Rectal suction biopsies to diagnose Hirschsprung's disease in a low-resource environment - optimising cost-effectiveness.

BACKGROUND: The diagnosis of Hirschsprung's disease (HD) by rectal suction biopsy (RSB) has cost implications that could be reduced by ascertaining the optimal number of specimens required. The aim was to audit our experience to optimise cost-effectiveness. METHODS: Medical records of all patients who underwent an RSB between January 2018 and December 2021 were reviewed. In 2020, we transitioned from using the Solo-RBT to the rbi2 system (requiring single-use cartridges). Descriptive statistics were reported and a comparative analysis of the diagnostic efficacy of the Solo-RBT versus the rbi2 system was performed. The cost of consumables was calculated according to the number of specimens submitted. RESULTS: Of 218 RSBs, 181 were first and 37 were repeat. The mean age at biopsy was 62 days (IQR 22-65). An average of two tissue specimens were obtained per biopsy. Of the 181 first biopsies, 151 were optimal and 30 suboptimal. HD was confirmed in 19 (10.5%) of the patients. Amongst biopsies where a single specimen was obtained, 16% were inconclusive, compared to 14% with two specimens and 5% with three specimens. The cartridges for the rbi2 system cost R530. If two cartridges are used at initial biopsy the total cost is double of a single tissue specimen sent for initial biopsy, and two specimens sent for repeat biopsies. CONCLUSION: In a low-resource setting, selecting the appropriate RSB system and obtaining a single specimen is sufficient to diagnose HD. Patients with inconclusive results should undergo a repeat biopsy where two specimens are obtained.

The Burden of Disease and Pathology at a Rapidly Expanding Tertiary Paediatric Surgical Unit in South Africa.

BACKGROUND: The precise burden of paediatric surgical care in South Africa is unknown. In the absence of epidemiological data, hospital-based study is a first step to gauge the burden and profile of paediatric surgical disease. We aim to describe the profile of pathology, pattern of referrals, and complications of paediatric surgical care at Chris Hani Baragwanath Academic Hospital (CHBAH). METHODS: A 1-year retrospective record review for the period 3/1/2019 to 1/1/2020 was conducted by evaluation of the morbidity and mortality databases of the Department of Paediatric Surgery (DPS). Number of admissions, consultations, complications, and surgeries performed were analysed and classified. RESULTS: A total of 11,932 unique patient encounters occurred. Emergencies (79%, 1841/2329) accounted for the majority of admissions. Trauma accounted for 49% (896/1841) of emergency admissions. Elective surgery constituted 52% (1202/2316) and emergency surgery 48% (1114/2316) of all procedures performed. The emergency department (55%, 1271/2329), outpatients department (19%, 447/2329), and peripheral hospitals (16%, 378/2329) were the source of the majority of admissions. A complication rate of 9% (208/2316) was observed. CONCLUSION: The high-volume subspecialist environment at CHBAH presents the ideal environment for delivery of specialist paediatric surgical services and training. Injury prevention, optimal use of existing resources, and additional physical, human and financial resources are required to meet the existing and predicted future burden of paediatric surgical disease.

Neonatal surgical outcomes: a prospective observational study at a Tertiary Academic Hospital in Johannesburg, South Africa.

PURPOSE: The neonatal period is the most vulnerable period for a child. There is a paucity of data on the burden of neonatal surgical disease in our setting. The aim of this study was to describe the frequency with which index neonatal surgical conditions are seen within our setting and to document the 30-day outcome of these patients. METHODS: This was a single-centre prospective observational study in which all neonates with paediatric surgical pathology referred to the paediatric surgical unit with a corrected gestational age of 28 days were included. RESULTS: Necrotising enterocolitis was the most frequent reason for referral to the paediatric surgical unit (n = 68, 34.34%). Gastroschisis was the most frequent congenital anomaly referred (n = 20, 10.10%). The overall morbidity was 57.58%. Surgical complications contributed to 18.51% of morbidities. The development of gram negative nosocomial sepsis was the most frequent cause of morbidity (n = 98, 50.78%). Mortality at 30 days was 21.74% (n = 40). Sepsis contributed to mortality in 35 patients (87.5%), 16 of which had gram negative sepsis. CONCLUSION: Gram-negative sepsis was a major contributing factor in the development of morbidity and mortality in our cohort. Prevention and improvement in infection control are imperative if we are to improve outcomes in our surgical neonates.

Management of fetal extraperitoneal rectal perforation: a case series and review of the literature.

PURPOSE: Fetal extraperitoneal rectal perforation (FERP) is an extremely rare entity. The objective of this report is to review the available literature on this condition and to add our experience with four additional cases managed at our institution. METHODS: A literature search was performed for journal articles addressing this condition. Management strategies and outcomes were then analysed, together with additional information provided from retrospective record review of four cases managed at our institution. RESULTS: A total of 18 patients were identified and included, 14 from the literature and 4 from our records. Initial investigations varied between authors with contrast enema being the most frequently performed study (7/18). All patients were treated with faecal diversion via colostomy formation. Exploratory laparotomy was performed in 6 cases, perineal debridement and washout in 9 cases while drains were left in situ in 14 cases. At 3-6 months of age, a distal contrast study was performed before closure of colostomy. CONCLUSION: Although FERP is a rarely encountered clinical condition, timely recognition and appropriate management can result in good outcomes. Diagnosis can be achieved based on clinical and abdominal X-ray features alone. General management principles involve a diverting colostomy and extended drainage with closure of the colostomy 3-6 months later.

Anorectal malformations and the impact of HIV on surgical outcome.

BACKGROUND: Anorectal malformations (ARMs) represent a significant surgical load in South African (SA) paediatric surgical centres. Surgical treatment of ARMs may be associated with postoperative complications owing to the nature of surgical procedures necessary in the neonatal and infant period. HIV and its effect on the immune response compound postoperative surgical complications. The impact of HIV exposure and its effect on the child's immune status, independent of the child's HIV status, has yet to be studied in the surgical population. OBJECTIVES: To assess the incidence of complications in our population of ARM patients and to explore whether these were increased in HIV-exposed but serologically negative children compared with HIV-unexposed children. METHODS: This was a prospective study of all patients presenting with ARMs to the paediatric surgery units attached to the University of the Witwatersrand, Johannesburg, SA. Specifically, exposure to an HIV-positive mother, patient HIV status and presence of surgical complications were documented. Data were analysed for the period August 2016 - September 2017. RESULTS: A total of 50 children were included (none were excluded); 19 (38%) were HIV-exposed but none were HIV-positive, and 28 (56%) were male and 22 (44%) female. Seventy-six operative procedures were performed, with 27 operative complications. In the HIV-exposed group, 68% of patients experienced operative complications, compared with 45% in the unexposed group (p=0.1); 50% of the HIV-exposed patients who had stoma formation experienced complications, compared with 20% in the unexposed group (p=0.08). CONCLUSIONS: The incidence of postoperative infectious complications in HIV-exposed patients was higher than in HIV-unexposed patients. The incidence of postoperative complications in HIV-unexposed patients parallels that in the international literature, except in the posterior sagittal anorectoplasty groups. It remains critically important to follow stringent perioperative protocols for infection prevention and aggressively treat any infection that arises, particularly in patients born to HIV-positive mothers, regardless of the patient's HIV status.

Choledochal malformations: Lessons learnt in Johannesburg.

BACKGROUND: Choledochal malformation (CM) is a well-described and relatively rare condition. CMs may present on antenatal ultrasound screening, through childhood and into adulthood. The aetiology is not well understood but the association with a pancreaticobiliary malunion predisposes to the development of CMs. OBJECTIVES: To review the experience of CMs in the Department of Paediatric Surgery, University of the Witwatersrand, Johannesburg to improve our patient care for this population. METHODS: After institutional ethics approval, a retrospective record review was conducted of patients presenting with CM to the Department of Paediatric Surgery, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg. All patients managed between January 2010 and May 2017 were included. RESULTS: A total of 35 patients underwent surgery for CMs and 2 patients were excluded from the study owing to incomplete records. Most of our patients (83%) presented with jaundice and a median (interquartile range) bilirubin level of 167 (32 - 234) mmol/L. In our cohort of patients those with type IV lesions presented at a younger age and with higher bilirubin and gamma-glutamyl transferase levels, although this finding was not statistically significant. CONCLUSION: Although uncommon, CMs may lead to significant morbidity and malignancy. Specialised care is necessary to improve longterm outcomes in these patients.

Paediatric pancreatic trauma: a review of the literature and results of a multicentre survey on patient management.

BACKGROUND: It is generally accepted that paediatric solid organ injury should be treated conservatively, unless there is haemodynamic instability unresponsive to resuscitation. When it comes to pancreatic trauma, there is much debate about appropriate management. OBJECTIVES: To review the literature and determine how pancreatic trauma is managed in South African (SA) tertiary institutions and compares with international standards. METHOD: A survey was emailed to 45 paediatric surgical consultants working in various paediatric surgical units in SA, Italy, England and Australia. The questionnaire comprised two scenarios of isolated pancreatic trauma (grade III), the main difference between them being the time interval between initial injury and presentation. In the first scenario, the patient presented 6 hours post injury whereas in the second scenario, the patient presented 6 days post initial injury. The survey enquired about diagnosis and subsequent work-up (including preferred imaging techniques), supportive management (including nutrition), the various options of definitive intervention and follow-up procedure. RESULTS: There were 21 responders from four different countries. In the first scenario, 10 surgeons would operate, 8 would treat conservatively and 3 would perform an endoscopic retrograde cholangiopancreatogram (ERCP) and stent. In. the second scenario, 4 surgeons would operate, 13 would treat conservatively and 4 would undertake ERCP with stent. There was no difference in management between the SA surgeons and their international counterparts. CONCLUSION: Management of blunt pancreatic trauma in SA is consistent with that reported in the literature. There is still controversy regarding the optimal management of pancreatic injury involving ducts. No absolute algorithm can be used to treat these patients. All patients should be treated individually and managed with an approach and techniques that are feasible.

The versatility of median sternotomy in general paediatric surgery.

BACKGROUND: While common in cardiac surgery, median sternotomy (MS) is rarely required in general paediatric surgery. In the era of advancing endoscopic techniques, sternotomy is perceived as an extremely invasive incision, associated with prolonged postoperative recovery and significant morbidity. METHODS: We conducted a retrospective chart review of all children undergoing MS for non-cardiac indications between January 2007 and September 2012 and describe the pathology, number of ventilated days, duration of intensive care unit stay and analgesic requirements. RESULTS: Our experience over the past 6 years includes 14 children, aged between 8 months and 13 years. Indications for surgery included penetrating mediastinal trauma (1), anterior and posterior mediastinal masses (4), acquired tracheo-oesophageal fistulas secondary to button battery impaction (2), bronchial foreign bodies (2) and bilateral pulmonary metastases secondary to malignancy (5). The range of postoperative ventilation required was 0 - 34 days (median 1 day) and the range of duration of stay in the paediatric intensive care unit 1 - 39 days (median 4 days). Postoperative analgesia was provided with intravenous or oral paracetamol with or without the addition of morphine. All the children tolerated the procedure well with no sternotomy-related complications on follow-up. CONCLUSION: This review highlights the variety of conditions in which MS provides unrivalled access to the mediastinum and how well the procedure is tolerated by the paediatric patient, and emphasises the importance of sternotomy being within the armamentarium of access techniques of the general paediatric surgeon.

Metabolic and performance adaptations to interval training in endurance-trained cyclists.

This study examined the effects of sustained high-intensity interval training (HIT) on the athletic performances and fuel utilisation of eight male endurance-trained cyclists. Before HIT, each subject undertook three baseline peak power output Wpeak tests and two simulated 40-km time-trial cycling performance (TT40) tests, of which the variabilities were 1.5 (1.3)% and 1.0 (0.5)%, respectively [mean (SD)]. Over 6 weeks, the cyclists then replaced 15 (2)% of their 300 (66) km.week-1 endurance training with 12 HIT sessions, each consisting of six to nine 5-min rides at 80% of Wpeak, separated by a l-min recovery. HIT increased Wpeak from 404 (40) to 424 (53) W (P < 0.01) and improved TT40 speeds from 42.0 (3.6) to 43.0 (4.2) km.h-1 (P < 0.05). Faster TT40 performances were due to increases in both the absolute work rates from 291 (43) to 327 (51) W (P < 0.05) and the relative work rates from 72.6 (5.3)% of pre-HIT Wpeak to 78.1 (2.8)% of post-HIT Wpeak (P < 0.05). HIT decreased carbohydrate (CHO) oxidation, plasma lactate concentration and ventilation when the cyclists rode at the same absolute work rates of 60, 70 and 80% of pre-HIT Wpeak (P < 0.05), but not when they exercised at the same relative (% post-HIT Wpeak) work rates. Thus, the ability of the cyclists to sustain higher percentages of Wpeak in TT40 performances after HIT was not due to lower rates of CHO oxidation. Higher relative work rates in the TT40 rides following HIT increased the estimated rates of CHO oxidation from approximately 4.3 to approximately 5.1 g.min-1.

Physiological and subjective measures of workload when shovelling with a conventional and two-handled ('levered') shovel.

Previous studies have suggested that the two-handled (levered) shovel is advantageous over the conventional spade from a biomechanical point of view. The aim of this experiment was to determine whether less energy was consumed while shovelling a load of sand with this shovel compared to a conventional tool. Accordingly, an experiment was designed in which subjects (n = 10) shovelled 1815 kg sand under laboratory conditions using either a conventional or a levered shovel. Heart rate and oxygen consumption were measured continuously during the trial and subjective data on perceived exertion, general fatigue and body discomfort were recorded after the trial. Although total energy expenditure was similar under both conditions (120 +/- 20 and 125 +/- 25 kcal; conventional versus two-handled spade), average heart rate was 4% higher when the two-handled shovel was used (p < 0.05). In addition, the mass of sand per scoop was 4% less with the two-handled shovel (p < 0.05). In conclusion, subjects used similar energy expenditure to shovel 1815 kg sand with the conventional shovel and the two-handled tool despite lower mass of sand per scoop with the latter. This can be explained by the fact that the increased mass of the additional handle compensated for the lower mass of sand per scoop. The higher average heart rate while shovelling with the two-handled shovel can be explained by the more erect posture.