Sigmoid volvulus in 16-year-old boy with an associated anomalous congenital band.

Sigmoid volvulus, a condition generally seen in debilitated elderly patients, is extremely rare in the pediatric age group. Frequent predisposing conditions that accompany pediatric sigmoid volvulus include intestinal malrotation, omphalomesenteric abnormalities, Hirschsprung's disease, imperforate anus and chronic constipation. A 16-year-old previously healthy African American male presented with a 12 hour history of sudden onset abdominal pain and intractable vomiting. CT was consistent with sigmoid volvulus. A contrast enema did not reduce the volvulus, but it was colonoscopically reduced. Patient condition initially improved after colonoscopy, but he again became distended with abdominal pain, so he was taken to the operating room. On exploratory laparotomy, a band was discovered where the mesenteries of the sigmoid and small bowel adhered and created a narrow fixation point around which the sigmoid twisted. A sigmoidectomy with primary anastomosis was performed. The diagnosis of sigmoid volvulus may be more difficult in children, with barium enema being the most consistently helpful. Seventy percent of cases do not involve an associated congenital problem, suggesting that some pediatric patients may have congenital redundancy of the sigmoid colon and elongation of its mesentery. The congenital band found in our patient was another potential anatomic factor that led to sigmoid volvulus. Pediatric surgeons, accustomed to unusual problems in children, may thus encounter a condition generally found in the debilitated elderly patient.

Quality improvement and patient care checklists in intrahospital transfers involving pediatric surgery patients.

BACKGROUND: Intrahospital transfers are necessary but hazardous aspects of pediatric surgical care. Plan-Do-Study-Act processes identify risks during hospitalization and improve care systems and patient safety. METHODS: A multidisciplinary team developed a checklist that documented patient data and handoffs for all intrahospital transfers involving pediatric surgical inpatients. The checklist summarized major clinical events and provided concurrent summaries by 3-month quarters (Q) over 1 year. RESULTS: There were 903 intrahospital transfers involving 583 inpatients undergoing surgery. Total handoffs were documented in 436 (75% of 583), with greater than 1 handoff in 202 (46% of 436). Documented problems occurred in 31 transfers (3.4%), the most during Q1 (19/191; 9.9%). Incidence fell to 3.5% (9/260) in Q2, 0.4% (1/243) in Q3, and 1.0% (2/209) in Q4 (P < .001). Patient care issues (14/31; 45%) were most common, followed by documentation (10, 32%) and process problems (7, 23%). The quality improvement team was able to resolve patient instability during transport (5 in Q1, none in Q3, Q4) and poor pain control (3 in Q2, 1 in Q3, Q4). Of the patients, 3.2% had identified problems with patient care during intrahospital transfer. CONCLUSIONS: Plan-Do-Study-Act review emphasizes ongoing process analysis by multidisciplinary teams. Checklists reinforce communication and provide feedback on whether system goals are being achieved.

How medical alumni now see their junior clerkships in surgery.

The purpose of this study is to determine the effectiveness and value of the junior medical student surgical clerkship for physicians now in practice. Questionnaires were sent to all Mercer University School of Medicine alumni (1986-2007) using a five-point Likert scale. One hundred and fifty-seven responses were received from 873 recipients (18%), 71 per cent training in nonsurgical specialties. "Scrubbing in" on cases was the most valuable activity (82%), followed by faculty rounds (76%), resident work rounds (70%), and lectures (69%). Least useful activities were question and answer sessions (54%), grand rounds (53%), and morbidity and mortality conferences (57%). The amount of time in the operating room was appropriate for 61 per cent, but to 8 per cent the operating room was a waste of time. Faculty evaluations gave the most effective feedback (75%). Alumni in surgical specialties and obstetrics and gynecology rated their experiences higher than nonsurgical physicians. Overall, only 44 per cent saw the material learned as important to general medical education. Opinions regarding the value of surgical clerkships to current practices were mixed. Undergraduate surgical education should emphasize common surgical conditions, surgical decision-making, and simple procedures relevant to a nonsurgical practice.

Swenson revisited: a one-stage, transanal pull-through procedure for Hirschsprung's disease.

BACKGROUND: Hirschsprung's disease is a common cause of neonatal intestinal obstruction. A variety of operations have been used to treat this neurogenic form of bowel obstruction. This report describes an experience with a 1-stage abdominal and transanal pull-through operation in 15 patients with rectosigmoid disease. METHODS: Fifteen infants with Hirschsprung's disease included 11 boys and 4 girls. Median age at diagnosis was 3 days, and median age of operation was 30 days. Diagnosis was confirmed by rectal biopsy. Biopsies to confirm the transition zone were performed intraabdominally through a left lower quadrant incision. A Swenson pull-through was performed via transanal dissection. RESULTS: There were no instances of anastomotic leaks, wound infections or postoperative bowel obstructions. All patients survived. Two had postoperative enterocolitis. Twelve of 15 patients did well and had 2-3 bowel motions per day. One with Down's syndrome had enterocolitis and required a colostomy. Two were lost to follow up. CONCLUSIONS: A one-stage transanal pull-through procedure in infancy is a safe alternative to staged procedures for Hirschsprung's disease.

Perineal reconstruction of female conjoined twins.

BACKGROUND/PURPOSE: Conjoined twins are some of the most challenging patients faced by surgeons. Pygopagus and ischiopagus twins present particular gastrointestinal and genitourinary reconstructive challenges. This study reviews the authors' experience with the perineal reconstruction of these types of conjoined twins. METHODS: Retrospective analysis was performed for 3 sets of female conjoined twins undergoing separation between 1999 and 2001. Particular attention was given to the separation and reconstruction of the distal gastrointestinal and urogenital structures. RESULTS: Three sets of female conjoined twins underwent successful separation 2 pygopagus, one ischiopagus tripus) with 5 surviving infants. The sixth infant died of congenital anomalies incompatible with life. Four of the 5 surviving infants had diverting enterostomies. Two of these enterostomies have been closed. Perineal reconstruction consisted of anoplasty (5 of 5), vaginoplasty (4 of 5), and urethroplasty (4 of 5). Although fecal and urinary continence are not completely measurable at this age (<3 years), all 5 survivors void spontaneously. Three infants with intestinal continuity have apparently normal defecation without the need of a bowel regimen. CONCLUSIONS: With careful preoperative planning and a multidisciplinary team of pediatric surgeons and urologists, satisfactory reconstruction and functional outcome of the female perineum can be achieved in conjoined twins.