In-situ emergency pediatric surgery in the intensive care unit.

BACKGROUND: The role of surgery in the intensive care unit (ICU) remains unclear. Although previous studies have not shown any increase in morbidity when operating on patients in the ICU for surgical procedures; there remains a reluctance to operate on sick patients in the ICU. AIM: We did a retrospective study of critically ill children and neonates who underwent in-situ surgery (ISS) to further evaluate its safety and potential. Surgery was aided with the use of operative loupes and high-intensity headlight. METHODS: The medical records of all patients who had undergone surgical procedures in the pediatric ICU over an 11-year period from January 1998 till December 2008 were retrospectively reviewed. We reviewed our experience looking specifically at wound infection rates along with other morbidities in 543 patients. RESULTS: Our morbidities were comparable with that of operations performed in the operating theater, with low wound infection rates (1%) for all surgeries undertaken in the pediatric ICU. CONCLUSION: ISS avoids the risks of transfer to the operative theater and the potential delays in theater access. Our results suggest that ISS in a tertiary-level pediatric surgical hospital is safe and does not impact adversely on clinical outcome.

Choledochal cysts: our ten year experience.

We present our experience in the management of choledochal cysts from 1999 to 2009. A retrospective review of all charts with a diagnosis of choledochal cysts in our institution in this ten-year period. Data was collated using Excel. A total of 17 patients were diagnosed with choledochal cyst: 9 females and 8 males. The average age at diagnosis was 28 months (range from 0 to 9 years). The most common presenting symptoms were obstructive jaundice 6 (35%) and abdominal pain and vomiting 4 (23%). Ultrasound (US) was the initial diagnostic test in all cases with 4 patients requiring further investigations. All patients underwent Roux-en-Y Hepaticojejunostomy. The average length of stay was 11 days. Patients were followed up with Liver Function Tests (LFTS) and US 4-6 weeks post-operatively. Three patients developed complications including post-op collection, high drain output requiring blood transfusion and adhesive bowel obstruction. Our overall experience with choledochal cyst patients has been a positive one with effective management and low complication rates.

Pancreaticoduodenectomy in children: optimising outcome of uncommon paediatric procedures.

Contemporary surgical practice is increasingly dominated by subspecialisation in response to improved outcome from high volume centres, though uncertainties persist for uncommon paediatric procedures. Three paediatric pancreaticoduodenectomies performed at Our Lady's Children's Hospital, Dublin, over a period of 9 years were evaluated to substantiate their continuing performance by paediatric rather than adult pancreatic surgeons. With ages ranging from 18 months to 8 years old, the mean operating time was 263 minutes, while the average hospital stay was 12 days. There was no perioperative mortality, although complication rate was 100%. Re-operation was required in 33%. The long term outcome of this small paediatric cohort was comparable to adult series despite the low patient accrual, underscoring the advantages of a multidisciplinary approach afforded by tertiary paediatric institutions for intricate yet infrequent operations in children.

Hairball--a case of mistaken identity.

We report a classical presentation of trichobezoar in an 8 year old girl who was referred for consultation querying a probable abdominal neoplasm in the left upper quadrant. A large mobile mass was palpable in the left upper quadrant extending toward the umbilicus. Of note, she also had symptoms of recurrent abdominal pain, nausea, vomiting and halitosis. Although a rare occurrence, trichobezoar must be considered as a differential diagnosis in a patient who had a history of pica, presenting with an abdominal mass.

A novel treatment of congenital hepatoportal arteriovenous fistula.

Congenital hepatoportal arteriovenous fistula is a rare cause of portal hypertension in young children. Unlike the acquired form, which is usually isolated and can be cured by hepatic artery (HA) embolization, recurrence of portal hypertension often occurs with congenital hepatoportal arteriovenous fistula after embolization and/or HA ligation because of early, rapid collateralization and the presence of multiple arterioportal fistula. Although long-term outcome after embolization is not known, liver transplantation has been proposed as the only option for this condition. However, portal vein and hepatic arterial anastomoses are made difficult because of the presence of portal vein arterialization and previous HA ligation, with a significantly increased risk of vascular complications. We report a case where resolution of portal hypertension has been achieved by an end-to-side portocaval shunt, to preserve the portal vein and HA for future liver transplantation, should it be required.

Gastroschisis and exomphalos in Ireland 1998-2004. Does antenatal diagnosis impact on outcome?

Antenatal detection of anterior abdominal wall defects (gastroschisis and exomphalos) enables detailed prenatal planning and counselling with appropriate intrauterine transfer, delivery in a tertiary referral centre with prompt access to paediatric surgery and early surgical intervention. The authors believed that there was a relatively low rate of antenatal detection in Ireland and that an improved antenatal screening program would allow increased detection thus avoiding emergency retrievals from peripheral obstetric centres. Our hypothesis was that there was a significant difference in management and outcome in children with anterior abdominal wall defects detected antenatally and those detected at birth. All anterior abdominal wall defects in The Republic of Ireland are assessed and closed in two surgical centres, Our Lady's Hospital for Sick Children, and the Children's University Hospital, Dublin. A retrospective review of all admissions in both centres revealed 96 neonates with anterior wall defects (excluding bladder exstrophy and cloaca) over a 7 year period from 1998 to 2004 inclusive. Medical records, operative reports, neonatal databases and admission details were reviewed. The antenatal data search included anomaly detection, prenatal management plan and intrauterine transfer. Perinatal data included place of birth, weight, gestational age, mode of delivery, time to surgery and type of surgery, the time to establish full enteral feeding and the length of hospital stay were used as overall markers of outcome. Fifty-three patients had gastroschisis and 43 exomphalos with an antenatal detection rate of 53% (n = 28) and 34% (n = 15), respectively, with an overall detection rate of 44%. There was no significant difference in the median birth weight (2.83 vs. 2.85 kg), gestational age at birth (37 vs. 37 weeks), time to full feeding (12 vs.14 days) and length of stay (20 vs. 17 days) between those detected antenatally or postnatally, respectively. About 77 had a primary closure performed of which 63 infants had surgery within the first 24 h of life. There was no difference in the time to surgery, frequency of complications or the surgical outcome in either group. Intrauterine transfer did not affect any outcome measure assessed. The demographics and the presence of associated anomalies did not differ between the groups. The hypothesis that antenatal diagnosis in anterior abdominal wall defects improves outcome has been demonstrated to be false. Despite this result, the importance of antenatal screening and prenatal management of complex foetal conditions with consultation with experienced paediatric and neonatal staff is without doubt.

Minilaparotomy cholecystectomy in children.

AIM: Scarcity of paediatric cholelithiasis limits the obtainable experience in paediatric laparoscopic cholecystectomy (LPC). We report minilaparotomy cholecystectomy (MLC) in children which may be a useful alternative to LPC avoiding the added cost of disposable laparoscopic equipment. METHODS: Nineteen cases underwent a retrograde MLC using a 2-4 cm transverse right upper quadrant incision. Various parameters were assessed. RESULTS: Mean age at presentation was 10.87 years, mean length of the incision 2.8 cm, mean operative time 36.5 min, mean analgesic requirement 2 days, mean time to feed/ mobilize 1 day each, and mean duration of hospital stay was 2.7 days. All had satisfactory cosmetic result without postoperative complications. CONCLUSIONS: MLC in children involves a small incision, excellent cosmetic scar and rapid postoperative recovery at relatively low cost. It is a good alternative to LPC.

Abdominopelvic mesh compartmentalization reduces the complications of radiotherapy in children: a preliminary report.

AIM: The aim of this report was to assess the effects of radiotherapy (RT) in children with abdominopelvic tumours in whom a biodegradable (Polyglactin 910) mesh had been inserted prior to commencement of radiotherapy. METHODS: Retrospective analysis was carried out of four patients with abdominopelvic tumours who underwent radiotherapy between 2000 and 2002 as part of their management. RESULTS: All children tolerated radiotherapy well with no evidence of acute or chronic radiation enteritis. One child developed prolonged postoperative ileus and a second child developed infective diarrhoea and fever, not related to radiation. CONCLUSION: We have highlighted a good tolerance of radiotherapy in children following the insertion of a Polyglactin 910 mesh prior to starting radiation and would recommend further larger studies with longer follow-up to support this.

The SIS extracellular matrix scaffold-preliminary results of use in congenital diaphragmatic hernia (CDH) repair.

There is no ideal bio-tensile material for tissue replacement in paediatric surgical conditions. A variety of materials have been described to replace or reinforce tissue deficits in congenital diaphragmatic hernia (CDH). The problems with these materials range from extensive surgery to body wall deformity and hernia recurrence. The ideal graft would be safe, strong, have the potential to grow and not require replacement, not affect chest wall development or produce deformity, and have minimal risk of recurrence. Surgisis is a biomaterial composed of porcine intestinal submucosa that provides inherent tensile strength as a collagen lattice and is ultimately replaced by native collagen tissue. Our objective was to prospectively assess the utility of Surgisis as a replacement graft in a cohort of 10 children undergoing primary or recurrent CDH repair. The graft was well tolerated, and there was no recurrence of herniation. We conclude that Surgisis collagen mesh may be a useful alternative for tissue replacement or reinforcement in difficult cases of CDH and diaphragmatic agenesis. The biological framework of Surgisis may also prove useful in other situations of complex tissue loss in children.

Gastric stromal tumors in children.

Gastrointestinal stromal tumors (GIST) in children are rare and their behavior has been regarded as difficult to predict on pathological criteria. We report our experience with two gastric GISTs in children aged 10 and 11 years. Both remain alive and free of disease at 5 years and 2 years respectively. Comparison of the pathological features in the resected specimens with a recently proposed guidelines for predicting outcome in this group of tumors is reported.

New technique for fixation of Broviac catheters.

Broviac catheters are in common use for administration of parenteral nutrition, cancer chemotherapy, and antibiotic therapy within the paediatric population. Inadvertent dislodgement of these catheters is common during the initial weeks before the Dacron cuff is anchored by the ingrowth of fibrous tissue. The authors describe a technique in which an internal fixation suture is placed to prevent dislodgement or migration.

Glutathione S-transferase: a potential new marker of intestinal ischemia.

BACKGROUND/PURPOSE: The accurate and early diagnosis of intestinal ischemia remains difficult chiefly because of a lack of a suitable marker that is noninvasive and easy to use. The glutathione S-transferases (GST) are a family of cytosolic enzymes involved in detoxification and released from a variety of cells when the cell membrane is damaged. The enzymes are distributed widely in the intestine and show isoform specificity in their distribution throughout the intestinal tract. Several previous reports have shown the utility of these enzymes in the diagnosis of liver and renal graft damage during and after organ transplantation. The object of this study was to determine if GST levels correlated with histologic changes of intestinal ischemia in a controlled animal model of mesenteric intestinal ischemia. METHODS: Control and experimental male Sprague-Dawley rats underwent laparotomy and ligation of the Superior Mesenteric Artery (SMA) and both control and experimental animals were studied at 30, 60, 90, 120, and 240 minutes. Blood taken from the Inferior Vena Cava (IVC) and Portal Vein (PV) and jejunal and ileal perfusates were assayed for alpha and mu isoforms of GST using a commercially available enzyme immunoassay. In addition, jejunal and ileal segments were sampled and reviewed by a histopathologist blinded to the group being studied. RESULTS: A reproducible pattern of intestinal ischemia was noted with worsening grades of injury observed with greater ligation times. Luminal alpha and mu GST release (as measured by the appearance in luminal perfusate) increased with increasing ischemia times. Increased ischemia times resulted in increased levels of alpha and mu GST in both portal and systemic venous samples but lagged behind the appearance of raised luminal GST values. CONCLUSIONS: The results suggest that GST may be an interesting and useful marker in the early detection of intestinal ischemia. Its detection in peripheral blood has implications for a more detailed study design to determine the sensitivity and specificity of this marker in more diverse clinical conditions such as necrotizing enterocolitis and superior mesenteric artery occlusion.

Cholecystectomy versus cholecystolithotomy for cholelithiasis in childhood: long-term outcome.

BACKGROUND/PURPOSE: The presence of cholelithiasis is being reported with increased frequency in childhood. Little is known about the natural history of the disease, and only a few studies have been published regarding long-term results of treated patients. Controversy still exists regarding optimal treatment. Both cholecystectomy and cholecystolithotomy with gallbladder preservation have been recommended as the preferred operative intervention. The purpose of this study was to compare the long-term outcome of cholecystectomy versus cholecystolithotomy for symptomatic gallbladder disease in children. METHODS: The charts of all patients with symptomatic cholelithiasis treated in the Dublin Paediatric Hospitals during a 25-year period from 1974 till 1999 were reviewed. Data obtained included age, sex, age at presentation of symptoms, methods of diagnosis, indications for operative treatment, time interval between presentation of symptoms and surgery, surgical technique, performance of a preoperative or intraoperative cholangiogram, stone biochemistry, gallbladder histology, radiologic follow-up, the presence of recurrent or residual stones and symptoms, and the need for reoperation. Patient data were grouped according to method of surgery. All parameters were compared and evaluated. Follow-up was by way of telephone contact with all patients and completion of a questionnaire. RESULTS: There were 18 patients over a 25-year period. Eight patients underwent cholecystectomy, and 10 patients had a cholecystolithotomy. Median follow-up was 2 years in the cholecystectomy group and 5 years in the cholecystolithotomy group. All patients in the cholecystectomy group are asymptomatic and have no recurrent or residual stones on follow-up ultrasound scan. Thirty percent of the patients in the cholecystolithotomy group have recurrent right upper quadrant pain, and 30% show recurrent stones 9.5 months (range, 7 to 12 months) postoperatively. One patient underwent cholecystectomy 8.5 months postcholecystolithotomy. CONCLUSIONS: The symptomatic high stone recurrence rate postcholecystolithotomy seen in our series suggest that cholecystectomy is the preferred treatment in patients with symptomatic gallbladder disease.

Neonatal sigmoid volvulus: a complication of anal stenosis.

Sigmoid volvulus is an exceptionally rare cause of intestinal obstruction in neonates. Only 7 cases have been reported in the English and French literature. The authors report a recent case of sigmoid volvulus in a neonate secondary to anal stenosis and review the diagnosis and management of this serious condition. The authors believe that carefully performed radiologic reduction is the preferable alternative to surgical intervention.

Complex branchial fistula: a variant arch anomaly.

A 5-year-old boy presented with an infected left-sided branchial fistula. Despite antibiotic treatment and repeated excision of the fistula, purulent discharge from the wound persisted. Three-dimensional computed tomography (3D CT) reconstruction greatly facilitated the diagnosis and management of this case by showing the course of the fistulous tract. The complexity of the tract suggests that this represents a variant arch anomaly because it contains features of first, second, third, and fourth arch remnants.

Extracutaneous Sweet syndrome involving the gastrointestinal tract in a patient with Fanconi anemia.

Acute febrile neutrophilic dermatosis, or Sweet syndrome, is a cutaneous eruption characterized clinically by the appearance of painful red plaques and nodules and histologically by an intense dermal neutrophilic infiltrate. Extracutaneous manifestations are rare. We report a patient in whom otherwise typical cutaneous Sweet syndrome was accompanied by an extracutaneous manifestation in the ileum.

Factors affecting nurses' attitudes towards the screening and care of battered women in Dublin A&E departments: a literature review.

The concept of one human being inflicting unnecessary pain and suffering upon another, on a daily basis, is a disturbing and incredulous thought at the very least. This concept also known as domestic violence is all too real for the many victims presently suffering at the hands of their abusive partners. In Ireland, almost one in five women have experienced some form of domestic violence. This phenomenon can also be identified and further clarified as 'woman battering' Due to the confidential and accessible service offered to the client the Accident and Emergency department is a vital source of assistance to women who have been beaten by their partners. Battered women frequently present with injuries both visible and non-visible. More often than not however, many women are treated solely for their injuries and pass through the healthcare system unnoticed. Lydon (1996) estimates that of all presenting cases of domestic violence in the A&E department, only 5% are actually detected. Some literature estimates 3% detection rates (Thompson et al. 1998, Hadley, 1992). The following literature review explores the history behind the phenomenon of violence against women and its extent in Ireland. The literature affirming the important role of the nurse in A&E is reviewed and several themes are explored that affect nurses' attitudes in the screening and care of battered women.