is a child who at the age of 18 months had presented with a left retinoblastoma. The lesion had involved the optic nerve (Stage IV), and was successfully treated by enucleation and radiotherapy. The radiation field did not include the mandible or the submandibular triangle. He was followed up until he left the area aged 11 years. He represented aged 12 years with a progressive swelling of the left submandibular gland. Histology of the surgically excised submandibular gland revealed a mucoepidermoid carcinoma of the submandibular gland. This case highlights the need for continual surveillance in survivors of retinoblastoma, as second primary tumours occur both within and outside of previous radiation fields. The clinical association between retinoblastoma and mucoepidermoid carcinoma of the submandibular gland has not been previously reported.