Search

Purpose Neurologically impaired children run a 12% to 45% risk of recurrent gastroesophageal reflux (GER) after fundoplication. Elimination of the reflux by "rescue" total esophagogastric dissociation (TEGD) encouraged us to use it also as a "primary" form of antireflux surgery in this group of patients. Methods Twenty-six (14 male, 12 female) patients underwent TEGD between 1994 and 2004, of which 16 were primary and 10 were rescue procedures for failed fundoplication. Results There was no operative mortality and postoperative complications were limited to one subphrenic collection, one esophagojejunal dehiscence, and one small bowel hernia beneath the jejunal Roux loop. Gastrostomy feeding was usually established by 3 to 5 days and the mean hospital stay was 10.2 days (range, 6-18 days). At follow-up of 7 months to 11 years, there was no recurrence of GER. Four late deaths were unrelated to the surgery. The children's nutritional status improved with the mean weight standard deviation score showing a statistically significant increase from −2.63 preoperatively to −0.96 postoperatively (Wilcoxon's signed rank P value ≤.005). Conclusions Total esophagogastric dissociation is a safe definitive solution for GER because it eliminates all risk of recurrent reflux. We therefore feel that TEGD can be used as a primary treatment of choice for severely neurologically impaired patients who are experiencing GER and are completely dependant on tube feeds.

Sclerosing encapsulating peritonitis (SEP) is a rare cause of bowel obstruction, most commonly associated with chronic ambulatory peritoneal dialysis. It has not previously been reported as a complication of ventriculoperitoneal (VP) shunts. We describe the clinical features of shunt-associated SEP and the important management considerations. Two children presented with small bowel obstruction after long-standing VP shunting of hydrocephalus. Neither had a history of recent shunt infection/revision nor evidence of shunt malfunction. In each case, the bowel was "cocooned" in a fibrous sheath with a notable absence of parietal adhesions. Both children were managed by meticulous adhesiolysis accompanied by shunt exteriorization. Both had prolonged ileus and required total parenteral nutrition. One required further laparotomy at which adhesiolysis was accompanied by irrigation with icodextrin 4% and systemic high-dose methylprednisolone. Weaning of steroids was accompanied by the introduction of azathioprine. A notable feature of intestinal obstruction because of SEP was severe pain despite adequate decompression. The restrictive "cocoon" that envelops the bowel prevents bowel dilatation and accounts for atypical radiologic findings in these cases.

UNLABELLED Twenty-four neonates presented with signs of testicular ischaemia over a 13-year period. They had a mean birth weight of 3.706 kg. The right testicle was affected in 13, the left in 9 and there was bilateral torsion in 2 babies. Two babies had no twist in the cord, but the testicles were nonviable macroscopically and microscopically. Twenty-one babies had primary exploration revealing necrotic testes in all patients and they underwent orchidectomies. The other three babies had conservative management and the affected testes had atrophied on follow-up. Sixteen babies had contralateral orchidopexy. Doppler ultrasound scans were reported as normal in 2 of 13 babies who had scans. No testes were salvaged following surgery. CONCLUSION The incidence of testicular torsion in the neonatal period was calculated as 6.1 per 100,000 live births. No testis was salvaged following surgery in our series of 24 patients. This dismal outcome underlines that immediate surgical exploration, although commonly performed, rarely saves torted testes.

A 3-year-old girl who had recently completed treatment for acute lymphoblastic leukaemia presented with a rapidly evolving painful black lesion on her right pinna (fi gure) and associated extensive erythema and swelling. Ecthyma gangrenosum was diagnosed. Despite treatment with antibiotics and granulocyte colony-stimulating factor, the swelling and erythema continued to spread: resection of the aff ected area was undertaken. Histological examination confi rmed ecthyma gangrenosum. Successful reconstruction of the pinna was subsequently done. Ecthyma gangrenosum is a skin infection characterised by a necrotic centre surrounded by an erythematous halo. The infection is more common in children than adults, and is particularly common in immuno compromised individuals: indeed, it can be the fi rst indication of an underlying serious illness. Ecthyma gangrenosum is classically caused by Pseudomonas aeruginosa, but can be caused by a wide range of other bacteria. The lesion commonly arises in the gluteal or perineal regions but can occur at any site, as demonstrated by this case. Initial treatment consists of antimicrobials, but surgical excision may be required. Rapid recognition and treatment are essential to avert substantial tissue destruction. Isolated ecthyma gangrenosum has an estimated mortality rate of up to 25%—which is greatly increased by concomitant sepsis. Lancet 2007; 369: 1540

This study aimed to characterize the disturbance of gastric electrical control activity in chronic intestinal pseudoobstruction (CIP) and to determine whether surface electrogastrography (EGG) could be used to diagnose the presence and type of CIP. Gastric electrical control activity was recorded for 30 min in each of the fasting and fed states by EGG in 14 adults with CIP proven on clinical, radiological, and histological grounds, and in 14 age- and sex-matched controls. Electrical activity was recorded from four pairs of Ag-AgCl bipolar skin electrodes, the captured signal amplified and digitalized, and running spectral analysis performed. The dominant frequency and power of spectrum were calculated using a sequence of computerized algorithms. Results were correlated with the known pathological diagnoses [visceral myopathy (M), N = 7; visceral neuropathy (N), N = 4; undifferentiated (U), N = 3]. Dysrhythmias were present in 13 of 14 patients. Tachygastria (electrical control activity frequency5 cycles/minute) and a normal amplitude response to food, was seen in five patients (N = 4, U = 1). Irregular continuous activity without a dominant frequency or bradyarrhythmia, together with a diminished electrical response activity (ERA) to food, were found in six patients (M = 5, U = 1). Mixed abnormalities were seen in two patients (M = 1, U = 1), and normal activity with a clear dominant frequency of 3 cycles/minute was present in only one patient (M = 1). This noninvasive technique is both sensitive and specific in providing evidence of a dysrhythmia in patients with CIP and discriminates between primary pathologies. EGG may prove diagnostically useful in these disorders and may provide insight into the disturbance of electrical control activity.