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Intestinal transplantation (ITx) is now a well-established treatment for infants and children with intestinal failure (IF), who develop complications related to longterm parenteral nutrition (PN). Transplantation of other organs such as kidney, liver and heart developed during the 1960s but did not reach widespread clinical application until the cyclosporine era of immune suppression in the early 1980s. ITx lagged behind as the intestine was found to be an organ with special problems of its own immunogenicity, its interface with the enteric lumen colonized with bacteria and transfer of a heavy load of immune competent cells of the donor at the time of engraftment. In addition, organ preservation was more fragile and consequences of ischaemic reperfusion injury more severe. At the same time, treatment of intestinal failure with parenteral nutrition (PN) had developed to give children with IF a reasonable quality of life. Long-term PN, however, has its own complications including central venous catheter related sepsis, venous thrombosis and PN associated liver disease. PN therefore is not a lifetime treatment. Sporadic cases of ITx were reported in the 1970s but all recipients died of technical complications, sepsis or rejection. Optimism for success in the cyclosporine era was short-lived as most grafts were lost to rejection. A total of 15 cases were reported between 1985 and 1990 with one long term survivor. This child received a neonatal donor intestine and has survived 19 years post transplant. Introduction of more effective tacrolimus immune suppression by Starzl in 1990 allowed for reports of 60% 1 year graft survival by 1993. Currently 90% 1 year survival is reported from some centres. Parenteral nutrition remains the current standard of care for infants and children with intestinal failure with a 54

Esophageal strictures due to caustic ingestion (CI) may require repeat esophageal dilations and dilation adjuvants, including local anti-fibrinogenic injection therapy, stent placement, and radial stricture incisions. Refractory strictures require surgical intervention. Pedicled colon patch esophagoplasty (CPE) may avoid the morbidity associated with total esophageal replacement, although reports of its use are limited. Indications and outcomes for CPE in patients undergoing repeat esophageal stricture dilations following caustic ingestion are described according to our local experience and literature reports.A retrospective review of indications for surgical management of esophageal strictures to tertiary pediatric surgical services between 2015 and 2020 focused on patients undergoing CPE. English-language literature (PubMed, Google Scholar, and Scopus) describing CPE was also reviewed.Eight (12%) out of 65 patients with esophageal strictures requiring 7 or more esophageal dilations with poor response underwent surgical stricture management over a 6 year period, which included stricture resection and re-anastomosis in 2 patients, total esophageal replacement with colon graft in 2 patients, gastric pull-up in 1 patient, and CPE in 3 patients. The patients undergoing CPE were aged 3-8 years and had 17 to more than 25 dilations following caustic ingestion over a 2-5 year period. One patient had a 4 cm stricture; the other 2 had strictures 7 cm in length. A transverse colon patch based on the middle and left colic vessels was utilized in all three, with the vascular pedicle placed retrogastrically via the esophageal hiatus and the patch inlay esophagoplasty concluded via right thoracotomy. Post-operative contrast studies showed near-normal anatomy, and the patients could tolerate full oral diets. During a 9-36 month follow-up period, only 2 patients required dilations of a proximal anastomotic stricture at 1 and 5 months postoperatively. One patient required additional proximal stricturoplasty with advancement of the original graft across the stricture via a cervical surgical approach.Colon patch esophagoplasty to restore esophageal luminal continuity and allow a normal diet should be considered for refractory esophageal strictures. CPE had excellent functional outcomes in our 3 patients and should be considered in selected cases instead of total esophageal replacement.

Atresias of the jejunum and ileum account for about one third of all cases of neonatal intestinal obstruction with a third of infants born prematurely or small for dates. Stenoses are much less common, accounting for about 5% of cases, and seldom present in the newborn period because of delay in diagnosis. While these conditions are associated with excellent prognoses in developed countries, delayed presentation and limitations in resources to support patients with delayed return of intestinal function contribute to overall lower survival rates in many African countries. Early recognition and proper surgical management are vitally important to improving the patient’s chance of survival in countries with limited access to health-care resources.

Short bowel syndrome (SBS) is defined as intestinal failure due to inadequate length of bowel for maintaining the nutrition and hydration of an individual without supplementation. Gastroschisis, atresias and necrotising enterocolitis are the commoner causes of neonatal SBS. Whilst there is potential for the intestine to adapt by lengthening, thickening and dilating, this can take several years, during which survival will be dependent on the availability of total parenteral nutrition (TPN).

The birth of conjoined twins has always fascinated mankind, with the public’s view of malformed children greatly influenced by the prevailing culture and religious beliefs. In prehistoric times, conjoined twins were depicted in cave drawings, on pottery, or as figurines. In folklore, they were often regarded as an omen of impending disaster, eliciting strong emotions ranging from wonder and admiration to rejection and hostility. Although malformed children were treated compassionately at times, historical records show that infanticide was frequently practiced and the mother was often held responsible for causing the malformation.

To determine a correlation between the 99mTc sucralfate scan and the endoscopy findings in children with caustic oesophageal injury. This is an observational analytic study of children who had both 99mTc sucralfate scan and endoscopy after caustic substance ingestion at our institution in a period between January 2009 and September 2016. The oesophageal injury was classified into low grade and high grade according to the degree of adhesion on 99mTc sucralfate scan and modification of Zargar endoscopic grading. Out of a total of 197 children, 40 children were identified who had both investigations done on average 26 h post-injury. Low-grade adhesion on 99mTc sucralfate scan was found in 27 children (68%), and all had low-grade Zargar’s oesophageal injuries. None of these subsequently developed residual pathology. Thirteen had high-grade adhesion and five of these had high-grade injury on endoscopy. Three (23%) developed oesophageal strictures. Correlation of 99mTc sucralfate and endoscopic findings reached statistical significance with a p value of 0.0014. No morbidity was associated with either the scan or endoscopy. We concluded that low-grade sucralfate scan finding has the potential to successfully eliminate the need for invasive endoscopy under general anaesthesia and thereby reducing procedure-related morbidity, hospitalization and associated costs. However, mandatory endoscopy is required in children with high-grade adhesion seen on 99mTc sucralfate scan. This requires confirmation using a larger prospective study.

Pediatric injuries are associated with significant morbidity and mortality, especially in low- and middle-income countries. Data to characterize the cause and risk factors associated with childhood injuries in low- and middle-income countries are very scarce. The aim of this study is to describe the cause of pediatric injuries and their possible changes between 2007 and 2011 using hospital-based data in Cape Town, South Africa.Data from injured children13 years of age who presented to the Red Cross War Memorial Children's Hospital's emergency department in 2007 and 2011 were captured in Childsafe South Africa's trauma surveillance system. Poisson regression was used to assess changes in rates of injury between 2007 and 2011 in terms of demographics, geographic location of injury, type of injury mechanism, injury severity, and anatomic region of the sustained injury.In total, 14,915 injured children with 15,414 injuries presented to Red Cross War Memorial Children's Hospital in 2007 and 2011. The mean age was 5.01 ± 3.5 years and 60.3% were male. Common mechanisms of injury included falls (n = 6,036; 40%), road traffic injuries (n = 1,939; 13%), burns (n = 1,885; 12.6%), and assault (n = 640; 4.3%). Comparing 2011 to 2007, the incidence of road traffic injuries has decreased by 7% (P .05) while burn injuries increased 11% (P .05). Seventy-three percent (73%) of injuries that presented to Red Cross War Memorial Children's Hospital occurred in the Cape Flats area of Cape Town, where many informal settlements exist.These epidemiologic findings suggest that while road traffic injuries decreased and burn injuries increased at Red Cross War Memorial Children's Hospital, there is a need for data that are population-based and not hospital based. If we could describe injuries accurately within the pediatric population of a city such as Cape Town, we could in turn use this data to strengthen the need for targeted interventions to address risk factors for pediatric injuries. Despite this, hospital-based data remain a powerful tool to study injuries in low and middle-income countries.

To review demographics, effect of preoperative chemotherapy on tumour thrombus, imaging, operative strategy, and outcomes of 12 patients presenting with intracardiac extension of Wilms tumour thrombus. A retrospective audit was undertaken on patients with intracardiac extension of Wilms tumour. Patients were identified from the oncology database and information obtained on clinical presentation, stage, preoperative treatment, surgical procedures and complications, histology, and survival status. Ethics approval was obtained from the University of Cape Town Human Research Ethics Committee. From 1984 to 2016, 337 children with Wilms tumour were treated. Twelve (3.6%) had intracardiac extension of tumour thrombus, nine into the right atrium, and three into the right ventricle. Ultrasound, computerized tomography, magnetic resonance imaging, and echocardiograms were used to assess thrombus level. Patients were staged as stage III(8) and IV(4). All patients received preoperative chemotherapy. Thrombus retracted from the heart in two cases. One patient died preoperatively. Eleven underwent laparotomy, median sternotomy, and cardiopulmonary bypass (CPB). Four underwent cavectomy. Five required cavoatrial patches. Thrombus extending into the hepatic veins was extracted in five patients. There was one intraoperative complication and one perioperative death. Thrombus histology showed viable tumour in 9 of 11 patients. Three patients died of progressive disease. Seven patients are currently disease free. A combination of imaging is required to determine thrombus extent, and this facilitates surgical planning. Preoperative chemotherapy may cause thrombus regression, thus avoiding CPB. CPB offers appropriate conditions for safe tumour thrombus excision. Full management in centres with appropriately experienced staff and facilities for CPB is recommended.

Aim No consensus exists about the optimal surgical technique for esophageal replacement. This study reports the surgical outcomes for the gastric pull-up and the colonic interposition procedures. Materials and Methods A retrospective review of children undergoing esophageal replacement surgery between January 2001 and June 2015 across four different pediatric surgery centers was conducted. Data collected included indications, epidemiology, surgical technique, complications, and outcomes. Patients were divided into group A, those that had a gastric pull-up procedure and group B, those that had a colonic interposition procedure. Results In total, 50 patients were included; 29 in group A and 21 in group B. Indications included esophageal atresia, caustic ingestion, and infective esophageal stricture. The median age at the time of surgery was 13 months. The mean length of follow-up was 5.2 years. Three patients died giving a mortality rate of 6%; 2 in group A and 1 in group B.In both groups, early postoperative complications included infective complications, such as wound infections, sepsis, and pneumonia (11), anastomotic leak (7), and respiratory complications (7). Late complications included adhesive bowel obstruction (2), anastomotic strictures (4), redundancy (1), and jejunostomy problems (1). Septic complications and anastomotic strictures occurred more frequently in group B. Further surgery was needed in eight patients; this was significantly higher in group B. Full oral feeding was achieved within 6 months in 91.5%. Conclusion The gastric pull-up and colonic interposition have comparable mortality and outcomes. The colonic interposition was associated with a higher rate of early septic complications, anastomotic strictures, and need for further surgery.

Of all the intra-abdominal solid organs, the liver is the most vulnerable to blunt abdominal trauma. The majority of liver ruptures present in combination with other abdominal or extra-abdominal injuries. Over the last three decades, the management of blunt liver trauma has evolved from obligatory operative to non-operative management in over 90% of cases. Penetrating liver injuries more often require operative intervention and are managed according to adult protocols. The greatest clinical challenge remains the timely identification of the severely damaged liver with immediate and aggressive resuscitation and expedition to laparotomy. The operative management can be taxing and should ideally be performed in a dedicated paediatric surgical centre with experience in dealing with such trauma. Complications can occur early or late and include haemobilia, intrahepatic duct rupture with persistent biliary fistula, bilaemia, intrahepatic haematoma, post-traumatic cysts, vascular outflow obstruction, and gallstones. The prognosis is generally excellent.

Microgastria is a very rare anomaly characterized by a very small tubular stomach that presents with severe gastroesophageal reflux disease due to the small reservoir capacity of the stomach. We present a patient with microgastria-related reflux and a failed fundoplication who was treated with total esophageal gastric dissociation (TEGD) resulting in an excellent outcome. In our experience with this good long-term result, we would suggest that TEGD be added to the armamentarium of procedures that can be used in the treatment of microgastria.

Successful outcome after surgery for atresia of the small intestine is still sometimes accompanied by significant complications. An understanding of the aetiology and the realization that the proximal blind ending dilated bulbous atretic bowel was the cause of most of these complications and resection of this segment with primary anastomosis of proximal to distal bowel led to a dramatic improvement in outcomes from a mortality of 90—100% to a survival of over 80% in the 1950’s. Subsequent improvement in some technical aspects of bowel anastomosis and neonatal perioperative care along with advances in nutrition both parenteral and enteral have made current treatment one of the many success stories of neonatal surgery.

Local anesthetic wound infusion has shown promising results in adults. Its use in children is limited to some centers and there are only a few prospective trials in this group of patients. Sub-fascial continuous local anaesthetic wound infusion (CLAWI) (0.2 % Bupivacaine) plus intravenous paracetamol and rescue intravenous morphine was compared to: (a) Epidural bupivacaine (EPI) plus paracetamol and rescue intravenous morphine for patients undergoing laparotomy. (b) Intravenous morphine and paracetamol (standard post-operative analgesia—SAPA) in children undergoing Lanz incision laparotomy for complicated appendicitis. ‘InfiltralLong’, PANJUNK® catheters were placed sub-fascially after peritoneal closure for post-operative bupivacaine infusion. Pain scores were recorded regularly by the same blinded pain specialist. The primary outcomes were pain control and total morphine. The secondary outcomes were time to full feeds, mobilization requirement for urinary catheter and complications. Sixty patients (18 laparotomy-CLAWI, 17 laparotomy-EPI and 12 appendectomy-CLAWI, and 13 appendectomy-SAPA) were analyzed. The average pain score was 2.5 (1–4) in the CLAWI groups, 3.0 (1–5) in the EPI group and 3.5 (2–5) in the SAPA group. Morphine requirements were markedly less for CLAWI. SAPA and EPI groups required urinary catheters for longer and took longer to mobilize (average 4 days compared to 2 days for CLAWI). There were no wound or bupivacaine complications in the CLAWI group. Continuous subfascial bupivacaine infusion is reliable, safe and effective in paediatric post-operative pain control with considerably reduced opiate requirements.

1Department of Paediatric Surgery, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands 2Department of Paediatric Surgery, University of Cape Town, 6th Floor ICH, Red Cross Children’s Hospital Klipfontein Road, Rondebosch, Cape Town, Western Cape 7701, South Africa 3Department of Radiology, University of Cape Town, 6th Floor ICH, Red Cross Children’s Hospital Klipfontein Road, Rondebosch, Cape Town, Western Cape 7701, South Africa *Corresponding author Arjan Sebastiaan van As, PhD Department of Paediatric Surgery University of Cape Town 6th Floor ICH, Red Cross Children’s Hospital, Klipfontein Road Rondebosch, Cape Town Western Cape 7701, South Africa Tel. 0027 82 654 3673 E-mail: Sebastian.VanAs@uct.ac.za

We present two case reports of disseminated mucormycosis and necrotizing fasciitis in an immunecompromised patient. First, a 3-month-old with untreated HIV infection presented in septic shock with abdominal wall-necrotizing fasciitis. Laparotomy revealed extensive abdominal wall necrosis, bowel, liver, kidney and subsequent retroperitoneal, posterior diaphragm and inferior vena cava involvement. Second, a 3-year-old on chemotherapy for Burkitt’s lymphoma presented with pancytopenia, sepsis, abdominal wall-necrotizing fasciitis and left lower limb ischaemia. At surgery, there was necrosis of the abdominal wall, the large bowel and the ureter and thrombosis of the iliac vessels. Histology in both cases showed necrosis with fungal invasion consistent with mucormycosis. Both patients suffered mortality. We discuss mucormycosis and review the literature regarding mucormycosis in immune-compromised paediatric patients. Keywords : child, immune-compromised, mucormycosis, necrotizing fasciitis, paediatric

Wilms tumour is named after Max Wilms. It is an embryonal tumour derived from the metanephros. It is the commonest childhood renal tumour and the third commonest paediatric malignancy. Synchronous bilateral Wilms tumours (BWT) represent 4-7% of all Wilms tumours (WT) and present at a younger age than unilateral Wilms tumours. At least 10% of synchronous BWTs have unfavourable histology, and up to 22% are associated with genitourinary abnormalities, aniridia, WAGR syndrome, Denys-Drash Syndrome, hemihypertrophy, or one of the other overgrowth syndromes. The long-term disease-free survival (DFS) rate for patients with unilateral Wilms' tumours is approaching 90%, and is around 70% for those with metastatic disease. For both synchronous and metachronous Wilms tumours the prognosis is less favourable with reported cure rates approaching 80% in the best centres and lower in resource poor settings. There is potential for a reduced quality of life due to renal insufficiency and the possible need for renal transplantation. The major clinical challenge in BWTs is preservation of functioning renal tissue using nephron sparing surgical techniques, while achieving cure with minimum therapy-related morbidity. Mortality is generally associated with progressive disease of anaplastic tumours. Chemotherapy followed by nephron sparing surgery has been able, in most cases, to eradicate the tumour while preserving renal function. Radiotherapy has largely been avoided because of fears of long term radiation injury to the residual functioning renal mass. Patient selection, appropriate pre- and post-operative chemotherapy and skilled surgical techniques all contribute to excellent outcomes where these are achievable.

Caustic ingestion continues to be a significant problem world-wide especially in developing countries and particularly in the under 6 years age group. The presence or absence of symptoms or oral lesions does not reliably predict the existence or severity of oesophageal lesions. Upper endoscopy remains the mainstay diagnostic modality for evaluation to define the extent and severity of the injury. The best predictor of morbidity and mortality is the extent of injury as assessed during initial evaluation. Early management strategies for caustic ingestion are well defined. Controversy still surrounds the use of steroids, antibiotics, antacid therapy in the acute phase, and the use of oesophageal stents and the frequency, timing and method of dilatation in the prevention and management of oesophageal strictures. There is a pressing need for non-invasive diagnostic modalities and effective therapeutic options to evaluate and treat the complications associated with caustic ingestion. Indications for definitive surgery or bypass and the type of procedure to use are also subject to ongoing debate.

Magnetic resonance imaging (MRI) has become the principal tool for Wilms tumor (WT) assessment and follow-up. MRI and histopathologic findings were not congruent in 2 of the q30 scanned patients with renal masses (2008 to 2011). Three lesions thought to be WT on MRI were found to be a sclerotic nephrogenic rest (1), cystic renal dysplasia (1), and focal chronic pyelonephritis (1). The "typical" features suggesting nephroblastomatosis and WT on MRI are unreliable and such lesions require biopsy for histopathologic diagnosis, especially when nephron-sparing surgery is necessary to preserve renal function.

Burns are a significant burden of pediatric injuries, particularly in low and middle-income countries, were more than 90% of burn-related pediatric deaths occur. This study explores pediatric burn-related injuries over a fifteen year time period in South Africa through an analysis of a pediatric trauma surveillance system.This retrospective observational study used data collected by Childsafe South Africa from the Red Cross War Memorial Children's Hospital (RCH) trauma registry in Cape Town, South Africa between 1995 and 2009 for children less than 13 years of age who presented with burn injuries to the hospital's casualty department. Demographic data and Abbreviated Injury Scores (AISs) were first assessed, followed by an analysis of time trends using Poisson regression. Logistic regression models were used to analyse factors related to hospital admissions.Between 1995 and 2009, 9438 children with burn-related injuries presented to RCH, of which nearly three-quarters resulted from scalds (73%; n=7024). The mean age of the injured children was 3.1 ± 2.9 years 58% were male. 11 deaths occurred in the hospital's casualty department. 39% of injuries were minor, 56% were moderate, and 5% were severe. During the 15-year study period, moderate burn injuries increased by 3%, while minor injuries decreased by 10% (p0.05). 49% of all children were admitted to the hospital. Hospital admissions increased by 3% (p0.05) during the study period.Pediatric burn injuries are a significant contributor to the burden of child diseases in developing county hospitals. Pediatric surveillance systems, such as Childsafe South Africa's, are important to study epidemiologic changes in burn injuries. Findings suggest the need for targeted interventions to address the prevention of specific burn-related injuries.

The goal of any treatment programme for short bowel syndrome SBS is to achieve nutritional enteral autonomy. This must begin with conservation of as much bowel as possible from the time of first presentation. Frequent causes of the short bowel syndrome are intestinal atresia, necrotizing enterocolitis, midgut volvulus, extended intestinal aganglionosis, ‘vanished gut’ often associated with gastroschisis and occasionally catastrophic trauma. Atresia is more amenable to successful surgery than other causes, except when associated with gastroschisis. Intrinsic dysmotility has a poor prognosis. Intestinal lengthening procedures are only indicated if there is sufficient bowel dilatation. Extended intestinal aganglionosis is rarely amenable to any form of non-transplant surgery. Options available are to conserve bowel, close stomas early (use all available bowel to the maximum or even re-feed stoma effluent into the distal unused bowel), release adhesions causing obstruction, resect strictures, taper or excise localized dilatations and finally address dilated bowel with lengthening and tailoring operations. These procedures aim to improve effective peristalsis, thereby reducing bacterial overgrowth and improving nutrient contact with enteral mucosa to maximize absorption and intestinal adaptation. The Bianchi longitudinal splicing operation and the serial transverse enteroplasty operations have stood the test of time in providing considerable improvement in enteral nutritional autonomy in around 60 % of cases. In SBS without dilatation attempts at ‘mechanically’ delaying transit (nipple valves, reversed bowel segments, colon interposition) have had inconsistent outcomes. Growing neomucosa and lengthening bowel by longitudinal stretch are still experimental.

This study was designed to determine whether a decrease in renal oxygenation occurs during CO2 pneumoperitoneum in children with normal renal function undergoing laparoscopy. Near infrared spectroscopy (NIRS) probes were applied to both the lateral flank (T10-L2) and lateral cerebral area of all patients with normal renal function undergoing a laparoscopic procedure. Information was recorded in 5-s intervals for 15-min before, during, and for 15-min after pneumoperitoneum insufflation and desufflation. Simultaneously, additional hemodynamic parameters (arterial saturation, mean arterial pressure, end tidal CO2, and urine output) were recorded every 5-min. Pneumoperitoneum pressures used were: 0–1 month old

A 2-year-old female presented acutely with peritonitis and small bowel obstruction. An abdominal radiograph demonstrated a radiopaque foreign body. At laparotomy she was found to have bowel perforations with entero-enteric fistulae caused by four magnets. The magnets were removed, and debridement and closure of the perforations performed. We review our case and highlight this problem to other medical practitioners as a potential cause of significant morbidity and mortality in the paediatric population.

Here in, we present a case of aggressive Gorham's disease in a 10 year old boy. We document its evolution from a seemingly benign buttock mass to a widely invasive disease that was ultimately fatal. We highlight the challenges in the management of such an aggressive, yet benign process and review the available literature on the subject.

Synchronous bilateral Wilms tumours (BWTs) represent 4% to 7% of all Wilms tumours (WTs) and present at a younger age than unilateral WTs do. At least 10% of synchronous BWTs have unfavourable histology, and up to 22% are associated with genitourinary abnormalities, aniridia, WAGR (WT, aniridia, genitourinary anomalies, and retardation) syndrome, Denys–Drash syndrome, hemihypertrophy or one of the other overgrowth syndromes. The long-term disease-free survival rate of patients with unilateral WT is now approaching 90% and is around 70% for those with metastatic disease. For both synchro¬nous and metachronous WTs, the prognosis is less favourable, with reported cure rates approaching 80% in the best centres but are often considerably less in resource-poor settings. Also, there is the potential for a reduced quality of life due to renal insufficiency and the possible need for renal transplantation. Thus, the major clinical challenge in BWTs is the preservation of functioning renal tissue, while achieving cure with the minimum of therapy-related morbidity. Although mortality is generally associated with progressive disease of anaplastic tumours, the emphasis of management has been increasingly placed on nephron-sparing surgical approaches in an attempt to reduce ultimate renal insufficiency. Chemo-therapy followed by nephron-sparing surgery has been able, in most cases, to eradicate the tumour while preserving renal function. Radiotherapy has largely been avoided because of fear of long-term radiation injury to the residual functioning renal mass. Patient selection, appropriate pre- and post-operative chemotherapy, and skilful surgical techniques all contribute to excellent outcomes, where these are achievable.

Primitive man's discovery and use of fire had a tremendous impact on modern development. It changed lifestyles, and brought with it new fuel sources and cooking methods. It also introduced devastation, injury, pain, disfigurement, and loss of life, and the need to continuously develop management, training and prevention programs.

Increasingly HIV-infected children can be expected to require surgery. The aim of this study was to compare the outcome of HIV-infected and HIV-unexposed children undergoing surgery.A prospective study of children less than or equal to 60 months admitted to a tertiary pediatric surgical service from July 2004 to July 2008. Children underwent age-definitive HIV testing and were followed up postoperatively for complications, length of stay and mortality.Three hundred and twenty-seven children were enrolled: 82 (23 %) HIV-infected and 245 (67 %) were HIV-unexposed. Eighty-four (26 %) children were malnourished, which was higher in the HIV-infected group [41 (50.0 %) vs. 43 (17.5 %), relative risk (RR) 2.9; 95 % confidence interval (CI) 2.0-4.1; p0.0001]. Three hundred and twenty-eight surgical procedures were performed. A similar number of major [28 (34.2 %) vs. 64 (26.1 %); p = 0.2] and emergency procedures [37 (45.1 %) vs. 95 (38.8 %); p = 0.34] were performed in each group. HIV-infected children had a higher rate of contamination at surgery [40 (48.7 %) vs. 49 (20 %); RR 2.43 (CI 1.7-3.4); p0.0001]. There were more complications in the HIV-infected group [34 (41.5 %) vs. 14 (5.7 %); RR 7.3 (CI 4.1-12.8); p0.0001]. The most common complications were surgical site complications 30 (55 %), followed by postoperative infections, 19 (34 %). Infections with drug-resistant organisms occurred more commonly in HIV-infected children [11/19 (58 %) vs. 2/13 (15 %); RR 3.8 (CI 1.3-14.2); p = 0.02]. The median length of hospital stay was longer in the HIV-infected group [4 (IQR 2-14) vs. 2 (IQR 1-4) days; p = 0.0001]. There was a higher mortality amongst the HIV-infected group [6 (7.3 %) vs. 0 (0 %); p0.0001].HIV-infected children have a higher rate of postoperative complications and mortality compared with HIV-unexposed children.

Liver disease in children in the developing world is a frequent occurrence, which is generally inadequately managed because of lack of resources. However, increasingly, there has been a demand for liver transplantation, where primary medical or surgical therapies have failed. The expertise and infrastructure required for a successful outcome are no different from those in more developed countries; if anything, the challenges are greater. Lack of deceased donors because of cultural and religious factors has driven the use of living donors. Short-term survival has generally been good, but long-term outcomes have rarely been reported. In this article, we review the experience of 2 centers at opposite ends of the continent and share our experience of slightly different settings and show that success can be achieved even in resource-reduced environments.

Objective: This observational pilot study investigated effects of aromatherapy massage in paediatric burn patients. Methods: The setting was a 17 beds level I burn unit in Cape Town, South Africa. Between January and October 2009 heart rates and respiratory rates of patients who underwent aromatherapy massage sessions were read before and after the sessions. Primary outcomes were decline in heart rates and respiratory rates, a sign of relaxation. Behavioural responses (sleep/awake state, facial expression, body posture) were documented as secondary outcomes. Results: A convenience sample of 71 paediatric burn patients (median age 3 years) underwent a total of 126 massage sessions. Mean heart rate decreased significantly from 118 (SD 20) to 109 (SD 21), t = 9.8, p < 0.001. Mean respiratory rate decreased significantly from 34 (SD 8) to 30 (SD 8), t = 10.2, p < 0.001. Most massage sessions (92.8%) elicited positive behaviour to the massage, e.g. the child fell asleep, calmed or asked to continue. Nine patients (7.2%) with a median age of 15 months who Conclusions: Aromatherapy massage seems to be a helpful nonpharmacological approach to reduce hospitalized paediatric burn patients' distress. Future studies with better research designs and validated outcome measures should confirm our findings. (c) 2012 Elsevier Ltd and ISBI. All rights reserved.

Spearman CWN, Goddard E, McCulloch MI, Hairwadzi HN, Sonderup MW, Kahn D, Millar AJW. Pregnancy following liver transplantation during childhood and adolescence. Pediatr Transplantation 2011: 15: 712–717. © 2011 John Wiley & Sons A/S. Abstract: More than 80% of pediatric transplant recipients will survive to reach adulthood, and many will consider having children. We report on outcomes and management of five pregnancies in four women undergoing orthotopic liver transplantation during childhood or adolescence and followed up at our Transplant Center. A retrospective clinical folder audit was performed. Mean age at transplantation was 13.3 ± 3.4 yr (range, 10–18 yr). Mean interval between transplantation and pregnancy was 15.4 ± 4.9 yr (range, 10–22 yr). Mean maternal age at conception was 28 ± 3.5 yr (range, 23–32 yr). Mean gestational age was 36.6 ± 1.7 wk. Mean birth weight was 2672 ± 249 g. Immunosuppression was cyclosporin based in three women and tacrolimus based in one woman. Pregnancy complications necessitating the induction of labor included fetal distress and rising maternal liver enzymes in two women, cholestasis of pregnancy and impaired renal graft function in one woman, fetal distress and preeclampsia in one woman. Modes of delivery were normal vaginal delivery in three women and cesarean section in one woman. No maternal or fetal deaths and no congenital malformations occurred. No episodes of rejection occurred during pregnancy. Two women experienced acute cellular rejection requiring an increase in baseline immunosuppression in the first year, following delivery. No graft losses occurred during a mean follow-up of 44 ± 17.9 months post-delivery. With careful management, pregnancy post-liver transplantation can have a successful outcome.

Intussusception is a recognised but unusual presenting feature of Burkitt lymphoma. We sought to identify the clinical features associated with intussusception in this setting, and assess the outcome following protocol directed chemotherapy.A retrospective case note review was performed on patients treated for Burkitt lymphoma at our institution between 1976 and 2010. Cases presenting with intussusception were identified from hospital records and oncology database.Fourteen of the 210 children seen with a diagnosis of Burkitt lymphoma during the study period (6.7%) developed intussusception. Median age was 6.1 years (range 2.5-10.9). Twelve patients presented with recurrent abdominal pain, and two patients with a jaw mass associated with endemic Burkitt lymphoma. Nine patients underwent a right hemicolectomy with ileo-colic anastomosis, and five had segmental small-bowel resections. Three patients had bone marrow involvement at diagnosis, two of whom died. All patients received chemotherapy. Median follow-up was 6.07 years (range 0.1-28.8).Small bowel lymphoma should be considered in children presenting with intussusception above the normal infantile peak age range. The presentation is often insidious, and complete obstruction may not be apparent. However, when surgically resected, the majority can achieve a good outcome with additional chemotherapy.

The aim of this study was to assess and analyse the attitudes and beliefs of medical students regarding organ donation, procurement, and transplantation. Medical students at the University of Cape Town were prospectively surveyed using a self-administered questionnaire. There were 346 study participants; the mean age was 21 (range 18-33) yr, 38% were male and 62% was female. Only 8% of respondents were registered donors; clinical and white students constituted the majority of this group. Of the 315 "non-donors," the main reason for not donating was "I have not really thought about organ donation" (59%). Most students (91%) would accept an artificial organ; and 87% and 52% of students would accept human and animal organs respectively. Muslim students (11%, p

Background: An increasing number of HIV-infected children require a surgical procedure. The aim of this study was to investigate factors associated with the development of complications in HIV-infected children undergoing surgery. Methods: A prospective study of HIV-infected children younger than 60 months undergoing surgery at a tertiary referral pediatric hospital from July 2004 to July 2008 was performed. Children were followed postoperatively for the development of complications, length of stay, and mortality. Results: Eighty-two HIV-infected children, with a median age of 11.5 months (interquartile range, 6-24 months), were enrolled. Most (68; 82.9%) had World Health Organization stage 3 or 4 HIV disease, 72 (88%) had Centers for Disease Control and Prevention stage 2 or 3 disease, and 60 (73%) were taking highly active antiretroviral therapy. Half (41; 50%) were underweight, 37 (45.1%) underwent emergency surgery, 28 (34.2%) required major surgery, and 40 (48.7%) had surgical site contamination at the time of surgery. The median length of hospital stay was 4 days (interquartile range, 2-14 days), and in-hospital mortality was 6 (7%). Thirty-four (42%) children developed 37 complications. On univariate analysis, malnutrition, HIV stage, or type of surgery was not associated with development of complications. In contrast, young age (6 vs 13.5 months; P = .0004), low hemoglobin (9.6 vs 10.5 g/dL; P = .04), or having a major procedure (14 [42%] vs 9 [18%]; P = .03; relative risk, 2.2 [1.2-4.8]) was associated with complications. On logistic regression, younger age (odds ratio = 4.3; P = .004; 95% confidence interval, 1.6-11.9) and major surgery (odds ratio = 6.8; P = .001; 95% confidence interval, 1.5-31.4) were associated with development of a complication. Conclusion: Young age and major surgery were the main predicators of complications in HIV-infected children undergoing surgery.

Background/ Purpose Primary hepatic sarcomas are rare and account for about 13% of primary hepatic neoplasms. There are few reported series of pediatric hepatic sarcomas, and the aim was to review our experience. Methods A retrospective analysis of cases managed from 1988 to 2007 by the pediatric liver unit in Birmingham, UK, was conducted. Results Nineteen children were identified. These presented with sudden abdominal pain (n = 6), obstructive jaundice (n = 3), incidental mass (n = 3), and chronic pain/distension (n = 3). Vascular involvement was identified in 3, and 6 had pulmonary metastases. Three patients had primary resection, and 3 only a biopsy. Thirteen had a biopsy followed by chemotherapy and resection. Surgery included extended hepatectomy (n = 11), hepatectomy (n = 3), and nonanatomical resections (n = 2). There was 1 major intraoperative complication. Median inpatient stay was 7 days. One biliary leak developed 4 weeks postoperatively. Five of the 16 patients who underwent resection of the primary tumor died. Eleven were alive at a median follow-up of 3 years. Conclusion This is a challenging group of patients. Local control remains pivotal to successful treatment. Good results can be achieved in a specialist center with multidisciplinary approach.

Educating physicians about transplantation during undergraduate training can improve organ procurement rates. The aim of this study was to evaluate and analyze the knowledge of medical students regarding transplantation.A previously validated self-administered anonymous questionnaire was distributed to all medical students.Of the 346 participants, 217 (63%) were preclinical students. Their mean age was 21 years (range, 18-33) and 62% were women. Twenty-nine (8%) students were registered as organ donors. One third of all study participants received formal transplantation teaching; a greater proportion of clinical students received teaching compared with the preclinical group (52% vs 22%, P.05). Knowledge was frequently reported for kidney (88%), liver (81%), bone marrow (78%), and heart (76%) transplantation. Small Intestine (13%), pancreas (9%), and pancreatic islets (4%) were the least recognized organs/tissues. Ninety-six percent and 62% of respondents were aware of kidney and liver living-donor transplants, respectively; the 27% of students with an interest in a surgical career had better knowledge of living-donor transplantation (P.05). Only 22 (6%) students knew which solid organ transplants were performed in South Africa.Medical students have limited knowledge about organ transplantation; there is a need for educational intervention early in the medical curriculum.

Each set of conjoined twins presents a unique challenge, which centers on the ability to separate and if necessary reconstruct shared organs and to achieve subsequent skin cover of the often very large residual defect after completion of the separation. This report describes the use of a bioprosthetic Permacol derived from porcine dermal collagen to reconstruct the chest and abdominal wall.