The impact of an operative note proforma at a paediatric surgical centre.

RATIONALE, AIMS AND OBJECTIVES: With expectations for standardization and evidence-based practice, the Royal College of Surgeons (RCS) published the 'Good Surgical Practice' in 2008. The document sets standards for operative records anticipating improved documentation, audits, medico-legal review and quality and safety of handover. We evaluated (1) documentation against RCS standards; (2) whether RCS standards are applicable to and adequate for paediatric surgery; and (3) the impact of a standardized operative proforma. METHODS: All general surgery and urology admissions during July 2011 and August 2012 were retrospectively reviewed using 23 set criteria. An operative note proforma was introduced in February 2012. Results were compared and statistically analysed using two-tailed Fisher's exact test, with Bonferroni correction where appropriate (SPSS 20.0, IBM SPSS Statistics, Armonk, NY, USA). RESULTS: There were 345 children admitted; 63.2% underwent an operation (119 in 2011 versus 99 in 2012); 55% of operations were day cases. The initial audit noted poor documentation in 7 of 23 criteria. Following introduction of the operative note proforma, documentation improved significantly: patient identifiers by 12.3%, procedure time 43.3%, assistant's name 31.9%, procedure type 21.4%, closure 6.2%, anaesthetist's name 15.9%, anaesthetic type 56.8% and surgeons grade 65.8% (P<0.05). Subgroup analysis in the latter cohort shows most of these effects to be related to the use of the proforma rather than education alone (P<0.05). Quality of documentation was better by consultants versus trainees in 2 of 23 criteria (P<0.05). CONCLUSION: We have demonstrated a simple and cost-effective way of improving the quality of operative documentation, in line with guidelines set out by the RCS, in a climate of increasing economic austerity.

Congenital abdominal wall defects and testicular maldescent--a 10-year single-center experience.

PURPOSE: The relationship between congenital abdominal wall defects (AWDs) and undescended testes (UDTs) is poorly defined. We report a study of infants with AWD and UDT. METHODS: Hospital records of newborns with AWD managed during 1998 to 2008 were reviewed. Data analyzed included nature of AWD, position of the testes at birth, final position of the testes, and surgical management. RESULTS: A total of 218 newborns with AWD were identified; 106 (49%) were boys. Of 79 boys with gastroschisis, 26 (33%) had UDT involving 35 testes. Of 27 with exomphalos, 6 (22%) had UDT involving 11 testes. Prolapsed testes were placed in the abdomen at AWD repair, whereas others were observed for "spontaneous" descent. Of 35 UDT in gastroschisis infants, 18 descended spontaneously, and 10 required orchidopexy. Three boys underwent laparoscopy for impalpable testes, 2 underwent orchidectomy, and 1 had bilaterally absent testes. Three cases await orchidopexy. In exomphalos boys with 11 UDTs, 1 gonad descended spontaneously, and 6 had groin exploration (1 absent testis and 5 orchidopexies). Two boys await orchidopexy, and 1 boy (bilateral impalpable testes) was lost to follow-up. CONCLUSION: Abdominal wall defects are strongly associated with UDT. In boys with gastroschisis, spontaneous descent of the testes may be anticipated in 50% of cases. In those with exomphalos, orchidopexy should be scheduled.

An alternative management option for colonic atresia preventing loss of the ileocecal valve.

PURPOSE: Management of colonic atresia is contentious, with primary anastomosis having a notable risk of anastomotic leak. In addition, resection of the terminal ileum and ileocecal (i-c) valve is frequently performed, risking side effects such as diarrhea, vitamin B(12) deficiency, and gall stone formation. METHODS: The hospital coding system was searched for all patients with a diagnosis of colonic atresia between July 2005 and July 2008. Four term neonates were managed by formation of an ileostomy, a "blow hole" stoma just proximal to the atresia, and a mucus fistula distal to the atresia. RESULTS: Average time to full feeds was 7.5 days (range, 3-12 days), and average length of stay was 23 days (range, 13-47 days). Stoma management, problematic in 2 infants, was individualized by a specialist stoma nurse. Ileostomy output was refed into the mucus fistula. Complications included 3 episodes of prolapse of the blow hole stoma in infant 2. All of the infants returned to the operating theater at 1 to 3 months of age for restoration of bowel continuity and closure of the ileostomy. The atretic segment was resected, and an end-to-end anastomosis was performed. Recovery was straightforward in all cases. CONCLUSION: A procedure that retains the i-c valve and most of the colon through creation of a blow hole stoma in the distended proximal colon with a diverting ileostomy and mucus fistula is described. The technique is recommended in selected infants as bowel length and anatomy can be preserved, despite the use of multiple stomas.

After the honeymoon comes divorce: long-term use of the antegrade continence enema procedure.

BACKGROUND: Having reported that 18% of children discontinue use of the antegrade continence enema (ACE) after 5 years, we aimed to determine long-term use after an ACE procedure. METHODS: A postal/telephone questionnaire was conducted. Subjects were consecutive children undergoing an ACE between 1993 and 1999. Outcome measures were use of ACE, reasons for nonuse, complications, and overall satisfaction. RESULTS: Of 84 eligible subjects, data were available on 61 (73%) aged 22.4 years (15.5-35.1 years). Underlying diagnoses included spina bifida (n = 27), anorectal malformations (n = 18), constipation (n = 11), Hirschsprung's disease (n = 1), sacral agenesis (n = 2), and trauma/tumor (n = 2). Follow-up was 11.02 years (8.34-14.39 years). Thirty-six (59%) of 61 patients were still using their ACE. Reasons for nonuse were lack of effectiveness (n = 14), complications (n = 5), psychologic issues (n = 2), and poor compliance (n = 2). There was no association between diagnosis and nonuse (chi(2), P = .63). In those still using ACE, the overall satisfaction score was 4.1 (1-5). Several individuals reported feeling abandoned on becoming adults and losing the support they had in childhood. CONCLUSION: There is a late "failure" rate for the ACE procedure. However, satisfaction was high among those still using the ACE. This study further emphasizes the need for robust transitional care arrangements.