Periumbilical necrotizing fasciitis in the newborn

Periumbilical necrotizing fasciitis (PNF) in the newborn is an invasive bacterial infection of the abdominal wall with a fulminant course and a high mortality rate. Little is known about the etiology, risk factors and microbiology of the disease. 18 patients with periumbilical necrotizing fasciitis were included in this retrospective study and were compared with 50 patients with omphalitis over a 6-year period, between 1992 and 1998. This represents the largest reported study. The children with periumbilical necrotizing fasciitis presented at a younger age compared to the omphalitis group (8.4 days vs. 9.1 days) and had a shorter clinical history (1.9 days vs. 2.8 days), suggesting that PNF is not a mere sequela of omphalitis but has distinctive underlying causes. None of our patients in the omphalitis group had a progression of the disease towards necrotizing fasciitis. The microbial spectrum of cultures obtained in patients with PNF consisted of mixed anaerobes and aerobes in 55%, and mixed aerobes in 36% of cases. Early aggressive therapy, including elective endotracheal intubation, immediate surgical debridement of the abdominal wall, antibiotics and supportive measurements resulted in a survival rate of 56%. Far from being satisfactory, this is nevertheless higher than the 12.5% to 45% survival rate quoted in previous publications.

Distinct roles for recombinant cytosolic 5'-nucleotidase-I and -II in AMP and IMP catabolism in COS-7 and H9c2 rat myoblast cell lines

Catabolism of AMP during ATP breakdown produces adenosine, which restores energy balance. Catabolism of IMP may be a key step regulating purine nucleotide pools. Two, cloned cytosolic 5'-nucleotidases (cN-I and cN-II) have been implicated in AMP and IMP breakdown. To evaluate their roles directly, we expressed recombinant pigeon cN-I or human cN-II at similar activities in COS-7 or H9c2 cells. During rapid (more than 90% in 10 min) or slower (30-40% in 10 min) ATP catabolism, cN-I-transfected COS-7 and H9c2 cells produced significantly more adenosine than cN-II-transfected cells, which were similar to control-transfected cells. Inosine and hypoxanthine concentrations increased only during slower ATP catabolism. In COS-7 cells, 5'-nucleotidase activity was not rate-limiting for inosine and hypoxanthine production, which was therefore unaffected by cN-II- and actually reduced by cN-I- overexpression. In H9c2 cells, in which 5'-nucleotidase activity was rate-limiting, only cN-II overexpression accelerated inosine and hypoxanthine formation. Guanosine formation from GMP was also increased by cN-II. Our results imply distinct roles for cN-I and cN-II. Under the conditions tested in these cells, only cN-I plays a significant role in AMP breakdown to adenosine, whereas only cN-II breaks down IMP to inosine and GMP to guanosine.

Duodenojejunal atresia with apple peel configuration of the ileum and absent superior mesenteric artery: observations on pathogenesis

A child with loss of the third and fourth part of the duodenum and of the proximal jejunum was found to have an apple peel configuration of the remaining small bowel. The complete absence of branches from the superior mesenteric artery impaired the blood supply of the distal duodenum. An annular pancreas was found in this patient with Down's syndrome. This anomaly may have impaired the flow through the pancreaticoduodenal arcade, which would normally compensate for the distal vascular occlusion. According to current understanding, duodenal atresia is a primary malformation. The current case suggests, however, that in rare circumstances vascular accidents may be the underlying cause for duodenal atresia.

Neural tube defects and congenital hydrocephalus in the Sultanate of Oman

A retrospective study was carried out in Oman to determine the incidence of neural tube defects (NTD) and congenital hydrocephalus (CH) and to identify any possible associations. National data retrieved from hospital records revealed the incidence of NTD in Oman to be comparatively low (1.25 per 1000), but the incidence of CH was much higher than that seen in Western Europe (0.44 per 1000) and was found to be associated with high rates of other congenital anomalies and neonatal death. There were no specific environmental factors associated with NTD and high environmental temperatures during the tropical desert summer (temperatures reach 48 degrees C) were excluded as a causative factor. In spina bifida families, later born children were more likely to be affected and there was also an association with increased maternal but not paternal age. Much higher consanguinity rates were noted in families with NTD and CH than in the general population.

Hirschsprung's disease in Oman

The incidence of Hirschsprung's disease (HD) was studied retrospectively in Oman using hospital-based data. In Oman there is a single pediatric surgery unit where a register has been kept from 1989 to 1994, and because all cases are referred to this unit, a national survey could be carried out. There were 85 children with HD born between 1989 and 1994, and during the period there were 261,000 livebirths among Omani nationals. The population frequency in Oman is 1 in 3,070 (0.3/1,000). Eighty percent of cases presented in the first 6 months. The incidence in different regions and within different tribes of Oman was also studied. The highest frequency (1 in 1,800) is in the North Sharqiya region. There was not a significant seasonal influence in spite of the very high temperatures seen in the desert summer. The ratio of male to female cases was 2.9:1 overall, but less for longer-segment involvement. The consanguinity rate (first and second cousins) was 75%, which is higher than the level of consanguinity in the Omani population. Down's syndrome was observed in nine cases (11%), and a variety of other malformations were seen, including piebaldism, deafness, and HD in two sibships.

Separation of ischiopagus tetrapus conjoined twins in the Sultanate of Oman

Premature male ischiopagus tetrapus twins weighing 2.2 kg were born unexpectedly. They required initial ventilation for respiratory distress syndrome and an emergency laparotomy for intestinal obstruction at 10 days of age. At 8 months of age, formal separation was carried out. Primary skin closure was possible without the use of any tissue expander. Anaesthesia was supplemented with continuous intra- and post-operative epidural analgesia, with great benefit. Both twins are alive and well 18 months after surgery. Details of the anatomical findings and preparation for surgery are discussed.

The frequency of posterior urethral valves in Oman

OBJECTIVE

To ascertain the frequency of posterior urethral valves (PUV) in Oman, using hospital records.

MATERIALS AND METHODS

The resident population of Oman is 1.5 million and all complex paediatric surgical cases are referred to a single unit in the capital city of Muscat. A register of patients has been kept in that unit since 1988. Hospital case-records were reviewed to determine associated abnormalities, date and place of birth, tribal origin and, from further interviews, the family pedigree and degree of consanguinity.

RESULTS

This retrospective survey identified 56 Omani children born between 1989 and 1994 who were treated in the Paediatric Surgery Department at the Royal Hospital, Muscat for congenital PUV. The calculated incidence was 1 in 2375 newborn males, which is 2-4 times higher than that previously reported in other populations. There was no relation to the estimated month of conception and therefore environmental hyperthermia due to the extreme ambient temperature does not seems not to be a causative factor. There was consanguinity in 40 of 46 cases (87%) where a complete family history was available. Parents were first cousins in 54% of cases, compared with the background rate of 24% in over 6000 families interviewed in the antenatal clinics at six hospitals in Oman. There was also a concentration of PUV within specific tribes. About one-third of the cases also had associated congenital abnormalities, the most frequent of which were genitourinary (17%), but gastrointestinal (9%) and spinal (7%) defects were also observed.

CONCLUSION

The frequency of PUV in newborn Omani males was 1 in 2375, which is considerably higher than any previously reported series. This was associated with an increased rate of consanguinity, but there was no clear pattern of inheritance.

Necrotizing fasciitis: a serious complication of omphalitis in neonates

Necrotizing fasciitis occurs when the inflammation (cellulitis) spreads beyond the umbilicus to include the subcutaneous tissue and underlying fascia. Presently, omphalitis is relatively uncommon because of aseptic delivery techniques and antimicrobial therapy. One hundred three neonates aged 7 to 28 days, with varying degrees of omphalitis, were treated on an outpatient or inpatient basis between 1989 and mid-1993. The neonates were full-term and weighed at least 2.5 kg. Patients with necrotizing fasciitis initially appear deceptively well, which results in less-than-optimum treatment at the outset, followed by a rapid and fulminating downhill course, in turn resulting in death within 24 to 72 hours. Early recognition of the condition, with aggressive resuscitation, appropriate antibiotics, and early surgery are necessary to salvage this high-risk group. The risk factors that may predict the development of necrotizing fasciitis and its early detection are discussed.

Lingual thyroglossal duct cyst presenting in infancy

Lingual thyroglossal duct cysts are a rare form of thyroglossal cysts. We present two infants, 10 and 12 weeks of age, with midline intraoral cystic swellings stretching from the base of the tongue to the thyroid cartilage. Complete excision of the cysts by Sistrunk's procedure were carried out. Both infants are well on follow-up, at 6 months postoperatively. Their unique presentation with regard to age, location, and symptomatology is discussed. Lingual thyroglossal duct cysts large enough to cause dysphagia, stridor, respiratory distress, and failure to thrive in infants have not been previously reported in the literature.

Bladder capacity in infants

Bladder capacity was measured at micturating cystourethrography and normal ranges were established for children up to 1 year of age. Bladder capacity was compared with patient weight and distance from first lumbar to third lumbar vertebrae (L1 to L3). The simplified formula--Capacity (mL) = 7 x weight (kg)--was shown to give a reliable estimate of the expected bladder capacity in infants independent of age; this is useful in those infants whose weight lies outside the normal range for their age. Similarly, a formula was deduced relating expected bladder capacity to the measured L1 to L3 distance on an anteroposterior radiograph, which is of potential use to radiologists.

Functional assessment of colonic interposition with 99Tcm-labeled milk

A prospective study was performed to evaluate the use of radionuclide imaging in the assessment of patients who have undergone esophageal reconstruction. Dynamic radionuclide imaging was performed on ten patients aged 11 months to 11 years who had undergone colon interposition via the normal esophageal route for esophageal atresia. Patients were considered clinically unsatisfactory if at the time of imaging feeding was troubled, or if weight gain had fallen to below the third centile before operation and remained below after operation. Each patient underwent erect imaging with a small milk feed labeled with 10 to 20 MBq (250 to 500 muCi) 99Tcm DTPA adjusted according to body surface area; supine studies were subsequently performed on five patients. All five clinically unsatisfactory patients showed conduit emptying delayed beyond 45 minutes and/or spontaneous reflux, significantly different from the clinically satisfactory patients (X2 = 6.4, P less than .02). Conduit complications were subsequently identified in three of the five clinically unsatisfactory patients. Radionuclide imaging with radiolabeled milk was found to be well tolerated, and obtained results that were clinically useful. These results suggest that dynamic radionuclide imaging can be more widely applied in the assessment of esophageal substitutes.

Could the stomach site help predict outcome in babies with left sided congenital diaphragmatic hernia diagnosed antenatally?

The site of the stomach in 36 babies presenting postnatally with left sided congenital diaphragmatic hernia (CDH) was assessed as a predictor of outcome. Babies with a thoracic stomach had a higher mortality (P less than .0005), and more frequently developed significant persistent foetal circulation (PFC) (P less than .001), than babies in whom the stomach was normally sited. Normal stomach site was associated with 100% survival and only a 20% incidence of significant PFC. It is possible that stomach site may be the most accurate predictor of outcome in left-sided CDH diagnosed antenatally, and may thus help in planning perinatal and postnatal management. It may also open the door for prenatal surgical correction of CDH by predicting a poor prognostic group or, perhaps more importantly, by predicting those babies with a good prognosis in whom antenatal surgery should not be attempted.

Congenital diaphragmatic hernia: the prognostic significance of the site of the stomach

Congenital diaphragmatic hernia is associated with a significant mortality, despite intensive treatment. The degree of pulmonary vascular hypoplasia is the main factor affecting mortality. Various features have been considered to determine the prognosis in these infants. In this study a series of 50 consecutive cases of left-sided diaphragmatic hernia has been reviewed. The site of the stomach (abdominal or intrathoracic), demonstrated radiologically and confirmed at operation, has been related to the final outcome (survival or death). An abdominal site is associated with an excellent prognosis (6.2% mortality), while an intrathoracic site is associated with a 58.8% mortality.

Choristoma of the soft palate

A 2-month-old girl presented with a history of intermittent cyanosis and dyspnea after feeding. This was found to be due to a 2 cm long polypoid lesion attached to her soft palate. This was removed and histologic examination showed it to be choristoma. Three years later she remains well with no evidence of recurrence.

"High" anorectal anomalies treated by early (neonatal) operation

Between 1973 and 1983, 18 patients with "high" anorectal anomalies were treated by one of the authors (N.V.F.) by immediate sigmoid loop-colostomy, followed by a sacroperineal or abdominosacroperineal pull-through operation as soon as possible thereafter. This was performed in seven patients between 1 and 14 days, in seven patients between 15 and 40 days, and in four patients between 60 and 120 days. Daily anal dilatations were started 7 to 10 days postoperatively and continued until the anus was soft and supple. The colostomy was then closed, the aim being to complete all treatment by the age of 3 to 4 months. Continence was assessed using Kiesewetter's criteria. Results in 70% were "good", 18% "fair", and 12% "poor". The clinical results are discussed together with the possible advantages of definitive surgery in the neonatal period for "high" anorectal anomalies.

Colonic interposition

Intrathoracic colonic interposition in children with esophageal atresia has been used for the past 36 years. The preferred routes have been via the left pleural cavity and retrosternally. Over the past 13 years the author has developed a method using the posterior mediastinum (normal esophageal route) for the colonic interposition. An analysis of 19 personal cases using this method is presented. A further nine cases using either the retrosternal or the Waterston routes and six cases using a modified neonatal operation are included. The evolution of the method currently used by the author is traced. Major problems remain, and further modifications relating to the optimal timing for the colonic interposition, length of colon graft, and sitting of the lower cologastric anastomosis continue to be tried and are discussed. The function of the graft has been studied with ten patients using 99Tc-labeled milk. The results of this study (unpublished) are presented. Gravity is shown to be the major factor influencing the onward passage of milk and food between the colon and stomach.

Purpura fulminans in neonates and childhood

Three cases of purpura fulminans are reported. A five-year-old boy was successfully treated for purpura fulminans but had autoamputation of both legs and autolysis of bladder and urethra. He did not show any sign of shock at the onset of the disease. However, before an irreversible change of the skin lesion and organ involvement occurred, prompt diagnosis was effected, and aggressive treatment was given. An eight-day-old girl suffered from purpura fulminans at her four extremities, skull, bladder, ovary and vagina. Interesting findings were obtained in case 2, who had a positive family history. Several black spots in the extremities had disappeared spontaneously before admission, whereas the other lesions got progressively worse, with subsequent severe attack. Her general condition was not parallel to the severity of the disease. A 20-day-old boy had purpura fulminans after severe aspiration pneumonia, and showed a typical clinical course of the disease. In all patients, sudden drop of Hb and leukocytosis occurred after the skin lesion appeared. The diagnosis was unequivocal in these cases. Clotting time and FDP were good indicators of the progress of the disease in conjunction with the clinical features. Prompt diagnosis and aggressive therapy are necessary, not according to the patient's condition, but according to the laboratory findings and the serious nature of the disease. Internal haemorrhage must be considered as well as the skin lesion, this being a fatal complication.

A prospective survey of the indications and morbidity of circumcision in children

Both the British Medical Association and the American Academy of Pediatrics recommend that circumcision should only be performed for medical reasons. No one has ever described which reasons are actually used, nor measured the morbidity of the procedure. Of 140 boys coming to day-case elective circumcision between the ages of 3 months and 14 years (mean 4.3 years), the commonest cause was a congenital phimosis (42.8%). Four (2.8%) patients required acute readmission postoperatively, and a further 4 developed meatal stenosis, requiring a formal meatotomy. Of 99 patients followed up in detail, 46% vomited, 36% oozed, 19% did not pass urine for more than 12 h and 26% could not wear pants for more than 7 days. Childhood circumcision has an appreciable morbidity, and should not be recommended without a medical reason.

The foreskin anoplasty

The role of anal sensation in fecal control is well established. A new operative method of creating a skin-lined anal canal using the patient's foreskin, as a secondary procedure, in patients with anal (colonic) prolapse following surgery for high anorectal anomalies, is described. The results in five patients treated between 1967 and 1979 are presented. A sixth patient, treated in 1983, is not included due to the short follow-up period.

Expiratory chest x ray examination in the diagnosis of inhaled foreign bodies

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Intractable constipation in children treated by forceful anal stretch or anorectal myectomy: preliminary communication

Sixty-one children with intractable constipation admitted between 1978-1981 under the care of the author were studied retrospectively. Ten of these patients were also studied prospectively by means of defaecating proctograms, and pre- and postoperative evoked anal potentials. It was found that 85.7% of the children who had anorectal myectomies benefited from the procedure. The possible mechanism by which the improvement is achieved is discussed.

Rectal prolapse in children

Some of the factors thought to be responsible for rectal prolapse in children are reviewed. In the United Kingdom management has in the past been conservative. It is suggested that children should be treated at an early stage by means of an injection of phenol in almond oil, in order to reduce the discomfort of recurrent manipulative reductions of the prolapse in the child and alleviate the anxiety of the parents. In 18 cases treated during the past 3 years a single injection performed under general anaesthesia, as a day case, was successful in preventing further prolapse of the rectum.

Colon interposition: a modification of the Waterston technique using the normal esophageal route

Intrathoracic colon interposition in children with esophageal atresia has been available for 30 yr. The retrosternal and left pleural cavity have been the preferred routes. The posterior mediastinal route does not appear to have been tried in children. Sixteen cases treated by the principle author (N.V.F.) using this route are presented. The mortality, anastomotic leakage and stricture rate (at each anastomosis) were 12.5%, respectively. The posterior mediastinal route is suggested as an alternative route for interposition of the colon or any other conduit.

Cecal fecalith mimicking intussusception

The rare finding of a cecal fecalith in an 8-year-old child is described together with a review of similar cases. These indicate not only the difficulty of diagnosis, but the dilemma faced by the surgeon at the operation.

Massive infiltrating cystic hygroma of the neck in infancy

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A case of diaphragmatic hernia, absent pericardium, and hamartoma of liver

A case is described of a diaphragmatic hernia associated with a left pericardial defect and hamartoma of the liver. The possible embryological origin of the first two defects from premature closure of the duct of Cuvier is discussed. The radiographic changes of the absent pericardium are mentioned and the histology of the liver hamartoma is described.