A comparison of clinical protocols for assessing postoperative fecal continence in anorectal malformation

BACKGROUND

We compared four protocols for assessing fecal continence (FC) in anorectal malformation (ARM).

METHODS

Of 111 ARM cases we treated by anoplasty from 1995 to 2007, 59 have been followed up for more than 4 years [male high (n = 23), male low (n = 12), female high (n = 7), and female low (n = 17)] and 27 for more than 7 years [male high (n = 11), male low (n = 5), female high (n = 5), and female low (n = 6)]. FC was assessed in these 86 cases using each of the four protocols; the Kelly score (0-6 points), the Japanese Study Group of Anorectal Anomalies (JSGA) score (0-8 points), the Holschneider score (0-14 points), and our original score (0-10 points). Results were re-classified into four outcome levels (good, fair, poor, very poor) for direct comparison.

RESULTS

Outcome was different by two levels (i.e., good vs. very poor) in 7 (8.1%) assessments and different by one category (i.e., fair vs. poor) in ten assessments (11.6%). Outcome was different most often in male high ARM cases and JSGA scores were most divergent.

CONCLUSIONS

Fecal continence in male high ARM appears to be assessed inconsistently and a review of protocols may be of value to standardize clinical assessment and enhance reliability.

Visualization of enteric neural crest cell migration in SOX10 transgenic mouse gut using time-lapse fluorescence imaging

BACKGROUND

Enteric neural crest cells (ENCCs) were labeled with VENUS, an enhanced green fluoroscein protein, to record their migration in genetically engineered transgenic (SOX10-VENUS) mice.

MATERIALS AND METHODS

Pregnant SOX10-VENUS mice were killed on day 12.5 of gestation. The colorectum was excised from each embryo (n = 20) and placed in tissue culture medium. Time-lapse images captured using fluorescence microscopy at 10-minute intervals for 3000 minutes were compiled into a video to display ENCC migration.

RESULTS

At 0 minutes, VENUS(+) ENCC were observed to be clustered in the cecum and proximal colon (vagal ENCC), and similar cells were also seen in the rectum/sacrum (sacral ENCC). After 500 minutes, vagal VENUS(+) ENCC had migrated caudally from the proximal colon to the midcolon, reaching the distal colon after 800 minutes. Sacral VENUS(+) ENCC had migrated rostrally and transversely by 1250 minutes and had integrated with vagal ENCC by 2500 minutes.

CONCLUSION

We recorded the actual rostral-to-caudal migration of vagal ENCC, caudal-to-rostral migration of sacral ENCC, and their integration in the developing mouse hindgut. Such direct evidence of ENCC migration may further elucidate understanding of ENCC development, thus providing insight into the histopathology of bowel dysmotility disorders.

Intraabdominal laparoscopy-assisted "open" vessel ligation of testicular vessels: a potential treatment for varicocele

AIM

We tested our laparoscopy-assisted "open" ligation (LOL) technique on testicular vessels.

METHODS

We ligated the left testicular artery and vein (TAV) in 8-week-old male Wister rats using LOL (LOL group; n=10) or laparotomy (open group; n=10). In LOL, a 0-degree laparoscope was introduced through a 5-mm epigastric trocar. A 3-mm grasper was used to expose the left TAV. A lapa-her-closure (LHC) needle loaded with 3-0 SurgiPro was directly inserted into the left lower quadrant where the left TAV should be and advanced under the vessels, and the suture material was released leaving one end outside. The LHC was then withdrawn a little and advanced again over the vessels to grasp the end of the suture material just released to bring it outside. This was proximally repeated. The two ends of both sutures were conventionally tied outside, and the knot was passed through the insertion site and tightened around the vessels. In the open group, the left TAV were ligated using two 3-0 SurgiPro ties. In both groups, the right side was left intact. All rats were sacrificed 2 weeks postoperatively, and both testes were examined with hematoxylin and eosin.

RESULTS

Treatment time was 5-7 minutes for LOL and 7-8 minutes for the open group. Postoperative recovery was uneventful. No adhesions were present between the ligated vessels and bowel in any rat. Histopathology of all left testes showed coagulative necrosis of germinal cells and seminiferous tubules; all right testes were normal.

CONCLUSION

LOL appears to be as effective as open ligation and may find application for treating varicocele.

Pulmonary artery size has prognostic value in low birth weight infants with congenital diaphragmatic hernia

AIM

The aim of this study was to examine the relationship between birth weight, pulmonary artery (PA) size, and outcome in congenital diaphragmatic hernia (CDH) to establish if PA size has prognostic value.

METHODS

The subjects for this study were 39 consecutive left-sided CDH patients treated at our institution according to the same protocol from 2002 to 2009. Other CDH patients with concurrent anomalies that eventually caused death or who became symptomatic more than 6 h after birth were excluded. Birth weight was used to create two groups; low birth weight (LBW; birth weight ≤ 2,500 g; n = 15) and normal birth weight (NBW; birth weight >2,500 g; n = 24). Right PA (RPA) and left PA (LPA) were measured by echocardiography (EC) during late pregnancy (fetal; gestational age (GA): 32-34 weeks), and on days 0, and 2 of life and compared.

RESULTS

Mean birth weights were significantly different between the two groups; however, gender, mean GA, and outcome were similar. In LBW survivors, RPA was significantly larger than in non-survivors. PA size was not related to outcome in NBW.

CONCLUSION

We are the first to show that RPA size has prognostic value in low birth weight infants with left-sided CDH.

A prospective analysis of endoloops and endostaples for closing the stump of the appendix in children

AIM

The aim of this study was to compare endoloops and endostaples for closing the stump of the appendix during laparoscopic appendectomy (LA) for uncomplicated appendicitis in children.

METHODS

All LA performed for appendicitis from 2005 to 2009 were analyzed prospectively. Cases of complicated appendicitis such as perforated appendicitis or intra-abdominal abscess were excluded, leaving 75 cases closed with loops and 81 cases closed with staples. Choice of technique was determined by the attending surgeon's preference. All patients were managed according to the same pre-, intra-, and postoperative protocols.

RESULTS

There were no significant differences between mean age at surgery, gender ratio, preoperative mean white blood cell count and mean C-reactive protein, histopathologic findings, mean duration of surgery, and mean hospitalization. There were no intra-operative complications in either group, but one loop case required conversion to open surgery (P = NS). There were no significant differences in the incidences of intra-abdominal abscess, transient ileus, small bowel obstruction, and wound infection. The postoperative readmission rate for management of complications was 4.0% for loop cases and 2.5% for staple cases (P = NS). Overall, using staples for a standard LA (anesthesia and stump closure) was U.S. $405 more expensive than when loops were used.

CONCLUSION

This is the first prospective study comparing endoloops with endostaples for closing the stump of the appendix during LA for uncomplicated appendicitis in children. Although stapling proved to be more expensive, the choice of technique should reflect the surgeon's experience and confidence to ensure that the patient has the safest possible LA.

Open versus laparoscopic treatment for pan-peritonitis secondary to perforated appendicitis in children: a prospective analysis

PURPOSE

Reports on laparoscopic treatment (LT) of peritonitis secondary to perforated appendicitis (PA) in children often include localized peritonitis/appendiceal mass, without specifically referring to pan-peritonitis (PP). This study compared LT with open treatment (OT) in only those patients with PP secondary to PA.

METHODS

PP was defined as generalized abdominal rigidity on presentation with purulent material intraoperatively found throughout the entire abdominal cavity. Based on this definition, we identified 23 cases of PP secondary to PA from all our cases of appendicitis from 2004 to 2008 and prospectively collected data.

RESULTS

Surgical intervention was LT in 12 cases and OT in 11 cases. Appendectomy was successful in all cases without intraoperative complications. Mean age at surgery, sex ratio, preoperative mean white blood cell count, and C-reactive protein were similar. Mean operative time was 119 minutes for LT and 107 minutes for OT (P = NS). Mean volume of saline used for peritoneal lavage was 2730 mL for LT and 2950 mL for OT (P = NS). Duration of analgesic usage was significantly shorter in LT (P = 0.01). Postoperative wound infections were significantly less in LT (P = 0.04: LT 0, OT 4/11). Adhesive bowel obstruction occurred in one LT case and three OT cases (P = NS); none required surgery. There were two cases of intraabdominal abscess in each group, all were conservatively treated. Time taken to become afebrile, for white blood cell count and C-reactive protein to normalize, for intravenous antibiotics to be ceased, and for oral feeding to be commenced were not significantly different. Mean hospitalization was significantly shorter for LT (P = 0.04).

CONCLUSIONS

LT would appear to be superior for the treatment of PP secondary to appendicitis in children and would even seriously consider it as the procedure of choice.

Ectopic pancreas presenting as a submucosal gastric tumor: case report and literature review

Ectopic pancreas is of little clinical significance. We report a case of ectopic pancreas in a 2-year-old girl presenting as a heterogeneous solid submucosal tumor of the posterior wall of antrum proximal to the pylorus, treated by distal gastrectomy and Billroth I reconstruction. We reviewed 15 cases in the English literature.

Indications for thoracoscopic repair of congenital diaphragmatic hernia in neonates

PURPOSE

We reviewed 26 consecutive cases of congenital diaphragmatic hernia (CDH) prospectively to establish selection criteria for successful thoracoscopic CDH repair (TR).

METHODS

Five preoperative deaths were excluded, leaving 21 subjects. TR was only considered once pulmonary hypertension (PH) improved on echocardiography, and if cardiopulmonary status was stable in the decubitus position in the neonatal intensive care unit (NICU) under conventional mechanical or high-frequency oscillatory ventilation (HFOV) with/without nitric oxide (NO) for at least 10 min as a marker for tolerating surgery and manual ventilation was possible for transfer to the operating room. All other patients had open repair (OR).

RESULTS

8/21 had TR and 13/21 had OR. There were significant differences between TR and OR for prenatal diagnosis (37.5 vs. 84.6%, p < 0.05) and earlier surgery (1.4 ± 0.8 vs. 2.5 ± 1.1 days after birth, p < 0.05), respectively. Intraoperative HFOV was required in all OR and 3 TR (p < 0.01). NO was required in 1 TR and 10 OR (p < 0.01). Organ herniation was significantly less in TR (50 vs. 100%, p < 0.01 for stomach; 0 vs. 54%, p < 0.05 for liver). Three TR required conversion to OR because of technical difficulties. One OR died from deteriorating PH.

CONCLUSIONS

Our selection criteria for TR would appear to be safe and reasonable.

Comparison of anorectal angle and continence after Georgeson and Peña procedures for high/intermediate imperforate anus

AIM

The anorectal angle (AA) influences defecation after pull-through (PT) for imperforate anus (IA). We compared postoperative AA and continence after Georgeson's laparoscopy-assisted colon PT (GPT) and Peña's posterior sagittal anorectoplasty (PSARP) for high/intermediate-type IA.

METHODS

We reviewed 33 high/intermediate-type IA cases (20 GPTs and 13 PSARPs) prospectively. All had colostomy initially as neonates. Anorectal angle was measured as the angle between the rectum and the anal canal on barium enema. A fecal continence evaluation questionnaire (FCEQ) consisting of 5 parameters (frequency of defecation, staining/soiling, perianal erosion, anal shape, and requirement for medication; maximum score = 10) was evaluated in 28 cases (15 GPTs and 13 PSARPs) followed up for more than 3 years.

RESULTS

Mean age at PT was similar (6.6 months for GPT and 6.3 months for PSARP; P = not significant). There was no significant difference in mean AA. The FCEQ scores for GPT were generally higher throughout the study and significantly better from 3 years postoperatively (P < .05).

CONCLUSIONS

We are the first to confirm that effective AA similar to PSARP can be achieved after GPT, although FCEQ would suggest that GPT has less detrimental functional impact.

Laparoscopic splenopexy and gastropexy for wandering spleen associated with gastric volvulus

Wandering spleen is not a common condition in childhood and has been described only rarely in association with gastric volvulus. The authors report the successful management of wandering spleen associated with gastric volvulus using laparoscopic splenopexy and gastropexy in a 4-year-old girl.

Anal canal duplication: experience at a single institution and literature review

PURPOSE

Anal canal duplication (ACD) is an extremely rare congenital intestinal anomaly. There are not many reports in the English literature, with just a few from each institution. The aim of this study was to describe the clinical characteristics, surgical treatment, and outcome of ACD in pediatric cases at a single institution.

METHOD

The medical records of ACD patients we treated from 1988 to 2009 were reviewed retrospectively.

RESULTS

There were ten cases, all females. Nine were asymptomatic without any history of perianal infection, identified only incidentally at routine check-up although one case had severe periproctal abscess. Mean age at diagnosis was 6 months (range 0-47 months). Concurrent pathology present were meningocele and presacral mass in one, presacral mass in one, and renal hypoplasia in one. In all cases, an extraneous perianal orifice opening in the midline posterior to the native anus was present, but in one case it was only identified at surgery because it had closed secondary to severe inflammation preoperatively. All had preoperative radiologic investigations, such as magnetic resonance imaging (MRI), barium contrast studies, and fistulography. Mean age at surgery was 14 months (range 1-48 months). All underwent surgical removal of the anal canal duplication, eight through a perineal approach and two through a posterior sagittal approach, depending on the length of the duplicated anal canal and the presence of concurrent anomalies. Histopathology of the excised anal canals showed squamous epithelium in all cases. The postoperative course was uneventful in all cases and all are well without complications at mean follow-up of 9.1 years (range 5-19 years).

CONCLUSION

This is the largest series of ACD at a single institution reported to date. For the clinician faced with an extraneous perianal orifice located posteriorly in the midline with respect to the native anus, ACD should be suspected. The treatment of choice in children is complete excision (perineal/posterior sagittal approach), even if asymptomatic. Morbidity is minimal, and outcome is excellent.

Intraoperative measurement of rectourethral fistula: prevention of incomplete excision in male patients with high-/intermediate-type imperforate anus

INTRODUCTION

We report a novel technique to measure the length of the rectourethral fistula (RUF) in male patients with high-/intermediate-type imperforate anus during laparoscopically assisted anorectal pull-through (LAARP) to prevent incomplete excision.

METHOD

During LAARP for RUF in 5 male patients (mean age, 4.6 months; prostatic in 3, bulbar in 2), the RUF was dissected carefully close to the urethra and opened; and a fine catheter with 10-mm calibrations was inserted by the laparoscopic surgeon until it was seen to emerge at or near the verumontanum by another surgeon performing cystoscopy. The laparoscopic surgeon then measured the distance from the point where dissection was ceased at the rectal end to the urethral orifice. The RUF was dissected free from the prostate for exactly this length, tied, and excised; and colon pull-through was performed to finish LAARP.

RESULT

Rectourethral fistulae ranged from 5 to 15 mm and were much longer than expected. All dissections were uncomplicated without any injury to the urethra, and postoperative courses were unremarkable. At mean follow-up of 11 months, urination is normal in all without evidence of residual fistula.

CONCLUSION

Knowing the exact length of the RUF facilitates safe and complete excision in an otherwise blind situation.

Intraoperative endoscopy during choledochal cyst excision: extended long-term follow-up compared with recent cases

INTRODUCTION

We routinely perform intraoperative endoscopy (IOE) of the intrahepatic bile duct (IHBD) and intrapancreatic bile duct (IPBD) with a pediatric cystoscope during excision of choledochal cyst (CC). Here we compare extended long-term follow-up patients with a series of recent cases.

METHODS

We compared 25 CC patients treated over the past 5 years (group 1) with 69 CC patients treated between 1986 and 1998 and followed up for more than 10 years (group 2), focusing on stone formation.

RESULTS

In group 1 (mean follow-up, 2.6 years) IOE identified IHBD debris in 7 (28%) of 25 and IPBD protein plugs in 9 (36%) of 25. In group 2 (mean follow-up, 14.6 years) IOE identified IHBD debris in 11 (16%) of 69 and IPBD protein plugs in 17 (25%) of 69. There was no relation between type of CC and incidence of IHBD debris or IPBD protein plugs. The incidence of postoperative stones to date is 0% in group 1 and 2.9% in group 2, rates far lower than those reported in the literature.

CONCLUSIONS

We attribute our lower incidence of stones directly to IOE and recommend that it be performed routinely during cyst excision. It is simple, is effective, and improves outcome.

Neuronal immaturity in normoganglionic colon from cases of Hirschsprung disease, anorectal malformation, and idiopathic constipation

AIM

Immaturity of neurons in normoganglionic colon in Hirschsprung disease (HD), anorectal malformation (AM), idiopathic constipation (IC), and normal controls (C) was assessed using polysialyated neural cell adhesion molecule.

METHODS

Polysialyated neural cell adhesion molecule immunoreactivity in 3 sections of normoganglionic colon from HD (n = 48), AM (n = 25), IC (n = 36), and C (n = 18) were scored semiquantitatively according to age; 1 day to 11 months (G1), 1 to 4 years (G2), and 5 years and older (G3).

RESULTS

Neurons in all specimens appeared mature irrespective of age on hematoxylin-eosin stain. Polysialyated neural cell adhesion molecule was positive (immaturity) in all specimens during G1 (1.34 in HD, 1.60 in AM, 0.89 in IC, and 1.59 in C) and decreased significantly with age in C (0.34* for G2, 0.25* for G3; *P < .01), decreased after 4 years old in IC (0.93 for G2, 0.10(#) for G3; (#)P < .05), decreased gradually in AM (1.10 for G2, 0.75( section sign) for G3; ( section sign)P < .05), but remained strongly positive in HD (1.34 for G1, 1.26 for G2, and 1.21 for G3; P = not significant), which after 4 years was significantly higher than C (P < .05).

CONCLUSION

Postoperative colonic dysmotility may be because of persistence of immature neurons in HD and impaired maturation of neurons in AM and IC.

Immature enteric neurons in Ncx/Hox11L.1 deficient intestinal neuronal dysplasia model mice

AIM

The Ncx/Hox11L.1 gene is required for adequate development of enteric neurons in mice and Ncx/Hox11L.1 deficient (Ncx-/-) mice are used as a model for human intestinal neuronal dysplasia (IND) because of similar histopathology (hyperganglionosis), however, some 50% of Ncx-/- mice develop megacolon with a caliber change in the proximal colon, and die when 21-35 days old. We used polysialylated neural cell adhesion molecule (PSA-NCAM) to examine the maturity of enteric neurons in Ncx-/- mice to further understand the etiology of IND.

METHODS

PSA-NCAM immunoreactivity was measured in specimens taken 1 cm proximal to the ileocecal valve (ileum), 1 cm distal to the ileocecal valve (proximal colon), and 1 cm proximal to the anus (distal colon) from 63 mice (Ncx-/-: n = 14, Ncx+/-: n = 30, and Ncx+/+: n = 19) on days 14 (D14), 21 (D21), and 27 or later (>D27).

RESULTS

PSA-NCAM was positive (indicating immaturity) in proximal colon (submucosal and myenteric plexuses) from 8/14 (57%) Ncx-/- mice (2/4 on D14, 4/6 on D21, and 2/4 on >D27) and from 5/30 (17%) Ncx+/- mice (0/2 in D14, 2/13 in D21, and 3/15 in >D27). PSA-NCAM was negative (indicating maturity) in all other specimens. The incidence of PSA-NCAM positive neurons in Ncx-/- appeared to be correlated with the mortality rate seen in IND mice.

CONCLUSIONS

Our data suggest that colonic dysmotility and pathology seen in Ncx-/- mice may be due to persistence of immature neurons in the proximal colon, which could also be the case in human IND and warrants further investigation.

Collis-Nissen fundoplication using a computer-powered right angle linear cutting stapler in children

We reviewed our clinical experience of using a computer-powered right angle linear cutter (CPRALC) for Collis-Nissen fundoplication (CNF) in three children with gastroesophageal reflux (GER) or failed Nissen associated with short esophagus. Case 1 was a 13-month-old female with persistent GER after type-C esophageal atresia repair. Case 2 was a 2-year-old female with dysphagia secondary to fundic wrap migration after laparoscopic Nissen. Case 3 was a 3-year-old male with post type-C esophageal atresia repair, dysphagia secondary to fundic wrap migration after open Nissen. All had short esophagus confirmed pre- or intra-operatively. After the esophagus was mobilized, Collis vertical gastroplasty was performed using CPRALC parallel to the lesser curve to elongate the esophagus. Nissen fundoplication was performed loosely around the neo-esophagus. There were no intra- or post-operative complications, although case 3 still has mild dysphagia, requiring dilatation. This is the first report of CNF performed using CPRALC in children. It would appear to be safe and effective for treating children with GER or failed Nissen associated with short esophagus.

Outcome of stoma closure in children: a comparison of laparoscopy-assisted and conventional open techniques

Laparoscopy-assisted stoma closure (LASC; n = 28) and conventional open closure (CSC; n = 24) were compared by assessing outcome in 52 consecutive cases of stoma closure (SC) in children.

Bone mineral density as a marker for the timing of pectus bar removal after Nuss procedure

Bone mineral density (BMD) was measured to establish the optimal timing for pectus bar (PB) removal after the Nuss procedure (NP). Twenty-three patients who had PB removal after NP were assessed according to: age at PB insertion/removal, duration of insertion, clinical outcome and BMD. BMD was measured just prior to insertion (in-BMD) and just prior to removal (out-BMD) and %BMD was determined by dividing subject BMD by BMD for age-matched controls. Age at insertion ranged from 4.3-2.7 years and age at removal ranged from 6.3-14.1 years. Duration of insertion ranged from 1.4-3.9 years. There were two cases of recurrence after NP. In these cases, PB insertion occurred at 5 and 4 years, and removal was at 6 and 8 years respectively and both BMD and %BMD were below normal. In the nine cases with no recurrence, PB removal occurred between 6-8 years old; BMD was normal, and %BMD was higher than in the two cases with recurrence. BMD and %BMD would appear to be valuable markers for the timing of PB removal.

Postoperative cystolithiasis in a case of cloacal malformation treated using an endoscopic pneumatic lithotripter through a combination of percutaneous and transurethral approaches

Long-term management of patients with cloacal malformation is still challenging to pediatric surgeons and urologists. Recently, we experienced postoperative cystolithiasis in a case of cloacal malformation. All stones were removed successfully by using an endoscopic pneumatic lithotripter through a combined approach from the cystostomy and the narrow reconstructed urethra. To the best of our knowledge, this was the first time for this combined approach to be applied in a patient with cloacal malformation. It has a particular appeal because it is simple, safe, and minimally invasive.

Gastric outlet obstruction possibly secondary to ulceration in a 2-year-old girl: a case report

Gastric outlet obstruction due to ulceration is extremely rare in childhood. We report a case of gastric outlet obstruction possibly secondary to peptic ulceration and our surgical management. Our approach, without vagotomy or antrectomy, would appear to be a safe and effective.

Rectal mucosal dissection during transanal pull-through for Hirschsprung disease: the anorectal or the dentate line?

PURPOSE

Both the dentate line (DL) and anorectal line (ARL) are anatomic landmarks for rectal mucosal dissection during transanal pull-through for Hirschsprung disease. We compared outcome after rectal mucosal dissection commencing above the DL (DL group; n = 8) with outcome after rectal mucosal dissection commencing on the ARL (ARL group; n = 6) with normal babies (Cont group; n = 10).

METHODS

Rectal mucosal dissection commenced on the ARL in the ARL group and at various levels (0-10 mm) above the DL in the DL group. Outcome was assessed prospectively for 6 months using a standard structured questionnaire.

RESULTS

Subject demographics were not significantly different. Differences in frequency of motions between the ARL and Cont groups were not statistically significant after 3 months of age, but the DL group had significantly more motions than the other 2 groups after 4 months of age (P < .01). At 6 months of age, fecal staining was 17% in the ARL group, 63% in the DL group, and 0% in the Cont group. Anal shape was normal in the ARL and Cont groups, but 50% of the DL group had visible anal mucosa.

CONCLUSION

Bowel function in the ARL group is similar to normal, and because the ARL is easily identifiable without the need for subjective interpretation, we recommend using the ARL as a landmark for rectal mucosal dissection during transanal pull-through for Hirschsprung disease.

Congenital diaphragamatic hernia associated with aortic coarctation: a case report

Congenital diaphragmatic hernia associated with cardiac anomalies is a major therapeutic challenge. We report a case of Congenital diaphragmatic hernia associated with coarctation of the aorta.

Repair of hypospadias with severe chordee using a long, wide, U-shaped flap that preserves ventral penile tissues intact for second-stage urethroplasty

PURPOSE

The aim of the study was to report a new technique for repairing hypospadias with severe chordee (HSC).

METHODS

Our new technique involves making a long, wide, U-shaped incision on the ventral penis from the coronal sulcus to very distal to the meatus and dissecting to create a flap (U-flap). During dissection, the urethra is divided just proximal to the meatus. After release of chordee, the U-flap is returned to the ventral penile shaft and sutured in place. A buttonhole made distally in the U-flap is anastomosed to the cut end of the urethra to create a neomeatus. Snodgrass urethroplasty is performed 6 to 18 months later. We have treated 11 patients with HSC (mean age, 22.3 months) using this technique.

RESULTS

Postoperatively, all U-flaps were viable. The neomeatus appeared to be more proximal because the penis was straighter. Urethroplasty using the central part of the U-flap was uncomplicated by scar tissue and successful in all cases. After a mean follow-up of 15.7 months, all patients have satisfactory penises without stenosis or diverticulum, although 1 had fistula.

CONCLUSION

Our U-flap technique allows the ventral penis to be preserved intact without scarring for second-stage urethroplasty and as a result is well suited for treating HSC.

Significance of pulmonary artery size and blood flow as a predictor of outcome in congenital diaphragmatic hernia

AIM

To determine if pulmonary artery size and blood flow have prognostic value in congenital diaphragmatic hernia (CDH).

METHODS

Twenty-eight consecutive left-sided CDH patients treated according to a standard protocol with high frequency oscillatory ventilation (HFOV) + nitric oxide (NO) had right and left pulmonary artery (RPA, LPA) diameters, LPA/RPA diameter (L/R) ratios, and PA blood flows examined by echocardiography (EC) on days 0, 2, and 5 after birth and compared prospectively.

RESULTS

Twenty-two patients (78.6%) survived. Of these, 15 required NO (NO-s), and seven did not (non-NO-s). All six patients that died required NO (NO-d). RPA in the NO-d group was significantly smaller than in the NO-s or non-NO-s groups on day 0 (2.90 +/- 0.41 vs. 3.40 +/- 0.49 or 4.01 +/- 0.43; P < 0.01, respectively). LPA in the NO-d group was significantly smaller than in the non-NO-s on day 0 (2.13 +/- 0.45 vs. 3.39 +/- 0.34; P < 0.01). L/R ratios in NO subjects were significantly smaller (NO-s 0.74 +/- 0.11; NO-d 0.73 +/- 0.11) than in non-NO-s subjects (0.84 +/- 0.03) on day 0 (P < 0.01). PA diameters and L/R ratios did not change significantly from day 0 to day 5 in all three groups. There was LPA flow on day 0 in all non-NO-s subjects, but none in all NO subjects. In the NO-s group, LPA flow was confirmed in 87% (13/15) on day 2 and in 100% on day 5, however, there was no LPA flow from day 0 to day 5 in any of the NO-d group.

CONCLUSION

Our data indicate that PA diameters on day 0 and LPA flow are strongly prognostic in left-sided CDH and L/R ratio would appear to be a simple highly reliable indicator of the necessity for NO therapy.