Do gastrostomies close spontaneously? A review of the fate of gastrostomies following successful renal transplantation in children.

Previous published data have shown the benefit of nutritional support delivered via a gastrostomy button (GB) for children on chronic dialysis. The use of the GB is suspended following renal transplantation (RT) in most children and it is usually removed 2-3 months later together with the chronic dialysis catheter when the child is on alternate-day steroids. We reviewed the outcome of gastrostomies following successful RT in children. The gastrostomies were created by an open technique (Stamm) with the child under general anaesthesia, usually at the time of insertion of a chronic dialysis catheter. Growth data and complications of the GB were collected in a prospective registry. Following RT, the GB was removed with the expectation that the tract would close spontaneously. Those in whom a gastrocutaneous fistula persisted underwent formal surgical closure. A total of 18 children have had gastrostomy buttons removed: 11 gastrostomies (61%) closed spontaneously, but 7 (39%) required operative closure at a median of 2 months (range 3 weeks-4 years) post-removal. The need for formal closure was significantly related to the duration that the gastrostomy had been in situ pre-transplant (non-parametric statistics, 0.05 > p > 0.01). Although nearly two-thirds of gastrostomies in this study closed spontaneously following RT, less than one-half of those that had been in situ for more than 1 year did so. We thus recommend formal closure of all gastrostomies that have been in situ for more than 1 year. This can be done at the same operation as the removal of the chronic dialysis catheter.

Congenital midureteric stricture.

Congenital midureteric obstruction is a rare entity which can be caused by either ureteric valves or strictures. We report our experience with four patients with midureteric obstruction due to stricture over a six-year period. The condition needs to be differentiated from obstruction of the pelviureteric and vesicoureteric junctions. Obstruction can be initially screened by ultrasound and confirmed by a radionuclide scan with furosemide challenge. Retrograde ureteropyelography and/or intravenous urography may be required to define the level of the stricture.

Blunt abdominal trauma in children.

Blunt abdominal trauma is the commonest cause of intra-abdominal injuries in children. The use of computerized axial tomography and non-operative management of haemoperitoneum are two significant developments in the last two decades in the management of blunt abdominal trauma in children. The concept of non-operative management was introduced in late 1979 and wherever possible remains the optimum treatment. Computerized tomography scan for paediatric abdominal trauma was first described in 1980 and remains the investigation of choice. There is no substitute, however, for a good history, astute physical examination, and strict adherence to the principles of primary and secondary survey, prompt resuscitation, vigilant monitoring and repeated evaluation.

Surgical correction of congenital megaprepuce.

Congenital megaprepuce (CMP) is a rare entity. Two infant boys presented with a tight congenital phimosis resulting in an excessively baggy, urine-filled prepuce and a swollen scrotum. Compression of the scrotum resulted in drainage of urine. We feel this to be a separate entity from a buried penis and recommend early surgery. The phimotic tip of the foreskin was excised and the inner layer preserved to cover the full length of the penile shaft. The outer layer of the foreskin, in reality the penoscrotal junction, was anchored to the base of the penile shaft. A V-shaped edge of ventral skin was excised and the edges approximated, giving the appearance of median raphe. The final appearance was that of a circumcised penis. A third patient awaits operation.

Gastrostomy buttons for nutritional support on chronic dialysis.

RATIONALE: Nutritional support for children on chronic dialysis often involves the use of nasogastric tubes or gastrostomy feeding. We report our experience using gastrostomy buttons (GB) over a 6.6-year period to document their success/failure, the feeding regimens employed and the impact on growth. DESIGN: In 339 patient months of prospective observation, 22 children (14 male) commenced gastrostomy feeding at a median age of 2.3 years (range 0.2-10.3 years). Sixteen patients had an initial gastrostomy catheter inserted at the same time as a chronic dialysis catheter. Eighteen patients were established on continuous cycling peritoneal dialysis (CCPD) and four on haemodialysis (HD). RESULTS: The mean duration of combined gastrostomy feeding and chronic dialysis was 14.5 months (range 2.4 56 months). In 20 of the children followed for 6 months on combined GB feeding and dialysis, the mean protein and energy intakes were 2.5 g/kg bodyweight/day (range 1.7-3.4 g) and 108 kcal/kg bodyweight/day (range 72-129 kcal). The mean energy intake achieved was 116% (range 98-155%) of the estimated average requirement (EAR) for energy. The mean percentage of total energy and protein intakes delivered via the GB during the study period was 61% (33-95%) and 61% (23-98%) respectively. Mean height standard deviation score (SDS) was -2.22 prior to GB feeding and -2.06 at the end of the study period (P = 0.005) and mean weight SDS was -2.22 and -1.16 (P = 0.001) respectively. The mean life of the GB was 7.7 months (range 2.6 14 months) with most button changes due to leakage problems. Two episodes of peritonitis were attributable to the GB with one requiring peritoneal dialysis catheter removal due to candida infection. The GB was removed at a mean of 2.8 months (range 0.8-8.3 months) after renal transplantation in 13 children. CONCLUSION: The gastrostomy button provides a valuable and aesthetically appealing route for nutritional support with few complications.

Antenatally detected urinary tract abnormalities: changing incidence and management.

UNLABELLED: To define the incidence of urinary tract abnormalities detected by antenatal ultrasound and assess changes in postnatal management we conducted a retrospective survey using data bases of the nephro-urology unit, obstetric ultrasound and perinatal pathology departments. The birth population (105,542) of the two Nottingham teaching hospitals between January 1984 and December 1993 was divided into two 5-year cohorts, 1984-1988 and 1989-1993. Detailed fetal scanning at 18-20 weeks gestation was introduced in 1989. During this 10-year period, 201 abnormalities of the urinary tract were noted with a 2:1 male to female ratio. The incidence of abnormalities in the first 5 years was 1 in 964 compared to 1 in 364 in the last 5 years. There was a significant increase in the number detected before 20 weeks gestation (12% in 1984-1988 compared to 62% in 1989-1993). Despite the increased incidence of abnormalities detected, the termination rate remained static between the two 5-year cohorts. Only 3 fetuses had intra-uterine intervention and 173 were live-born. Eight infants subsequently died in association with other major congenital abnormalities. The incidence of transient abnormalities (antenatal dilatation with no abnormality noted on postnatal ultrasound) increased from 6% in 1984-1988 to 18% in the 1989-1993 cohort. A more conservative approach to postnatal management is reflected by 71% of infants having operations between 1984 and 1988 compared to 35% in 1989-1993. CONCLUSION: The advent of detailed fetal scanning at 18-20 weeks gestation has significantly increased the detection rate of urinary tract abnormalities with no significant increase in pregnancy termination rates. The need for antenatal intervention is a rare event and most problems can be managed conservatively both pre- and postnatally.

Coeliac axis thrombosis associated with the combined oral contraceptive pill: a rare cause of an acute abdomen.

We report a case of coeliac axis thrombosis and splenic infarction presenting in a girl of 14 years who had been on the oral contraceptive pill (OCP), Marvelon (ethinyloestradiol 30 microg plus desogestrel 150 microg, Organon, Cambridge, UK), for 3 weeks. She had no other risk factors for thrombo-embolism. Diagnosis was made with duplex Doppler ultrasound and confirmed with dynamically-enhanced comput-ed tomography and magnetic resonance angiography, thus avoiding the need for percutaneous arteriography. Though mesenteric thrombo-embolic disease is recognised in association with use of the combined OCP, it has not previously been reported to affect the coeliac axis. Paediatricians and surgeons should be aware of the risks to young girls on the OCP, and consider it in their differential diagnosis of the acute abdomen.

Fecolith impaction in a duplex vermiform appendix: an unusual presentation of colonic duplication.

The authors report a case of colonic duplication associated with urogenital abnormalities, which presented after obstruction of its proximal communication with the intestine. The case is unusual because the proximal communication was via a partial duplication of the appendix, which became obstructed after impaction of a fecolith.

Intussusception nephrosis and Drash syndrome.

A 6-month-old female infant presented with intussusception. Post-operatively she was noted to have nephrotic syndrome. The oedematous bowel wall may have been the cause of the intussusception and this has not been previously described. In addition her karyotype was XY suggesting her nephropathy was associated with Drash syndrome.

Computed tomography in the management of paediatric abdominal trauma.

Since the installation of a whole body computed tomography (CT) unit at the Royal Alexandra Hospital for Children in March 1978, it has been shown to play an invaluable role in the management of abdominal trauma in selected cases. Our experience with 16 cases is presented, and the advantages of CT over alternative diagnostic aids are discussed.