Ureteric stents in pyeloplasty: a help or a hindrance?

OBJECTIVE: To examine whether routine ureteric stenting influences outcome of pyeloplasty for pelvi-ureteric junction obstruction (PUJO). PATIENTS AND METHODS: A 10-year review was conducted of 105 consecutive open Anderson-Hynes dismembered pyeloplasties performed for PUJO, covering two periods: (1) pyeloplasties performed without ureteric stents (1994-1998) and (2) pyeloplasties performed with ureteric stents (1999-2003). Outcomes (expressed as means+/-SEM) of unstented patients (UPs; n=47) and stented patients (SPs; n=58) were compared and results analysed using ANOVA and chi-square tests. RESULTS: Fifty-five patients (53.9%) presented with antenatal hydronephrosis, whilst 47 (46.1%) presented postnatally (at mean age 88.4+/-7.1 months) with one or more of the following: pain (n=30, 63.8%), urinary tract infection (n=16; 34.0%), haematuria (n=3, 6.4%), abdominal mass (n=3, 6.4%), acute renal failure (n=2, 4.3%), incidental finding (n=4, 8.5%). Pyeloplasty was performed (at mean age 58.9+/-5.3 months) for one or more of the following: pain (n=40, 38.1%), haematuria (n=6, 5.7%), urinary tract infection (n=18, 17.1%), poor initial or deteriorating function (n=29, 27.6%), severe or deteriorating hydronephrosis (n=41, 39.0%), calculus (n=1, 0.95%). Recognised complications of surgery were significantly higher in UPs (5 of 47; 10.6%) than SPs (0 of 58); P=0.016. These were leakage (n=4, 8.5%) and obstruction by blood clot (n=1, 2.1%). Nine SPs (15.5%) developed stent-related complications, including stent migration (n=5, 8.6%), infection (n=3, 5.2%) and calculus (n=1, 1.7%). SPs had significantly shorter hospital stay (2.71+/-0.25 days) than UPs (4.30+/-0.38 days); P<0.01. Preoperative renal pelvis antero-posterior diameter in SPs (3.24+/-0.25 cm) and UPs (3.21+/-0.28 cm) was comparable (P=0.80). Following pyeloplasty, a significant improvement from these preoperative baselines occurred earlier in SPs (at 3.10+/-0.46 months) than UPs (at 15.71+/-3.05 months); P<0.01. CONCLUSION: Stented pyeloplasty significantly reduces complications from surgery, particularly leakage, and results in shorter hospital stay and earlier resolution of hydronephrosis, but at the expense of stent-related complications which could be avoided in future by the use of external stents.

Follow-up after inguinal herniotomy or surgery for hydrocele in boys.

A retrospective review of 556 boys who had undergone inguinal herniotomy or surgery for hydrocele was carried out to assess the value of early routine postoperative follow-up. Of 386 children given an appointment, 319 (82.6 per cent) attended. The testis was no longer palpable in the normal scrotal position in 12 boys; eight were normal on further review and four required orchidopexy. Six hydroceles, all of which resolved, and four contralateral hernias were detected. Nineteen boys (4.9 per cent) were referred later with recurrent hernia (two patients), ipsilateral high testis (two), or contralateral hernia or hydrocele (15). Of 170 children not given a routine appointment, ten (5.9 per cent) were subsequently referred back with a transient hydrocele (two) or a contralateral hernia (eight). After a total of 440 appointments, eight boys (1.8 per cent) were found to have a significant abnormality. The rate of referral back to hospital was similar in both groups. Early discharge would make more efficient use of outpatient resources without significantly affecting overall outcome.

Recurrent necrotizing enterocolitis.

In the decade 1981 to 1991, 16 infants developed recurrent necrotizing enterocolitis (NEC). They comprised 12 (6%) of 196 neonates referred for further management of NEC and four others referred with major congenital anomalies. Their median gestational age was 32 weeks (range, 27 to 40), median birth weight was 1,260 g (range, 790 to 3,230), and the sex distribution was equal. Recurrent NEC occurred after a median interval of 37 days (range, 11 to 163) from the onset of the initial episode. All but one of the 16 infants were either premature (n = 10) or mature with major congenital anomalies (n = 5). Nine patients had previously undergone surgery for NEC. Medical treatment was successful in 11 patients with recurrent NEC. Two infants died, both of liver failure related to parenteral nutrition; one of whom had suffered four separate episodes of NEC and was found to have a superior mesenteric artery occlusion. There was no consistent association between recurrent NEC and the type or timing of enteral feeds or the anatomical site or method of management of the original attack. The mortality of 12.5% was similar to that for primary NEC.

Abdominal inflammatory myofibroblastic tumours in children.

Inflammatory myofibroblastic tumours (inflammatory pseudotumours) occurring at intra-abdominal sites in children have rarely been described. This paper reports three patients with this tumour, two of whom presented with fever, anaemia and an abdominal mass, the third with chronic duodenal obstruction. All had experienced significant weight loss. At operation, each had a large fibrous tumour (7-18 cm in diameter) originating from the transverse mesocolon, small bowel mesentery and duodenum respectively. Intraoperative frozen section histological examination in one patient was misinterpreted as a sarcoma. All the lesions were judged to have been completely excised, but one was ruptured during operation and the patient subsequently developed recurrent tumour nodules. Abdominal inflammatory myofibroblastic tumours are rare. They may be suspected before operation but their clinical, radiological and pathological features may be confused with those of malignancy. Complete excision is necessary to avoid local recurrence.

Sonographic detection of the lead point in intussusception.

Using ultrasonography, a caecal duplication cyst was identified as the pathological lead point in a 6 year old boy with acute intussusception. The patient underwent definitive surgery rather than inappropriate treatment by attempted radiological reduction. Various pathological lead points in intussusception can now be defined by ultrasound.

Rationalising the management of swallowed coins in children.

OBJECTIVE: To assess the management of swallowed coins in children and identify aspects that could be improved. DESIGN: Study of records of three hospital departments for 1986-90. SETTING: Accident and emergency, radiology, and operating theatre departments in a children's hospital. SUBJECTS: 50 children reported to have ingested coins. MAIN OUTCOME MEASURES: Radiological investigations performed, position of coin, symptoms of child, and surgical intervention. RESULTS: 50 children were recorded to have swallowed coins during 1986-90. Five children had only chest radiography, five only abdominal radiography, and 40 had both. A coin was detected in the oesophagus in 15 children, six of whom had symptoms, and below the cardia in 26, none of whom had symptoms; no coin was seen in nine children. Eleven children had further abdominal radiographs despite the absence of gastrointestinal symptoms; one child had a coin removed from the stomach. CONCLUSIONS: Children are being unnecessarily exposed to radiation and surgical intervention, and a consensus on management of swallowed coins is needed. Most children require only a single chest and neck radiograph.

Xiphoomphaloischiopagus tripus conjoined twins: successful separation following abdominal wall expansion.

A case of xiphoomphaloischiopagus tripus conjoined twins is reported. Particular emphasis was paid to the large abdominal wall defect that would be produced by separation, and the complications resulting from the use of intraperitoneal Silastic tissue expanders are described. As a result of adequate tissue expansion and the use of a vascularized pedicle graft from the fused limb, primary abdominal wall and pelvic closure was possible without complications of wound healing. The consistent finding of a shared lower urinary tract with one ureter from each infant entering each bladder should be anticipated in this type of twinning.