Virtual consultations: delivering outpatient clinics in paediatric surgery during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has resulted in many changes to clinical practice, including the introduction of remote clinics. Those familiar with remote clinics have reported benefits to their use, such as patient satisfaction and cost benefits; however, ongoing challenges exist, including delivering optimal patient-centred care. As a tertiary paediatric surgery unit in the UK, completing remote clinics was a new experience for most of our surgical team. We completed a service evaluation early into the COVID-19 pandemic aiming to define and address issues when delivering remote clinics in paediatric surgery. Remote clinics were observed (telephone and video), with follow-up calls to families following the consultations. RESULTS: Eight paediatric surgeons were observed during their remote clinics (telephone n = 6, video n = 2). Surgeons new to remote clinics felt their consultations took longer and were reluctant to discharge patients. The calls did not always occur at the appointed time, causing some upset by parents. Prescription provision and outpatient investigations led to some uncertainty within the surgical team. Families (n = 11) were called following their child's appointment to determine how our remote clinics could be optimised. The parents all liked remote clinics, either as an intermediate until a face-to-face consultation or for continued care if appropriate.Our findings, combined by discussions with relevant managers and departments, led to the introduction of recommendations for the surgical team. An information sheet was introduced for the families attending remote clinics, which encouraged them to take notes before and during their consultations. CONCLUSIONS: There must be strong support from management and appropriate departments for successful integration of remote clinics. Surgical trainees and their training should be considered when implementing remote clinics. Our learning from the pandemic may support those considering integrating remote clinics in the future.

Postoperative complications after reconstructive surgery for cloacal malformations: a systematic review.

The repair of cloacal malformations is most often performed using a posterior sagittal anorecto-vagino-urethroplasty (PSARVUP) or total urogenital mobilization (TUM) with or without laparotomy. The aim of this study was to systematically review the frequency and type of postoperative complication seen after cloacal repair as reported in the literature. A systematic literature search was conducted according to preferred reporting items for systematic reviews and meta-analyses guidelines (PRISMA). Eight records were eligible for this study which were qualitatively analyzed according to the Rangel score. Overall complication rates reported in included studies ranged from 0 to 57 %. After meta-analysis of data, postoperative complications were seen in 99 of 327 patients (30 %). The most common reported complications were recurrent or persistent fistula (n = 29, 10 %) and rectal prolapse (n = 27, 10 %). In the PSARVUP group, the complication rate was 40 % and in the TUM group 30 % (p = 0.205). This systematic review shows that postoperative complications after cloacal repair are seen in 30 % of the patients. The complication rates after PSARVUP and TUM were not significantly different. Standardization in reporting of surgical complications would inform further development of surgical approaches. Other techniques aiming to lower postoperative complication rates may also deserve consideration.

Substance P and vasoactive intestinal peptide are reduced in right transverse colon in pediatric slow-transit constipation.

BACKGROUND: Slow-transit constipation (STC) is recognized in children but the etiology is unknown. Abnormalities in substance P (SP), vasoactive intestinal peptide (VIP) and nitric oxide (NO) have been implicated. The density of nerve fibers in circular muscle containing these transmitters was examined in colon from children with STC and compared to other pediatric and adult samples. METHODS: Fluorescence immunohistochemistry using antibodies to NO synthase (NOS), VIP and SP was performed on colonic biopsies (transverse and sigmoid colon) from 33 adults with colorectal cancer, 11 children with normal colonic transit and anorectal retention (NAR) and 51 with chronic constipation and slow motility in the proximal colon (STC). The percentage area of nerve fibers in circular muscle containing each transmitter was quantified in confocal images. KEY RESULTS: In colon circular muscle, the percentage area of nerve fibers containing NOS > VIP > SP (6 : 2 : 1). Pediatric groups had a higher density of nerve fibers than adults. In pediatric samples, there were no regional differences in NOS and VIP, while SP nerve fiber density was higher in sigmoid than proximal colon. STC children had lower SP and VIP nerve fiber density in the proximal colon than NAR children. Twenty-three percent of STC children had low SP nerve fiber density. CONCLUSIONS & INFERENCES: There are age-related reductions in nerve fiber density in human colon circular muscle. NOS and VIP do not show regional variations, while SP nerve fiber density is higher in distal colon. 1/3 of pediatric STC patients have low SP or VIP nerve fiber density in proximal colon.

Decrease in nerve fibre density in human sigmoid colon circular muscle occurs with growth but not aging.

BACKGROUND: Studies in animals suggest that enteric neurons decrease in density or number with increasing age. Neurons containing nitric oxide (NO), vasoactive intestinal peptide (VIP) and Substance P (SP) have been implicated. In human large intestine, NO-utilizing neurons decrease during childhood or early adulthood but it is not known if the innervation of the muscle changes. This study examined the density of nerve fibres containing these transmitters in sigmoid colon circular muscle from children and adults. METHODS: Fluorescence immunohistochemistry using antibodies to neuronal NO synthase (nNOS), VIP and SP was performed on sigmoid colon from 18 adults with colorectal cancer, two children with familial adenomatous polyposis, and normal colon from nine children with Hirschsprung's disease. The percentage area of immunoreactive (IR) nerve fibres containing each transmitter in circular muscle was quantified in confocal images. KEY RESULTS: In the adult sigmoid colon circular muscle, the percentage area of nerve fibres containing nNOS>VIP>SP (6 : 2 : 1). Paediatric groups had significantly higher percentage area of nerve fibres containing nNOS, VIP or SP-IR than adults, with the decrease in nerve fibre density occurring from birth to 30 years. Circular muscle thickness increased between 12 and 30 years. Total nerve fibre area remained constant, while the muscle increased in thickness. CONCLUSIONS & INFERENCES: In human sigmoid colon circular muscle, there are reductions in nNOS-, VIP- and SP-IR nerve fibre density with growth from newborn to late adolescence but little further change with aging. The reduction in nerve density is due to an increase in circular muscle thickness rather than a loss of nerve fibres.

Blunt abdominal trauma in children: how predictive is ALT for liver injury?

BACKGROUND: The liver is the second most commonly injured intra-abdominal organ in children. CT scanning is currently regarded as the "gold standard" in screening for intra-abdominal injury following blunt trauma. However, the risks associated with performing CT in children are not insignificant and, in addition, CT is not always readily available. This study investigates the utility of alanine aminotransferase (ALT) in screening for liver injury in paediatric trauma. METHODS: Two groups of patients were compiled from a prospectively identified trauma registry-one with liver injuries and another with intra-abdominal injuries other than to the liver. Inclusion in the study required that an initial ALT level had been obtained after injury. Where CT had been performed, a paediatric radiologist blind to the ALT results graded the severity of the liver injuries. The study groups were compared and a receiver operating characteristic (ROC) curve generated to derive the optimum ALT threshold to identify liver injury. RESULTS: 51 patients with liver injury and 65 with other intra-abdominal injuries were identified. An ALT level of > or =104 IU/l gave a sensitivity of 96% and a specificity of 80%. When liver injuries were stratified to identify only clinically significant liver injuries (grades III, IV and V), this ALT threshold identified 100% of patients with 70% specificity. CONCLUSIONS: In this sample, ALT appears to be a useful predictor for the presence or absence of liver injury. In haemodynamically stable children with clinical suspicion of isolated liver injury, identification of a normal ALT level (<104 IU/l) may reduce the need for unnecessary transportation for CT scanning with subsequent radiation exposure.

The use, value and safety of herniography.

AIMS: To assess the safety, sensitivity and specificity of out-patient herniography when used to diagnose hernias in the presence of a normal or equivocal physical examination. MATERIALS AND METHODS: This retrospective study reviewed the symptoms, clinical findings, radiological findings, surgical findings and clinical outcome of 112 patients referred for herniography over a 5-year period. RESULTS: No significant complications were encountered. Thirty hernias were diagnosed. There was one false-positive and one false-negative examination giving herniography a sensitivity of 96.6% and a specificity of 98.4%. CONCLUSION: Herniography is a sensitive, specific, safe and reliable investigation which should be available to and used by all surgeons who perform hernia repair operations.

Ante-natal testicular torsion: only one cause of the testicular regression syndrome?

It has been suggested that the most likely cause of the Testicular Regression Syndrome (TRS) is ante-natal torsion of the testis. As testicular torsion is twice as common on the left this theory cannot explain the incidence of right sided or bilateral cases. From a 5-year retrospective surgical and pathological review, we confirmed that the left testis was the most commonly affected, that boys with TRS tended to be delivered closer to term, and that frequently both testes were present at birth, but one or both subsequently vanished. We also found that direct trauma can produce histological findings indistinguishable from TRS. Close to term, fetal testes are liable to be intrascrotal and therefore susceptible to direct trauma. As the left testis descends into the scrotum at an earlier stage than the right, it is therefore at greater risk of injury. Since the findings of TRS can be produced by direct trauma, we suggest that intra-partum trauma may predispose to the TRS.

Children's femoral fractures: the Edinburgh experience.

Femoral fracture is a relatively common cause of trauma admission to the paediatric surgical services in Edinburgh. Our current policy is to use gallows traction for babies and infants under 2 years and external Liston splintage with straight leg balanced skin traction for older children followed by either early mobilization or the application of a hip spica or cast brace. We reviewed the use of this management protocol over a 10-year period (323 cases) in order to assess its value and complications. A prospective study was made of 143-patients between 5 and 10 years after their fracture to assess residual disability. We found our management protocol to be a simple, highly reliable method of treatment with a minimum of complications or long-term disability.