Management of Paediatric Testicular Torsion - Are we adhering to Royal College of Surgeons (RCS) recommendations.

Introduction In 2015, the Royal College of Surgeons of England (RCS) commissioned the East Midlands Clinical Network to develop a set of guidelines for the management of paediatric torsion. Two quality measures identified were the provision of surgery locally where possible and 100% of explorations within three hours. We sought to assess the adherence to these quality measures within our referral network. Materials and methods Retrospective data were collected for all paediatric scrotal explorations performed within our centre between January 2014 and July 2016. Patient demographics, sources of referral, transfer times, time to surgery and operative findings were obtained. Results A total of 100 patients underwent a scrotal exploration. Median age at presentation was 11 years (range 4 months to 15 years). Fifty-three per cent of referrals were from network hospitals. The median duration of symptoms was 25 hours (range 1-210 hours). The median transfer time from local centres was 120 minutes (range 45-540 minutes). The median time to theatre from the decision being made to operate was 60 minutes (range 30-600 minutes). Eighty-seven per cent of cases were explored within three hours. There were 13 cases of torsion with one orchidectomy. When taking into account the transfer time for external patients aged over five years without precluding comorbidities, exploration within three hours dropped to 18 of 46 (39%). Conclusion The RCS guidelines recognise the need for specialist input in very young patients. A large proportion of explorations are, however, currently taking place in older patients with unacceptably long transfer times. We propose an extension of this review nationally to work towards the local provision of care for suitable patients.

Anorectal manometry with and without ketamine for evaluation of defecation disorders in children.

INTRODUCTION: Anorectal manometry (ARCM) provides valuable information in children with chronic constipation and fecal incontinence but may not be tolerated in the awake child. This study aimed to evaluate the effect of ketamine anesthesia on the assessment of anorectal function by manometry and to evaluate defecation dynamics and anal sphincter resting pressure in the context of pathophysiology of chronic functional (idiopathic) constipation and soiling in children. METHODS: This was a prospective study of children who were investigated for symptoms of chronic constipation and soiling between April 2001 and April 2004. We studied 52 consecutive children who had awake ARCM, biofeedback training and endosonography (awake group) and 64 children who had ketamine anesthesia for ARCM and endosonography (ketamine group). We age matched 31 children who had awake anorectal studies with 27 who had ketamine anesthesia. RESULTS: The children in awake and ketamine groups were comparable for age, duration of bowel symptoms and duration of laxative treatments. ARCM profile was comparable between the awake and the ketamine groups with regard to anal sphincter resting pressure, rectal capacity, amplitude of rectal contractions, frequency of rectal and IAS contractions and functional length of anal canal. Of 52 children who had awake ARCM, dyssynergia of the EAS muscles was observed in 22 (42%) and median squeeze pressure was 87mm Hg (range 25-134). The anal sphincter resting pressure was non-obstructive and comparable to healthy normal children. Rectoanal inhibitory reflex was seen in all children excluding diagnosis of Hirschsprung disease. CONCLUSIONS: Ketamine anesthesia does not affect quantitative or qualitative measurements of autonomic anorectal function and can be used reliably in children who will not tolerate the manometry while awake. Paradoxical contraction of the EAS can only be evaluated in the awake children and should be investigated further as the underlying cause of obstructive defecation in patients with chronic functional constipation and soiling.

Out with the old and in with the new: a comparison of rectal suction biopsies with traditional and modern biopsy forceps.

AIMS: Rectal suction biopsy, the gold standard for the diagnosis of Hirschsprung disease, has been associated with a varying incidence of complications and inadequate biopsy. The rbi2 is a modern alternative to the 'Noblett' biopsy forceps and has recently become available. The aim of this study was to compare the performance of this novel tool with the Noblett forceps. METHODS: Single-center retrospective study of all infants (<1 year) undergoing rectal suction biopsy from January 2004 to December 2007. During the study period, 2 different biopsy forceps were used--the Noblett forceps (first 2.5 years) and the rbi2 (last 1.5 years). A specimen was defined as inadequate if it was too small or contained inadequate submucosa for histological diagnosis. Fisher's Exact test and Mann-Whitney U test were used as appropriate. RESULTS: During the study period, 238 specimens were obtained from 88 infants in 102 biopsy episodes. Overall, 13 episodes were inadequate. There were no demographic differences between the 2 groups, and no serious complications (hemorrhage requiring transfusion, rectal perforation, pelvic sepsis) occurred in any infant. A significantly higher proportion of specimens taken with the Noblett forceps were inadequate compared with the rbi2 (Noblett 30/153 [20%] vs rbi2 6/85 [7%]; Relative risk (RR) = 2.8; 95% confidence interval, 1.2-6.3; P = .01). There was a nonsignificantly higher incidence of inadequate biopsy episode with the Noblett forceps compared with the rbi2 (Noblett 10/63 [16%] vs rbi2 3/40 [7%]; RR = 2.2; 95% confidence interval, 0.6-7.3; P = .24). The rbi2 carries a small cost premium for each biopsy episode compared with the Noblett forceps, but this is low when compared with the cost of repeat biopsy. CONCLUSIONS: Rectal suction biopsy is a safe procedure with a low incidence of complications. The rbi2 offers superior efficacy over the Noblett forceps, and its use is likely to be more cost-effective.

Familial bilateral congenital diaphragmatic hernia.

Familial inheritance of congenital diaphragmatic hernia is uncommon. We report two siblings with identical bilateral diaphragmatic defects.