Ultrasound-guided transversus abdominis plane blocks for laparoscopic appendicectomy in children: a prospective randomized trial.

BACKGROUND: The effect of adding transversus abdominis plane (TAP) blocks to local anaesthetic infiltration on morphine consumption and postoperative pain in children undergoing laparoscopic appendicectomy is unknown. METHODS: After random allocation, 93 children aged 7-16 were randomized to receive ultrasound-guided TAP blocks placed before surgery or not (control). All subjects had port sites infiltrated with ropivacaine and were prescribed i.v. patient-controlled analgesia (PCA) with morphine and oral paracetamol for postoperative pain. The primary outcome was the proportion of subjects using >200 µg kg(-1) morphine. Secondary outcomes included PCA morphine use, pain scores, time intervals to the first use of PCA and other analgesics, sedation scores, postoperative nausea or vomiting, and time to hospital discharge. RESULTS: The procedure duration was longer in the TAP group (111 compared with 97 min for controls, P=0.03). The duration in the recovery ward and that of the hospital stay were similar. There was no difference in the proportion of subjects requiring >200 µg kg(-1) of PCA morphine [control 31/45 (69%), TAP 29/42 (69%), P=0.99]. There was no significant difference in PCA morphine use, time intervals to the first use of PCA or other analgesics, or amounts of other analgesics. More patients in the TAP group had complicated appendicitis [TAP 13/42 (31%), control 5/45 (11%), P=0.02]. Pain scores were reduced for the TAP group in the recovery ward only (median score 0 vs 2, 95% confidence interval 0-3, P=0.03). CONCLUSIONS: TAP blocks increased anaesthesia time by 14 min on average but offered no clinically important benefit over local anaesthetic port-site infiltration to paediatric patients undergoing laparoscopic appendicectomy.

A retrospective audit of three different regional anaesthetic techniques for circumcision in children.

Postoperative analgesia for male circumcision surgery has been traditionally provided by a landmark-based dorsal penile nerve block (DPNB-LM) or by caudal epidural analgesia (CEA). In this study we report on a retrospective analysis of the effectiveness and safety of CEA, DPNB-LM and ultrasound-guided dorsal penile nerve block (DPNB-US) in our institution over a six-year period. Information was gathered from each patient's medical record. A total of 216 circumcisions were performed on patients aged from five months to 15 years. One hundred and fifteen patients received CEA, 46 DPNB-LM and 55 DPNB-US. Patients in the DPNB-LM group required rescue morphine administration in the recovery unit more frequently (30.4%) than either the DPNB-US (3.5%) or CEA groups (3.6%). Similarly, the DPNB-LM group required a larger total dose of morphine, and had longer recovery ward stays than CEA or DPNB-US groups. Time to first analgesia was greatest for the CEA group while there was no significant difference between time to first analgesia for DPNB-LM and DPNB-US. Sixty-three percent of patients in the DPNB-LM group, 1.7% of CEA and 5.5% of the DPNB-US required intraoperative opiates (P < 0.0001). There was no difference in time to hospital discharge.

Use of ultrasound in 187 infants with suspected infantile hypertrophic pyloric stenosis.

The diagnostic efficacy of ultrasound (US) in the diagnosis of infantile hypertrophic pyloric stenosis (IHPS) was evaluated, with particular attention paid to whether prematurity, age or weight correlate significantly to the sonographic measurements. The medical records of 187 infants with suspected IHPS were reviewed retrospectively. Eighty-seven had an US examination with details of the pylorus. Fifty-nine of these gave a positive diagnosis. The US criteria for a positive diagnosis were pyloric muscle thickness (PMT)>or=3 mm and pyloric muscle length (PML)>or=17 mm. The mean overall PMT was 4.14 mm and mean overall PML was 18.99 mm. Premature infants had a lower mean PML (17.8 mm) than the term infants (PML mean 19.3 mm); however, this was not significant (t-value 1.92, P=0.062). The sensitivity and specificity of PMT was 91 and 85%, respectively, and of PML 76 and 85%, respectively. The ability of US to diagnose IHPS using our criteria was significant (t-value, PMT 14.93 and PML 6.89; P<0.0001). There was no significant correlation between age, weight or prematurity and a sonographic diagnosis of IHPS (Pearson's coefficient<0.3). Therefore, the same US criteria should apply irrespective of prematurity, age or weight. Borderline PMT and PML measurements necessitate repeat US or alternative imaging.

Ultrasound guided dorsal penile nerve block in children.

We describe a technique for using a portable ultrasound scanner (38 mm broadband (10-5 MHz) linear array transducer (Sonosite Titan SonoSite, Inc. 21919 30th Drive SE Bothell, WA.)) to guide dorsal penile nerve block in children under general anaesthesia. Real-time scanning is used to guide bilateral injections into the sub-pubic space, deep to Scarpa's fascia either side of the midline fundiform ligament. Scanning can confirm that the local anaesthetic has spread to contact the deep fascia on each side. A subcutaneous wheal of local anaesthetic along the penoscrotal junction completes the block.

Lipoblastoma: pathophysiology and surgical management.

BACKGROUND/PURPOSE: Lipoblastoma/lipoblastomatosis is a poorly understood and uncommon soft tissue tumor of infancy and early childhood. Twenty-four patients that presented to a single institution over a 15-year period were reviewed for clinical features and outcome. METHODS: A retrospective review was conducted. RESULTS: Twenty-five cases were identified; 1 chart was not available for review. Fourteen girls and 11 boys with a median age of 20 months (2 months, 10 years) presented with 26 separate tumors. Nineteen were focal and 7 diffuse. The tumors were located on the trunk (n = 13), leg (n = 6), arm (n = 3), and head and neck (n = 4). Five patients (all with diffuse type) had up to 3 recurrences. CONCLUSIONS: Patients with focal lipoblastoma are unlikely to require further surgery after initial resection. Patients with diffuse lipoblastoma (lipoblastomatosis) are likely to have recurrent disease (usually within 2 years) and should undergo close follow-up. Genetic analysis of the specimen will help exclude liposarcoma. Recurrent lesions are best imaged with magnetic resonance imaging to assess extent and plan reconstruction if necessary.

The radiologist says malrotation: does the surgeon operate?

The management of malrotation when it is an incidental finding is unclear. This retrospective study reports an analysis of radiological and operative findings in a series of 71 patients. There were no deaths. We report a false-positive rate of 15% for upper gastrointestinal contrast studies reported as showing malrotation. Our findings and a review of the literature demonstrate that in the asymptomatic child over 2 years of age, the evidence supporting mandatory correction of malrotation is weak.

Webbed penis.

A simpler technique to correct the webbed penis is described and the literature discussed.

An experimental study of optimal parameters for bipolar electrocoagulation.

The role of artery diameter, probe force application (94, 250 or 491 g), coagulation time (2, 10, or 20 secs) and BICAP generator output (5, 10) were studied in rabbit arteries of 3 to 5 mm hemicircumference. Arterial welds were then tested to destruction by increasing intraluminal pressure. The best arterial welds were achieved by the highest force and coagulation time; high generator output did not improve weld strength. These in vitro experiments suggest that when treating a bleeding peptic ulcer, BICAP therapy should be done with a low generator output of 5 or less, for at least 20 seconds per site, and with as great a compression force as possible.

Laboratory and animal model evaluation of the Cryotech LCS 2000 in hepatic cryotherapy.

Hepatic cryotherapy is increasingly used in the treatment of patients with multiple hepatic metastases, particularly from colorectal cancer. The Cryotech LCS 2000 system, with insulated shaft-circulated liquid nitrogen probes, was designed for this purpose and was evaluated on the bench and in an animal model. The 9-mm probe was considerably more effective than the 5-mm probe when judged on time to create an iceball of a given diameter. The use of thawing gas reduced the time until the probe could be removed from 25 to 5 min but heated gas only produced a further reduction of 2 min. In the animal model, significant reduction in treatment times occurred with vascular inflow occlusion. The zone of necrosis as a percentage of the original iceball diameter was significantly higher following a twin freeze/thaw cycle. The relationship of the edge of the iceball to the eventual zone of hepatic necrosis was studied using different unabsorbable markers. India ink and sutures proved unreliable but a Teflon cannula was more successful and the margin was only of the order of 2 mm. The discrepancy between this observation and the percentage of the original iceball diameter which apparently becomes necrotic (64 and 82%) for single- and double-freeze lesions, respectively, suggests that the cryolesion undergoes shrinkage within 1 month and that the diameter of necrosis underestimates the true zone of destruction.