Paediatric anal endosonography.

PURPOSE: This study was performed to determine the endosonographic features of the anal canal in normal children and to compare these findings with the endosonographic features in children with congenital anorectal malformations. METHODS: Two groups of children were examined by anal endosonography (AES): group 1 ( n=30) were controls, and group 2 ( n=15) were children born with anorectal malformations. RESULTS: In the normal group, the sphincter elements were clearly visualised. The intersphincteric plane produced a double image, which differs from the adult appearance. Of 15 patients who had anorectoplasty, AES identified accurate placement of the neoanus within the sphincters in 13 and slight malposition in two patients. CONCLUSIONS: This study details the endosonographic appearances of the anal canal in healthy children aged from 1 month to 14 years. AES provided useful anatomical detail in patients following anorectoplasty.

Rectal gastric heterotopia in infancy.

Heterotopic gastric mucosa is rare in children with most cases presenting in association with Meckel's diverticulum. The authors present a 2-year-old boy with gastric heterotopia of the anorectum, who presented with painless, intermittent rectal bleeding.

Patterns of presentation of human immunodeficiency virus type 1-infected children to the paediatric surgeon.

PURPOSE/METHODS: Review of the records of infants and children admitted with human immunodeficiency virus type 1 (HIV-1) infection was undertaken to determine the mode and pattern of presentation at the Paediatric Surgical Unit, King Edward VIII Hospital, Durban. RESULTS: Over the 2-year period-December 1994 to December 1996-63 patients with recognised HIV infection presented to the surgical unit. Seventeen were known to have acquired immunodeficiency syndrome (AIDS). Infection was the most common presenting problem (n = 37). In this group, 14 had abscesses, cellulitis, or osteitis. 18 had perineal sepsis-11 had acquired rectovaginal fistulae, two had fistulae-in-ano, one a perianal abscess, two had perineal condylomata, and two had rape-related injuries and sepsis. Three children presented with overwhelming sepsis, one neonate presented with haemorrhagic colitis caused by cytomegalovirus, and one older child presented with oesophageal candidiasis. Generalised lymphadenopathy was the presenting complaint in 14 children. Biopsy results showed nonspecific reactive changes in six children, HIV-reactive changes in five, and tuberculosis in three patients. Ten children presented with non-HIV-related problems; nine were neonates with congenital anomalies. An older child presented with a coin impacted in his oesophagus. Two children presented with tumours-one had a Kaposi sarcoma and one had a Wilms' tumour. CONCLUSIONS: Twenty-six percent had clinical manifestation of AIDS, 19% presented with lesions diagnostic of HIV infection, 22% presented with signs or symptoms that were suggestive of the disease, and 33% were asymptomatic of HIV infection.

Surgical lessons learned from the Shigella dysenteriae type I epidemic.

An epidemic of Shigella dysenteriae type I is spreading through Africa. It is a particularly infectious and virulent form of dysentery which can cause clinical confusion with other endemic diseases and may present to the surgeon as a result of its complications. A total of 140 children with Shigella dysenteriae type I presented to the paediatricians at King Edward VIII Hospital in 1995; 35 were referred to the surgeons because of abdominal tenderness, distension, peritonitis or perforation. Ten children underwent laparotomy--four for peritonitis and six for perforation. Of the four children with peritonitis, three had transmural colitis. Therefore laparotomy was only performed for objective evidence of perforation. Of the subsequent non-operated group with the clinical features of peritonitis, none developed further surgical problems in the acute phase and none died. It is suggested that surgery in the acute phase should be avoided unless there is evidence of perforation.

T-cryptantigen (TCA) activation in surgical neonates: a hidden problem.

The Thomsen-Friedenreich cryptantigen (TCA) is located on the surface of all red cells, but is concealed by a layer of neuraminic acid. When bacteria that produce neuraminidase disrupt this coating, the TCA can be exposed and activated. If blood products containing antibody to the TCA are subsequently administered, haemolysis can result. While the relationship between TCA and necrotising enterocolitis (NEC) is well described, the incidence of TCA activation in other forms of sepsis in surgical neonates is not known. In a prospective study, 117 patients admitted to the Surgical Neonatal Nursery were examined for evidence of TCA activation. Of the 117 babies, 69 were clinically non-septic and only 1 had weak TCA activation (1.4%). Forty-eight were clinically or bacteriologically septic; 8 of these demonstrated TCA activation (17%), 3 of whom died. Forty of the septic group showed no evidence of TCA activation although 27 grew organisms on culture; 17 in this group died. Two of the TCA-activated babies received unwashed red cells, and both haemolysed; 4 TCA-activated babies received washed red cells and none haemolysed. Although 1 of the well babies in this study demonstrated TCA activation, we would not recommend routine TCA testing on clinically well babies. We would, however, recommend routine testing in all clinically septic infants, as 17% showed signs of TCA activation in this study. We would also suggest the adoption of a selective transfusion policy in TCA-activated patients to avoid the risk of haemolysis. This may help to reduce unnecessary morbidity and mortality in a high-risk group of neonates.

The adaptive immune response to major surgery in the neonate.

The effect of major surgery on components of the adaptive immune response in babies has not previously been reported. In a prospective study, eight neonates undergoing uncomplicated surgery for repair of esophageal atresia were investigated. They were compared with ten age-matched normal babies not undergoing surgery. The parameters of the immune response investigated were: total leukocytes (WBC), lymphocytes and their subsets (T-helper, T-suppressor, natural killer [NK], B-lymphocytes), monocytes, immunoglobulins (Ig) G and M, the cytokines tumor necrosis factor-alpha (TNF-alpha) and interleukin 1-beta (Il-1beta), and C-reactive protein (CRP), an acute-phase protein. When compared to the normal controls, the operated group showed a fall in all types of WBC following surgery, but only the falls in B-lymphocytes and NK cells were significant on postoperative day 3 (P < 0.05). The suppression in WBC was temporary, and by day 7 the operated group had significantly higher numbers of total WBC and T-helper cells than the controls (P < 0.05), who were undergoing their physiological postpartum fall in WBC. Within the operated group, there was a significant fall in the numbers of total lymphocytes, T-suppressors, and B-lymphocytes compared to preoperative levels (P < 0.01). The ratio of T-helper/T-suppressor cells increased significantly following surgery. There was a vigorous immune response in terms of the humoral factors: CRP, TNF-alpha, and Il-1beta all rose significantly postoperatively (P < 0.02).

Prediction of neonatal sepsis by thromboelastography.

The thromboelastogram (TEG) measures functional defects in coagulation, from fibrin formation through platelet aggregation to fibrinolysis. It is comparable with standard laboratory tests of coagulation; however, it provides additional useful qualitative information. This prospective study documents the TEG findings in 103 neonates: 60 were normal and healthy and provided a reference range; 12 surgical babies had established sepsis, 15 had early sepsis, and 16 were non-septic. TEG abnormalities were detected only in those patients with early and established sepsis. Abnormalities were found in all but 1 of this group of 27 patients (96%), whereas only 16 (59%) had thrombocytopenia, 2 (6%) had leukocytosis, and 6 had leukopenia. The TEG had a sensitivity for sepsis of 96% and a specificity of 96%. This exceeds the values for routine full blood-count parameters and other laboratory indicators of sepsis. It was found to be a simple, quick, and sensitive indicator of early sepsis that enabled the clinicians to manage septic newborns earlier.

A comparison of colo-colic and ileo-colic intussusception.

There are many differences in the clinical features of intussusception between African and temperate countries. The records of 192 patients with intussusception who presented to the Pediatric Surgical Service at King Edward VIII Hospital, Durban, South Africa during a 10-year period were reviewed. Compared with temperate countries, the patients were older (median, 1 year 7 months), presented later (median, 4.2 days), had a higher proportion of colo-colic lesions (17%), had absence of primary bowel pathology, and had a high surgical rate (82%). To define clinically important differences, the clinical and pathological features of 158 cases of ileo-colic intussusceptions were compared with 34 colo-colic cases. Compared with the ileo-colic group, colo-colic lesions occurred in older children (median, 3.8 years) (v 1.5 years; P < .001). In the colo-colic group, there were fewer shocked and pyrexial patients, and the rate of successful nonoperative reduction was higher. The groups had a similar incidence of surgical intervention (82%). In the ileo-colic group, there was a higher mortality rate and more complications, but only the higher resection rate (P < .001) was statistically significant.

Membranous atresia of the body of the stomach.

Pyloric and prepyloric webs and atresias have long been recognized and frequently reported; however, membranous atresia of the body of the stomach has not been reported previously. The authors report such a case.

A long-term follow-up study of children with supracondylar fractures of the humerus.

A retrospective study to assess the long-term results of the treatment of supracondylar fractures of the humerus was undertaken to provide guidance on the management of these troublesome injuries. In our experience as long as there was less than 25% displacement on an anteroposterior (A/P) or lateral x-ray, and less than 10 degrees angulation on an A/P or lateral x-ray, it is not essential to achieve an anatomical reduction, and good elbow function could be expected. Although children do not appear to correct for valgus or varus deformity there was no functional deficit from this deformity in this series. It was found that major displacements were more likely to have a worse result than undisplaced or minimally displaced fractures. These results would support a conservative approach to the management of these fractures--closed reduction followed by three weeks in a collar and cuff. If the position proved unstable, closed reduction was re-attempted or internal fixation performed. Conservative treatment was safe and effective, and the results comparable with other series that advocate internal fixation.

Duodenal ulcer is associated with low dietary linoleic acid intake.

It has been suggested that the falling incidence and virulence of duodenal ulcer is related to increased dietary polyunsaturated essential fatty acid intake. The adipose fatty acid profile, which closely reflects dietary intake, was measured in 35 men with chronic duodenal ulcer and 35 matched control men. The mean percentage of linoleic acid in adipose tissue was significantly lower in the ulcer group (10.0 (0.7) v 12.3 (0.7)%, p less than 0.01) and this difference was found in both smokers and non-smokers. This finding suggests that the diets of duodenal ulcer patients are deficient in linoleic acid and this could be of aetiological importance.

Dietary linoleic acid, gastric acid, and prostaglandin secretion.

Basal and pentagastrin-stimulated gastric acid secretion, fasting serum gastrin concentrations, and the gastric output of prostaglandin E and its major metabolite 13,14-dihydro 15-keto prostaglandin E2 were measured in 9 normal subjects before and after 14-20 days of dietary supplementation with linoleic acid. Mean maximal gastric acid output fell from 36.0 +/- 3.3 (SEM) to 30.1 +/- 2.9 mmol/h (p less than 0.05), although mean basal acid output was not significantly affected (8.3 +/- 2.1 and 7.2 +/- 1.7 mmol/h, respectively). Mean fasting serum gastrin concentrations increased from 19.2 +/- 3.1 to 30.9 +/- 3.8 ng/L (p less than 0.01) after linoleic acid, probably because of acid suppression. The mean output of prostaglandin E increased from 498 +/- 110 to 1254 +/- 465 ng/h (p less than 0.05); that of its metabolite increased from 165 +/- 18 to 1168 +/- 645 ng/h (p less than 0.01). These findings show that in normal subjects essential fatty acid weakly inhibits gastric acid secretion, but considerably increases gastric prostaglandin output.

Should a paediatrician be present at non-rotational forceps deliveries?

In a series of 500 consecutive deliveries there were 35 non-rotational forceps deliveries for delay in the second stage of labour. There was no statistically significant difference in the frequency of resuscitations in this group compared with that in 329 spontaneous vertex deliveries. It is concluded that a paediatrician need not be called routinely to these forceps deliveries when there is no evidence of fetal distress.