Abdominal posterior rectopexy with an omental pedicle for intractable rectal prolapse: a modified technique.

INTRODUCTION: Rectal prolapse is a relatively common paediatric surgical condition. It has a number of benign aetiologies. Management is usually centred on regulating bowel habits. Surgery is considered after the failure of medical treatment. Numerous surgical techniques have been described with a spectrum of results. MATERIALS AND METHODS: We adopted a limited abdominal approach to achieve a posterior rectopexy using an omental pedicle in intractable cases. This technique has not been performed in children previously. RESULTS: From 2005 to 2008 we have applied this technique on five patients with recurrent rectal prolapse which had failed to respond to medical treatment, injection sclerotherapy or perianal cercalage. One patient had solitary rectal ulcer syndrome, and was initially treated with a defunctioning colostomy, had a concomitant sigmoidectomy performed at the time of rectopexy. None of the patients had cystic fibrosis. There were three females and two males, with a mean age of 9.6 years (4.7-14.0). No operative complications were encountered. The mean hospital stay was 5.4 days (3-8). None of the patients experienced recurrence at a mean of 2.1 years (0.2-2.8) follow up. The cosmetic result was regarded as satisfactory by all patients. CONCLUSION: This early experience with abdominal posterior rectopexy using an omental pedicle graft is encouraging. This technique does not involve the use of synthetic material and hence the risk of infection is low.

Traumatic rupture of right hemidiaphragm in a child.

Acute right-sided diaphragmatic ruptures are rare in children. We report a case of traumatic right-sided diaphragmatic rupture in a child that was managed by delayed repair. The clinical presentation and importance of making an accurate diagnosis and confirmation of any associated visceral injury before definitive surgery is highlighted.

Diagnostic difficulties in the management of H-type tracheoesophageal fistula.

PURPOSE: To evaluate the diagnostic difficulties and pitfalls in establishing the diagnosis of congenital H-type tracheoesophageal fistula. MATERIAL AND METHODS: A retrospective review of all cases of H-type tracheoesophageal fistula that were diagnosed in a single unit over a 6-year period. The variables assessed were age at presentation, presenting symptoms, time to diagnosis, investigations, and time to surgical repair of H-type fistula. The investigations leading to a definitive diagnosis are assessed and discussed. RESULTS: Between 1998 and 2004, five cases of H-type tracheoesophageal fistula presented to our unit. All cases had an upper gastrointestinal contrast study/tube esophagogram. In addition, four cases had a chest radiograph, three cases had a bronchoscopy, and one case an esophagoscopy. The median delay from the time of first presentation to diagnosis of H-type tracheoesophageal fistula was 14 days (7-58 days). Median age at surgery was 15 days (8-60 days). CONCLUSION: Although symptoms are usually present from birth, the diagnosis of H-type fistula is difficult and often delayed. The various diagnostic techniques are not entirely reliable and fistula identification can be elusive. The authors present recommendations for the diagnostic work-up, which may increase the diagnostic potential and avoid unnecessary delays in the diagnosis and management of H fistula.

Solitary rectal ulcer syndrome in children. A report of three cases.

Solitary rectal ulcer syndrome (SRUS) is a rare condition in children. It is well recognised in the adult literature. We report our experience with 3 patients; two boys presented at a very young age (18 and 24 months, respectively) with a clinical picture simulating inflammatory bowel diseases. The other patient was a fifteen-year-old girl presenting with severe rectal stricture as a result of the syndrome, which is the first to be reported in the paediatric literature.

Management of rectal prolapse in children.

PURPOSE: Rectal prolapse in children is not uncommon and usually is a self-limiting condition in infancy. Most cases respond to conservative management; however, surgery is occasionally required in cases that are intractable to conservative treatment. This study was designed to analyze the outcomes of rectal prolapse in children and to propose a pathway for the management of these cases in children. METHODS: A retrospective analysis of all cases of rectal prolapse referred to our surgical unit during a period of five years was performed. End point was recurrence of prolapse requiring manual reduction under sedation or an anesthetic. Results are presented as median (range) and statistical analysis was performed using chi-squared test; P < 0.05 was considered significant. RESULTS: A total of 49 children (25 males) presented with symptoms of rectal prolapse at a median age of 2.6 years (range, 4 months -10.6 years). All children received an initial period of conservative treatment with watchful expectancy and/or laxatives. Twenty-five patients were managed conservatively without any additional procedures (Group A), and 24 patients had one or more interventions, such as injection sclerotherapy, Thiersch procedure, anal stretch, banding of prolapse, and rectopexy (Group B). Management of rectal prolapse was successful with no recurrences in 24 patients (96 percent) in Group A vs. 15 patients (63 percent) in Group B at a median follow-up period of 14 (range, 2-96) months. An underlying condition was found in 84 percent of patients in Group A vs. 54 percent in Group B (P = 0.024). The age at presentation was younger than four years in 88 percent of patients in Group A vs. 58 percent in Group B (P = 0.019). CONCLUSIONS: Rectal prolapse in children does respond to conservative management. A decision to operate is based on age of patient, duration of conservative management, and frequency of recurrent prolapse (>2 episodes requiring manual reduction) along with symptoms of pain, rectal bleeding, and perianal excoriation because of recurrent prolapse. Those cases presenting younger than four years of age and with an associated condition have a better prognosis. The authors propose an algorithm for the management of rectal prolapse in children.

Multiple magnet ingestion and gastrointestinal morbidity.

Foreign body ingestion is common but multiple magnet ingestion is rare. When more than one magnet is ingested, gastrointestinal complications may occur. The magnets are attracted to each other across the bowel wall and this may lead to pressure necrosis, perforation, fistula formation, or intestinal obstruction. We report a case of perforation following the ingestion of 12 small magnets. Clinicians who care for children should be aware of this hazard.

Children and mini-magnets: an almost fatal attraction.

Children imitating adults often appear to indulge in harmless fun, however at times these activities have more serious implications. The recent fashion of body piercing among adults has encouraged children to have similar procedures or imitate them by applying small magnets to sustain the jewellery used in piercing in position. This paper describes a series of 24 cases presented to the Sheffield Children's Hospital over a period of eight weeks. The children imitated body piercing by using small powerful magnets across parts of their body including nose, ears, penis, and tongue. Some swallowed the magnets while attempting to use them, resulting in one near fatal surgical complication. The paper describes the details of the patients, the procedures used to detect the magnets, and the management of the different complications encountered.

Synchronous bilateral Wilms' tumor.

Synchronous bilateral Wilms' tumor (WT) accounts for 5% of all WTs. Of 34 cases of WT we treated, 7 (20.6%) were bilateral, 5 of them males. This high frequency of bilaterality as well as the male preponderance in our series is different from that reported in other parts of the world; this may reflect regional variations of WT. The details of diagnosis, therapy, including the role of preoperative chemotherapy, and outcome are presented.

Neonatal intestinal atresia.

Full text is available as a scanned copy of the original print version.

Abdominal situs inversus with congenital duodenal stenosis: rare association.

Abdominal situs inversus carries a significant mortality because the majority of cases (95 %) have associated cardiac and splenic defects. A review of all cases reported in the English literature confirms in addition the presence of significant gastro-intestinal pathologies, mainly annular pancreas, midgut volvulus and duodenal atresia. We report on an additional case of abdominal situs inversus without cardiac or splenic abnormalities, who had partial duodenal obstruction secondary to a mucosal diaphragm. This seems to be the thirteenth case associated with duodenal obstruction and the sixth case secondary to a mucosal duodenal diaphragm, to date, in this setting.

Esophageal atresia and tracheoesophageal fistula: success and failure rates in the United Arab Emirates.

The management of esophageal atresia (EA) and tracheoesophageal fistula (TEF) has improved markedly over the years, with a current overall survival of 80%-90%. This however, is not the case in developing countries, where mortality continues to be high. The results of treatment of 41 consecutive cases EA and/or TEF have been analyzed to determine factors pertinent to the outcome. The distribution of anomalies and a postoperative survival of 86.8% were comparable to those from developed countries. Aspiration pneumonia was unusually frequent in our patients (78%), but did not adversely influence outcome. Associated congenital anomalies as well as low birth weight continue to be important predictors of outcome in our setting. Our post-operative complications were similar to those from developed countries apart from a high incidence of stricture formation. This was attributed to gastroesophageal reflux, non-ventilation post-operatively, and the use of silk sutures to construct the anastomosis.

Ondine's curse with Hirschsprung's disease.

Hirschsprung's disease can be associated with other congenital abnormalities, some of which are neural in origin. A rare association is with congenital failure of automatic control of respiration--central hypoventilation syndrome, sleep apnoea or Ondine's curse. Patients with this combination tend to have a short life expectancy. Diaphragmatic pacing by electrophrenic stimulation has proven useful in management of patients with central hypoventilation. Three children, two females and one male, with this combination are described. The male child, who had total intestinal aganglionosis, died at the age of one month despite an ileostomy and nocturnal mechanical ventilation. The two females had aganglionosis more typical of Hirschsprung's disease, one requiring colostomy. At the ages of 2 and 6 years, respectively, phrenic nerve stimulators were implanted. Both girls remain independent of nocturnal, mechanical ventilation two and three years after commencement of diaphragm pacing. In patients with Ondine's curse and Hirschsprung's disease in whom the aganglionosis can be effectively managed, diaphragm pacing may lead to independence from mechanical ventilation and prolongation of life of an acceptable quality.

Ovarian cysts and tumours in infancy and childhood.

Cysts and tumours of the ovary are not uncommon in childhood. In 33 years between 1950 and 1982 106 patients were operated on at Alder Hey Children's Hospital and the Royal Liverpool Children's Hospital. Of these 71 were pre-menarchal. The mode of presentation, pathology and diagnostic difficulties of the pre-menarchal lesions are reviewed. The value of ultrasound scanning has become apparent in recent years. Most cysts and tumours are benign, but dysgerminomas are the most common malignant tumours encountered. Even when there is evidence of spread of the tumour the prognosis in these remains reasonably good.

Management of fetal urinary tract anomalies detected by prenatal ultrasonography.

Over a three and a half year period 32 babies were referred with a urinary tract anomaly diagnosed by prenatal ultrasound. This diagnosis was subsequently confirmed in 19 infants by postnatal assessment. Three of 13 infants in whom the original diagnosis was incorrect were subsequently found to have intra-abdominal pathology but no urological anomaly, while the other 10 had lesions in the urinary tract but not those suggested prenatally. Nineteen of the 29 babies with urological abnormalities were clinically normal at birth; 20 underwent surgery. There were three deaths; two from a combination of renal and pulmonary failure secondary to posterior urethral valves, and a third (in an infant who had normal renal function) from diaphragmatic hernia and cardiac anomalies. Prenatal diagnosis was thought to have been of benefit in six patients, of probable benefit in 16, and of no benefit in seven.

Gastric trichobezoar associated with transient pancreatitis.

A Pakistani girl presented with acute abdominal pain and raised serum amylase and alkaline phosphatase concentrations. She was found to have a gastric trichobezoar with a tail extending to the mid-ileum. The altered biochemical parameters returned to normal after surgical removal of the bezoar. Irritation of ampulla of Vater by the bezoar tail is believed to have caused transient pancreatitis.