Is pre-operative imaging of external angular dermoid cysts in children necessary?

AIM

To investigate the frequency and modality of pre-operative imaging in children with an external angular dermoid cyst and whether this influenced subsequent management.

METHODS

A retrospective study was undertaken to assess the presentation, investigation, treatment and outcomes in children aged less than 16 years with an external angular dermoid cyst. All children who underwent external angular dermoid cyst excision between January 2008 and April 2021 at a regional children's hospital were analysed.

RESULTS

Sixty-one patients (32 boys) were identified. Fifty-four were managed by paediatric surgeons and seven by ophthalmic surgeons. Pre-operative imaging was performed in 19 (31%) patients, including plain radiographs (3), ultrasound scan (14), computerised tomography scan (1), and magnetic resonance imaging scan (2). None of these investigations showed evidence of an intracranial or orbital extension of the cyst or changed management. All cysts were excised under day-case general anaesthesia. There was one minor postoperative complication and two recurrences.

CONCLUSIONS

External angular dermoid cysts rarely communicate through the bone with the orbit or anterior cranial fossa. Routine pre-operative imaging is unnecessary unless there are clinical features such as an atypical location (e.g. temporal), eye signs (e.g. strabismus, proptosis and globe displacement) or a draining sinus.

Epigastric Hernias in Children: A Personal Series and Systematic Review of the Literature

Epigastric hernias are relatively uncommon in children, and there is a paucity of literature on their incidence, presenting features, natural history, and surgical outcomes. A systematic review was conducted according to PRISMA guidelines. Articles describing the incidence, outcome, and interventions for pediatric epigastric hernias, both open and laparoscopic, were analyzed. Eight relevant articles published between 1975 and 2019 were included in the analysis. Of 81 children, 58% were females, 35% were symptomatic and 8% were multiple. All hernias contained preperitoneal fat only and were repaired using standard open surgery or laparoscopic techniques. No recurrences were recorded. In a personal series of 37 hernias in 36 children of median age 4 years, there were no recurrences; however, this series included two children with a recurrent or persistent epigastric hernia after surgery by others. Epigastric hernias in children are relatively uncommon. They typically contain only preperitoneal fat but more than a third are symptomatic. Standard open repair can be undertaken with minimal morbidity. Laparoscopic repair takes longer and provides a marginal cosmetic benefit.

Esophageal length in children: Reference data and a novel predictive equation

Minimal information exists on the length of the child's esophagus, namely the distance from the cricopharyngeus to the esophagogastric junction (EGJ). We aimed to investigate the relationship between esophageal length (EL) and the age, height, and weight of the child. Children undergoing upper gastrointestinal endoscopy between February 2019 and May 2021 at our institution were prospectively audited. Children with anatomical esophageal disorders were excluded. Endoscopic distances from the incisors to the cricopharyngeus and EGJ were obtained, and novel predictive equations derived to predict EL. Intra-observer agreement for endoscopic measurements showed an intra-class correlation coefficient of 0.99. A total of 290 children aged 0.4-17.3 years were included in the analysis; they were divided into a model development cohort (n = 261) and a model validation cohort (n = 29). Measured EL correlated best with height (r = 0.92) as compared to age (r = 0.90) or weight (r = 0.83). The optimal equation for predicting EL was 0.156 × height (cm) - 1.336 (adjusted R²  = 0.841); this had a success rate of 76% in the validation cohort. The optimal equation for predicting distance from incisors to EGJ was 0.199 × height (cm) + 6.470 (adjusted R²  = 0.889); this had a success rate of 69% in the validation cohort. This is the first study to report a predictive equation for estimating esophageal length in children. Accurate prediction of esophageal length may assist with clinical esophageal procedures in children such as nasogastric and pH probe placement.

Intestinal malrotation in extremely premature infants: a potential trap

INTRODUCTION

Intestinal malrotation is life-threatening and often presents during infancy with bilious vomiting. The prevalence and presentation among extremely premature infants are unknown.

METHODS

We retrospectively reviewed all infants born at less than 28 weeks' gestation diagnosed with symptomatic intestinal malrotation in a tertiary neonatal intensive care unit over a 10-year period (2010-2020).

RESULTS

Seven of 514 (1.4%) extremely premature infants developed symptomatic intestinal malrotation during this period. All were non-syndromic. In comparison, the prevalence of symptomatic intestinal malrotation in 7382 infants ≥ 28 weeks' gestation admitted during the same period was 0.2%. Intestinal malrotation was confirmed at laparotomy in all extremely premature infants and six of seven had midgut volvulus. All but one presented with marked abdominal distension; none had bilious vomiting and only three had bilious gastric aspirates. A subacute onset with non-specific features such as recurrent apnoea and bradycardia, feed intolerance, and intermittent abdominal distension was common. All infants underwent a Ladd procedure. Two required extensive bowel resection resulting in short gut syndrome and three underwent further surgery for adhesive small bowel obstruction. One patient died at 10 months of age from respiratory failure but the others were well 1-3 years later.

CONCLUSIONS

Symptomatic intestinal malrotation in extremely premature infants has a relatively high prevalence. It may present with marked abdominal distension without bilious vomiting, demanding a high index of suspicion. An atypical presentation, potential alternative abdominal pathologies, coexisting comorbidities, and concerns about survival in these fragile babies may deter the surgeon despite the opportunity of a good outcome.

A self-report questionnaire for pregnancy-related symphyseal pain

BACKGROUND

Symphyseal pain (SP) experienced during pregnancy is a common condition that can negatively influence function and wellbeing. Despite its adverse impact on quality of life, standardised diagnostic criteria for SP as a distinct type of pelvic girdle pain (PGP) are lacking.

OBJECTIVES

To develop a reliable self-administered instrument that could differentiate SP from posterior PGP in pregnant women, and ultimately be used for epidemiological or clinical purposes.

METHOD

Qualitative data from 17 women (four focus groups) were used to develop a questionnaire. The questionnaire was tested against physical therapy diagnoses based on clinical assessment in 122 pregnant women with SP (n = 41), posterior PGP (n = 41) or no PGP (n = 40); 30 women repeated the questionnaire a day later to assess reliability. Multinomial logistic regression models were used to assess the performance of candidate items in distinguishing between the groups.

RESULTS/FINDINGS

The single questionnaire item relating to location of worst pain (diagrammatic form) is useful for differentiating SP from posterior PGP and individuals with no PGP. The worst pain location question with the addition of the Pelvic Girdle Questionnaire provides a measure of "SP with impact", and is the best combination for distinguishing SP and posterior PGP. Test-retest reliability scores were excellent.

CONCLUSION

These findings provide new opportunities for diagnosing pregnancy-related SP, and highlight questionnaire items which best differentiate SP from posterior PGP. These items could be used in future epidemiological research, and in clinical settings as a quick, effective screening tool.

Laparoscopic diverticulectomy or laparoscopic-assisted resection of symptomatic Meckel diverticulum in children? A systematic review

Recent reports have recommended laparoscopic diverticulectomy for symptomatic Meckel diverticulum (MD) rather than laparoscopic-assisted extracorporeal resection. This technique may risk leaving residual ectopic mucosa leading to complications. This systematic review attempts to quantify the relative risks of both approaches. A systematic review was conducted according to PRISMA guidelines. Articles were eligible for inclusion if they reported data on the laparoscopic management of symptomatic MD in children. Eleven reports were identified, all of which were institutional retrospective studies. Pooled outcome data on 248 children showed no statistically significant difference in complications between laparoscopic diverticulectomy (n = 133) and laparoscopic-assisted segmental resection (n = 115) (3% vs. 6.1%, p = 0.39). One patient from the diverticulectomy group re-presented with recurrent bleeding necessitating segmental small bowel resection. Conclusions are limited by the number of patients and variable follow up. Short, wide MD with a height:base ratio of < 2; diverticula with thickening or ischemia at the base and those complicated by volvulus or small bowel obstruction are probably best treated by laparoscopic-assisted extracorporeal resection. For other symptomatic diverticula laparoscopic diverticulectomy is a reasonable approach with a less than 1% risk of leaving residual ectopic gastric mucosa.

Scoliosis after thoracotomy repair of esophageal atresia: a systematic review

Standard surgical repair of esophageal atresia/tracheoesophageal fistula (EA/TEF) is via a right posterolateral thoracotomy. A recognized complication is the later development of scoliosis. The prevalence and pathogenesis of secondary scoliosis are poorly understood. We, therefore, conducted a systematic review on this topic. All English language articles reporting incidence, outcomes and/or interventions for scoliosis in children after EA repair via thoracotomy were identified. Fourteen relevant articles published between 1969 and 2019 reporting 1338 children were included in the analysis. The aggregate prevalence of scoliosis among 937 children without congenital vertebral anomalies was 13%, but this figure varied widely between studies. Severity of scoliosis was documented in 181 children; eight children had a Cobb angle > 40° and 10 had undergone spinal surgery. The spinal curvature in affected individuals was dominantly or exclusively convex to the left. In conclusion, the reported prevalence of scoliosis varies widely but on average affects about one in eight children after open repair of EA/TEF. Most cases are mild and do not require intervention. It is currently uncertain whether secondary scoliosis is preventable by using meticulous thoracotomy techniques or thoracoscopic repair.Level of evidence IV.

Contemporary management of Hirschsprung disease in New Zealand

BACKGROUND

The aim of this study was to report the contemporary management of Hirschsprung disease (HD) in New Zealand.

METHODS

We undertook a national multi-centre retrospective review of all newly diagnosed cases of HD during a 16-year period (2000-2015). Demographics, genetic and syndromic associations, family history, radiology and histology results and surgical interventions were analysed.

RESULTS

A total of 246 cases (males:females 4:1) were identified, an incidence of 1:3870 live births. Short-segment disease was present in 81.7%, long-segment disease in 8.5%, total colonic aganglionosis in 6.5% and unknown in 3.3%. HD was diagnosed by 4 weeks' corrected gestational age in 67%. Thirty cases (12%) also had Trisomy 21. Fifty-three (21.5%) patients required a repeat rectal biopsy for definitive diagnosis. A contrast enema was performed in 55% and identified the transition zone with 69% accuracy. Primary pull-through surgery was undertaken in 59% (65% of short-segment cases) at a median age of 27 days; others were initially managed by a defunctioning stoma. The commonest definitive procedure was a Soave-Boley endorectal pull-through (79%) (or similar variant). During a median follow-up of 7.4 years, six (2.5%) survivors underwent a redo pull-through, 13 (5.5%) an appendicostomy, 16 (6.8%) a defunctioning stoma and 10 never had a definitive procedure. Total colonic aganglionosis was significantly more likely to be fatal (12.5% versus 0.5%, P < 0.0005) or associated with a permanent end stoma (27.5% versus 4.5%, P < 0.0005).

CONCLUSIONS

Most New Zealand born infants with short-segment HD are currently managed by primary pull-through, usually in the first months of life.

Outcomes of infants born at 23 and 24 weeks' gestation with gut perforation

PURPOSE

The provision of neonatal intensive care to infants born at 23 or 24 weeks' gestation poses medical, surgical and ethical challenges. Gastrointestinal perforation is a well-recognized complication of preterm birth, occurring most often as a result of necrotizing enterocolitis (NEC) or spontaneous intestinal perforation (SIP). Given the risk of morbidity and mortality in these 'periviable' infants, this complication may prompt transition from active management to palliative care. In our institution, the surgical care of periviable infants with gut perforation has not been dictated by gestational age. This study reports our outcomes.

METHODS

A retrospective cohort analysis of integrated neonatal medical and surgical care of all infants born between 23⁺⁰ and 24⁺⁶ weeks' gestation admitted to a tertiary level neonatal intensive care unit (NICU) during a 16 year period (2002-2017).

RESULTS

A total of 198 periviable neonates (73 born at 23 weeks' gestation and 125 born at 24 weeks) were admitted during the 16-year period; most were inborn with only 26 retrieved from regional centers. Twenty-six of these infants developed gut perforation: 14 SIP, 8 NEC, 3 esophageal perforation and one after reduction of an incarcerated inguinal hernia. Twelve (46%) periviable infants with gut perforation survived to discharge home, seven of whom had no/mild disability at 2-3 years corrected gestational age. Of the 198 periviable infants admitted to NICU, 116 (58%) were alive at a corrected gestational age of 2-3 years and 29 of the 56 (51%) assessed had mild or no disability.

CONCLUSIONS

In the setting of combined medical and surgical care in a tertiary level NICU almost half of all periviable infants with a gut perforation survived, many with no/mild disability at 2-3 years corrected gestational age. Rigid protocols that rely on gestational age alone to guide treatment are not appropriate. These results support the contention that, when possible, extremely preterm infants should be born and cared for in units with combined medical and surgical expertise.

LEVEL OF EVIDENCE

Level III cohort study.

Thrombocytosis and portal vein thrombosis after splenectomy for paediatric haemolytic disorders: How should they be managed?

Splenectomy is indicated in selected children with haemolytic anaemia. Postoperatively, thrombocytosis occurs in at least 80% and is one of the factors implicated in the development of acute portal venous thrombosis after splenectomy in adults. A literature review shows that children are also at risk of this complication, but the incidence is low. The risk is greatest in those with particularly large spleens. Laparoscopic splenectomy does not reduce the risk of this complication. Early detection and anticoagulation usually leads to successful resolution of the thrombosis and can mitigate the risk of developing cavernous transformation of the portal vein and chronic portal hypertension. Any child with severe or unexplained postoperative abdominal pain, fever and/or vomiting after splenectomy demands urgent abdominal imaging to exclude this complication. In asymptomatic individuals, a routine Doppler ultrasound scan 1 week postoperatively is advisable if they had a particularly large spleen, longer than usual duration of surgery and/or have a marked postoperative thrombocytosis. There is no evidence for routine administration of antiplatelet drugs and/or subcutaneous heparin prophylaxis in children after splenectomy, including those who develop postoperative thrombocytosis, but children with particularly large spleens may be a subset that benefit.

Ethnic variations in the childhood prevalence of Hirschsprung disease in New Zealand

BACKGROUND

Epidemiological studies have suggested that there may be ethnic variations in the prevalence of Hirschsprung disease (HD) but no study has systematically investigated this issue or potential ethnic variations in the extent of aganglionosis in HD. This study aimed to investigate this in a childhood population in New Zealand.

METHODS

A multicentre national retrospective review was undertaken of all newly diagnosed cases of HD at each of the four paediatric surgical centres in New Zealand over a 16-year period (January 2000 to December 2015). Original histological, radiological and operative reports were obtained and analysed. Self-identified ethnicity was recorded from admission documents. Birth statistics were obtained from Statistics New Zealand.

RESULTS

A total of 246 cases of HD were identified. The prevalence of HD was 1:3790 live births for European, 1:6610 among Māori, 1:1834 among Pacific Peoples, 1:3847 among Asian and 1:5694 among Middle Eastern. The prevalence of HD was statistically significantly greater in Pacific Peoples (P < 0.0005). The proportion of children with long-segment HD was also significantly greater in Pacific and Asian populations than others (P = 0.04). These findings were not due to differences in the proportion of familial cases of HD among the different populations.

CONCLUSIONS

The prevalence and phenotype of HD varies significantly between different ethnic groups within New Zealand. This may well be related to variations in the frequencies of HD-associated gene mutations within these populations.

Preoperative laryngotracheobronchoscopy in infants with esophageal atresia: why is it not routine?

The value of laryngotracheobronchoscopy (LTB) immediately prior to repair of esophageal atresia with or without tracheo-esophageal fistula is contentious. Currently, there is a wide range of opinion on the utility of this investigation which is reflected by huge variation in clinical practice. This review is a critical analysis of the arguments for and against performing routine LTB prior to esophageal atresia repair. Reserving LTB for selected cases only is potentially disadvantageous since it limits the surgeon's and anesthetist's familiarity with the procedure, equipment, and range of potential findings. There is sufficient evidence to suggest that routine preoperative LTB becomes the standard of care.

Acute appendicitis

Acute appendicitis is the most common reason for abdominal surgery in children. Luminal obstruction of the appendix progresses to suppurative inflammation and perforation, which causes generalised peritonitis or an appendix mass/abscess. Classical features include periumbilical pain that migrates to the right iliac fossa, anorexia, fever, and tenderness and guarding in the right iliac fossa. Atypical presentations are particularly common in preschool children. A clinical diagnosis is possible in most cases, after a period of active observation if necessary; inflammatory markers and an ultrasound scan are useful investigations when the diagnosis is uncertain. Treatment is by appendicectomy after appropriate fluid resuscitation, analgesia and intravenous antibiotics. Laparoscopic appendicectomy is better than open appendicectomy in most cases because it is associated with less postoperative pain and a shorter hospital stay, but recovery after acute appendicitis is mostly dictated by whether the appendix was perforated or not. Management of the appendix mass remains controversial and not all affected children need an interval appendicectomy. This article discusses tips and pitfalls in diagnosis and addresses many of the controversies that surround the management of this condition.

Tailgut cysts in children: a report of two cases and literature review

Tailgut cysts are rare congenital lesions that typically manifest as a presacral, retrorectal, multicystic mass. Even though they are derived from remnants of the embryonic tailgut, they most often present in women. Differential diagnosis includes rectal duplication cyst, sacrococcygeal teratoma, and anterior meningocele. Treatment demands complete excision to prevent infection and malignant degeneration. Fewer than 20 pediatric cases have been reported. Two further affected children are described, one of whom presented uniquely with urinary tract obstruction and acute renal failure.

Adherence, tolerance and effectiveness of two different pelvic support belts as a treatment for pregnancy-related symphyseal pain - a pilot randomized trial

BACKGROUND

Pregnancy-related pubic symphysis pain is relatively common and can significantly interfere with daily activities. Physiotherapist-prescribed pelvic support belts are a treatment option, but little evidence exists to support their use. This pilot compared two pelvic belts to determine effectiveness (symptomatic relief), tolerance (comfort) and adherence (frequency, duration of use).

METHODS

Unblinded, 2-arm, single-center, randomized (1:1) parallel-group trial. Twenty pregnant women recruited from the community (Dunedin, New Zealand), with physiotherapist-diagnosed symphyseal pain, were randomly allocated to wear either a flexible or rigid belt for three weeks. One author, not involved in data collection, randomized the allocation to trial group. The unblinded primary outcome was the Patient Specific Functional Scale (PSFS). Secondary outcomes were pain intensity during the preceding 24 hours and preceding week (visual analogue scale [VAS]), and disability (Modified Oswestry Disability Questionnaire [MODQ]). Duration of use (hours) was recorded daily by text messaging. Participants were assessed at baseline, by weekly phone interviews and at intervention completion (three weeks). To assess comfort, women wore the alternate belt in the fourth week.

RESULTS

Twenty pregnant women (mean ± SD age, 29.4 ± 6.5 years; mean gestation at baseline, 30.8 ± 5.2 weeks) were randomized to treatment groups (flexible = 10, rigid =10) and all were included in analysis. When adjusted for baseline, PSFS scores were not significantly different between groups at follow up (mean difference -0.1; 95% CI: -2.5 to 2.3; p =0.94). Pain in the preceding 24 hours reached statistical significance in favor of the flexible belt (VAS, p = 0.049). Combining both groups' data, function and pain were significantly improved at three weeks (mean difference -2.3; 95% CI: 1.2 to 3.5; p< 0.001). Belts were worn for an average of 4.9 ± 2.9 hours per day; women preferred the flexible belt. No adverse events were reported.

CONCLUSION

These preliminary results suggest the flexible pelvic support belt may be more effective in reducing pain and is potentially better tolerated than a rigid belt. Based on these data, a larger trial is both feasible and clinically useful.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12614000898651 , 25th August, 2014.

Clinico-pathological factors influencing lymph node yield in colorectal cancer and impact on survival: analysis of New Zealand Cancer Registry data

BACKGROUND

Lymph node yield (LNY) and lymph node ratio (LNR) are recognized as independent prognostic factors in colorectal cancer (CRC).

OBJECTIVES

To examine the relationship between LNY and other clinico-pathological variables, and the prognostic value of LNY and LNR on patient survival in CRC.

METHODS

The clinico-pathological and survival data for patients diagnosed from January 2000 to July 2012 were retrieved from the New Zealand Cancer Registry. Multiple linear regression was used to identify clinico-pathological factors influencing LNY, and Cox regression was used to determine the association between LNY and LNR and patient survival.

RESULTS

14,646 patients were included in the study (mean age 70.3 years, 50.1% male). Mean LNY was 17.4. Younger age, right-sided disease, higher T stage, female sex and no neoadjuvant radiotherapy (rectal cancer) were all associated with higher LNY (P ≤ 0.001). Overall survival in Stage I-III disease increased with higher LNY (for LNY ≥ 12, HR = 0.67, 95% CI 0.64-0.72; P < 0.001). Survival in Stage III-IV disease was inversely related to LNR (HR = 0.56, 95% CI 0.51-0.62; P < 0.001).

CONCLUSION

LNY is influenced by patient age, site of disease and T stage. LNY (Stage I-II) and LNR (Stage III-IV) have independent prognostic value in CRC.

Polyorchidism with presumed contralateral intrauterine testicular torsion

•

The sentence, “Since then fewer than 200 cases have been reported in children and adults²” has been updated to “Since then nearly 230 cases of polyorchidism have been reported with a meta-analysis revealing 140 cases of histologically confirmed polyorchidism in children and adults.²”

•

The sentence “It occurs mostly on the left side, with only a few reports of right sided polyorchidism^3,4” has been changed to “Right sided polyorchidism is less common than on the left side.”

•

Prenatal testicular torsion reportedly occurs in approximately 6.1 per 100,000 births.^7,8 The frequency may be higher given that the infarcted testis gets resorbed giving rise to reports of the “vanishing testis” as is most likely in this case.⁸ While prenatal testicular torsion is increasingly being recognized and treated as a surgical emergency,⁹ prenatal testicular torsion in association with polyorchidism has not been previously reported.” has been included.

INTRODUCTION

Polyorchidism was first described by Blasius in 1670¹ during a routine autopsy. We report a child with unilateral polyorchidism and a contralateral absent testis, a combination not reported previously.

PRESENTATION OF CASE

A 2-year-old boy was referred to the outpatient clinic with an impalpable left testis. At laparoscopy, the left vas deferens and testicular vessels ended blindly proximal to a closed internal ring. No gonadal tissue was identified. On the right side, a single vas deferens and testicular vessels were seen entering the internal ring as normal. The right side of the scrotum was explored and two testes were identified within a single tunica vaginalis.

DISCUSSION

Polyorchidism is rare with a literature search identifying approximately 230 reported cases. Whilst prenatal testicular torsion is increasing being recognized and treated as a surgical emergency,⁹ prenatal testicular torsion in association with polyorchidism has not been previously reported.

CONCLUSION

We describe a unique case of a 2-year-old boy with right-sided polyorchidism and an absent left testis associated with a blind ending vas deferens and testicular vessels, presumed secondary to intrauterine testicular torsion.

Influence of age and site of disease on lymph node yield in colorectal cancer

AIM

Colorectal cancer (CRC) is the second-leading cause of cancer death in New Zealand. Lymph node yield (LNY) is an independent prognostic factor in CRC and 12 or more lymph nodes in the resected specimen is the current recommended standard, regardless of age or site of disease. The aim of this study was to examine the effect of age and site of the disease on LNY.

METHOD

Patients undergoing elective surgery for CRC at Dunedin Hospital between 1995 and 2012, who enrolled in studies involving prospective data and tissue collection, were included in the current study. The relationship between LNY and demographic and pathological variables including age, sex, tumour location and stage were investigated.

RESULTS

824 patients were included (mean age 70.5 years, 51% female). The mean (SD) LNY was 17.9 (10.1).There was a weak but significant negative correlation between age and LNY (r=-0.08; p=0.024) that was more evident in patients with right-sided tumours (r=0.18; p=0.001). Right-sided tumours also had a higher LNY (mean 20.5) than left colon (mean 16.8) and rectal cancer (mean 14.6) (p<0.001). Overall the mean LNY reduced by 1 for every 7 years advancement in age.

CONCLUSION

LNY is higher in right-sided colon cancer and reduces with age. Further research should consider whether the recommended standard for LNY in the specimen should take account of age and tumour location.

Sonographic anatomy of the pubic symphysis in healthy nulliparous women

Pregnancy-related symphyseal pain is a condition commonly encountered by clinicians but its pathogenesis is poorly understood. The pubic symphysis is readily visualized with ultrasound, yet the normal sonographic anatomy of the joint has not been accurately documented. This study aimed to describe the anatomy of the pubic symphysis in healthy, nulliparous women using ultrasound. An experienced and inexperienced sonographer scanned the joint in 30 female volunteers (mean age 26 years). Interobserver and intraobserver reliability of ultrasound measurements were examined and the accuracy of these measurements was validated by ultrasound and dissection of six female cadaver pelves (mean age 75 years). In healthy young women, pubic symphysis morphology varied, and six categories of anterosuperior joint shape were defined. Mean values of several anatomic parameters were obtained in supine and standing positions: joint width (widest 10.1 mm, narrowest 2.6 mm); superior pubic ligament (SPL) length and depth (41.4 and 3.4 mm, respectively); and pubic crest length (left 24.4 mm, right 24.4 mm). Statistically significant relationships between SPL width and depth and anthropometric variables (body mass index, pelvic width, and body fat percentage) were established. Larger ultrasonographic measurements, such as wide joint width and SPL length, could be measured more reliably than smaller measurements, such as narrow joint width and SPL depth, in both healthy volunteers and cadavers. Findings from this study provide normative reference data for examination of the pubic symphysis in pregnant women and may therefore be relevant to understand pregnancy-related symphyseal pain.

Redefining the surface anatomy of the saphenofemoral junction in vivo

The surface anatomy of the saphenofemoral junction (SFJ) is especially relevant to surgeons. It is variably described in contemporary anatomy and clinical texts but is usually stated to lie 2.5-4 cm below and lateral to the pubic tubercle. The aim of this study was to map the SFJ accurately in healthy adults using ultrasound. One hundred healthy adults (mean age 27 years; 64 men) were scanned by an experienced sonographer using a 13-5 MHz linear probe. The center of the SFJ was recorded bilaterally in relation to the most superficial point of the pubic tubercle. The SFJ was readily identified in all participants. Its center was a mean of 2.4 ± 0.6 cm lateral (range 1-4.5 cm) and 1 ± 0.9 cm inferior to the pubic tubercle (range 2.5 above to 4 cm caudal to it). The junction was inferior to the pubic tubercle in 90% of lower limbs and at or above that level in 10%. In men, the SFJ was a mean of 2.6 cm lateral to the pubic tubercle and 1.2 cm inferior to it, compared with 2.2 and 0.6 cm, respectively, in women (P < 0.001). The SFJ was also slightly nearer the pubic tubercle in younger and thinner participants (P < 0.01). The center of the SFJ lies in a square extending 1-4 cm lateral and up to 3 cm below the pubic tubercle in >90% of adults. The junction is slightly closer to the pubic tubercle in women. These results provide a more robust guide to the surface anatomy of the normal SFJ.

Head and neck fascia and compartments: no space for spaces

An accurate understanding of the arrangement of cervical fascia and its associated compartments is essential for differential diagnosis, predicting the spread of disease, and surgical management. The purpose of this detailed review is to summarize the anatomic, clinical, and radiological literature to determine what is known about the arrangement of cervical fascia and to highlight controversies and consensus. The current terminology used to describe cervical fascia and compartments is replete with confusing synonyms and inconsistencies, creating important interdisciplinary differences in understanding. The term "spaces" is inappropriate. A modified nomenclature underpinned by evidence-based anatomic and radiologic findings is proposed. This should not only enhance our understanding of cervical anatomy but also facilitate clearer interdisciplinary communication.

The anatomy of the sacrococcygeal cornual region and its clinical relevance

There has been no systematic study of the anatomy of the region between the sacral and coccygeal cornua. Reference texts describe an intercornual ligament connecting these structures. The aim of this study was to investigate the anatomy of this region, which may be relevant to unexplained cases of coccygeal pain (coccydynia) and local nerve blocks. The bony anatomy of the sacrococcygeal (SC) cornual region was analyzed in 33 CT scans obtained from supine adults of mostly European origin with no known SC pathology, 7 μCT scans of cadaver SC specimens, and 105 Asian Indian adult skeletons. A further five cadaver SC specimens were examined histologically. SC cornual fusion was seen in 45% of CT/μCT scans (mean age 67 years, 20 males) and in 20% of adult skeletons (78 males); there was no association with age or sex. In the absence of SC fusion, the mean intersacrococcygeal cornual gap was 7.1 ± 2.4 mm; this was bridged by an intercornual ligament composed of parallel vertical collagen fibers reinforced by elastin fibers on its anterior surface. Small nerve branches were observed adjacent to the ventral aspect of the intercornual ligament and, in one case, traversing the ligament. Ipsilateral sacral and coccygeal cornua are therefore normally bridged by an intercornual ligament that is probably innervated. The cornua are fused on one or both sides in 20-45% of adults. These findings may have implications for some cases of coccydynia and for anesthetists performing local nerve blocks.

Magnetic resonance imaging morphology and morphometry of the coccyx in coccydynia

STUDY DESIGN

Retrospective case-control study.

OBJECTIVE

To determine if differences exists between the bony anatomy of the coccyx in patients with coccydynia and that in subjects with no known coccygeal pathology.

SUMMARY OF BACKGROUND DATA

Numerous bony characteristics of the coccyx have been described in patients with coccydynia but their significance is uncertain. This study aimed to evaluate these in patients with coccydynia and compare them with normal coccyges.

METHODS

Magnetic resonance scans of the coccyx from 107 adults (mean age, 43 ± 12 yr; 84 females) with clinically diagnosed coccydynia were retrospectively analyzed and compared with 112 computed tomographic scans from sex-matched adults with normal coccyges. The following were assessed: coccygeal segmentation; sacrococcygeal and intercoccygeal joint fusion, angles, and curvature; bony spicule formation; and subluxation.

RESULTS

Compared with normal, females with coccydynia had a more ventrally curved coccyx (curvature index, 85 ± 7 vs. 90 ± 5; P< 0.01), a lower prevalence of sacrococcygeal joint fusion (27% vs. 58%, P< 0.01), and a higher frequency of bony spicule formation (44% vs. 19%, P< 0.01). Males with coccydynia showed a trend toward a more ventrally curved coccyx (curvature index: 86 ± 6 vs. 89 ± 5, P< 0.08), and a lower prevalence of sacrococcygeal (27% vs. 60%, P< 0.02) and intercoccygeal (0% vs. 22%, P< 0.02) joint fusion. Combining statistically significant coccygeal parameters in a logistic regression model yielded sensitivity, specificity, and positive predictive values of 72%, 71%, and 73%, respectively in females and 52%, 92%, and 73%, respectively in males.

CONCLUSION

This is the most detailed comparison of coccygeal morphology and morphometry in adults with and without coccydynia investigated using cross-sectional imaging. Anatomical differences in joint fusion and coccygeal curvature may either predispose to the development of coccydynia or arise as a result of this condition.

Why do potential body donors decide against donating?

BACKGROUND

The Department of Anatomy at the University of Otago has been accepting body bequests for anatomical study for about 70 years. Donated bodies are used to teach anatomy to medical and dental students and surgical trainees and a wide range of other undergraduate and postgraduate students rely on body specimens to learn anatomy. Maintaining a robust body bequest programme is essential for these educational programmes. The profile of our body donors is reasonably well understood but little is known about why individuals who are interested in body donation decide not to complete the registration process.

AIM

To investigate the reason(s) why applicants request bequest information but do not complete the registration process.

METHODS

In March 2012, an anonymous questionnaire was sent to 142 individuals who had contacted the Department between January 2010 and August 2011 requesting bequest information but had not completed the registration process.

RESULTS

Eleven questionnaires failed to reach the intended recipient reducing the sample size to 131. Seventy eight respondents (60%) completed the questionnaire. The prime motivation for enquiring about body donation was a desire to aid medicine. The commonest single reason for not completing the registration process was our donor weight restriction of 90 kg, cited by 25% of respondents. Other reasons included objections by a family member and restrictions related to potential prion disease. Fourteen respondents had lost their registration form, and a further 15 hadn't yet made up their mind whether to donate; 18 of these have since completed the registration process.

CONCLUSIONS

Restrictions on the acceptance of a body at the time of death deter some interested individuals from body donation. About 40% of respondents to this survey had either lost their form or were still considering body donation, many of whom were prompted to complete the registration process by this survey. Bequest programmes should consider sending a follow-up letter to individuals who request information but subsequently fail to register within a few months.

The mucosal folds at the pancreaticobiliary junction

PURPOSE

The structure and function of the mucosal folds in the terminal bile and pancreatic ducts and hepatopancreatic ampulla are poorly characterised. The distribution, muscularity, and innervation of these folds were investigated.

METHODS

The pancreaticobiliary junction was excised from ten cadavers (five male, 66-90 years) and examined histologically by serially sectioning (4-μm thickness) along the length of the terminal bile and pancreatic ducts from the tip of the major duodenal papilla. Three surgical specimens (two male, 63-72 years) were also evaluated. Sections were stained with haematoxylin and eosin, anti-actin (smooth muscle), anti-S100 (innervation), and anti-cholecystokinin (CCK)-A receptor antibodies. ImageJ software was used to compare relative radial fold projection and semi-quantitatively assess the smooth muscle and nerve content. In one additional cadaver specimen, folds were examined by scanning electron microscopy.

RESULTS

Mucosal folds in the terminal bile duct were arranged circumferentially in a lattice-like arrangement and were distributed over an average distance of 7.3 mm along the terminal bile duct compared to 4.2 mm along the pancreatic duct (P = 0.001), projected further into the lumen, and were more densely innervated than those in the terminal pancreatic duct. Folds in both ducts contained smooth muscle which was more prominent in folds nearest to the major duodenal papilla. Mucosal folds in cadaver and surgical specimens showed no evidence of CCK-A receptor immunoreactivity.

CONCLUSIONS

This study demonstrates that the mucosal folds of the terminal bile and pancreatic ducts contain muscle and nerve fibres, suggesting an active rather than purely passive function.

Is the pelviureteric junction an anatomical entity?

OBJECTIVE

The concept of the pelviureteric junction has existed for more than a century and yet there is no clear anatomical definition of this junction. This systematic review addresses the question of whether the human pelviureteric junction is a discrete anatomical entity.

METHODS

A systematic literature review was undertaken to investigate the normal gross and microscopic anatomy of the pelviureteric junction using the electronic databases MEDLINE, PubMed, Cochrane Library and Google Scholar.

RESULTS

In most individuals there is a gradual transition between the renal pelvis and ureter with no external features indicating the presence of a discrete pelviureteric 'junction'. Internally, however, luminal mucosal folds are prominent in this region. There is no consensus on the arrangement of muscle fibers at the pelviureteric junction (which may be age-dependent) although some studies suggest a focal thickening in the muscle wall consistent with physiological observations suggesting a high pressure zone capable of regulating urine flow. Studies of innervation have shown no evidence of specialization at this site.

CONCLUSIONS

There is some evidence that a pelviureteric region can be delineated anatomically and physiologically. However, although it may be a useful clinical concept, there is no sound anatomical basis for an actual pelviureteric junction.

Fundamental ratios and logarithmic periodicity in human limb bones

Fundamental mathematical relationships are widespread in biology yet there is little information on this topic with regard to human limb bone lengths and none related to human limb bone volumes. Forty-six sets of ipsilateral upper and lower limb long bones and third digit short bones were imaged by computed tomography. Maximum bone lengths were measured manually and individual bone volumes calculated from computed tomography images using a stereologic method. Length ratios of femur : tibia and humerus : ulna were remarkably similar (1.21 and 1.22, respectively) and varied little (<7%) between individuals. The volume ratio of femur : tibia was approximately half that of humerus : ulna (1.58 and 3.28, respectively; P < 0.0001). Lower limb bone volume ratios varied much more than upper limb ratios. The relationship between bone length and volume was found to be well described by power laws, with R(2) values ranging from 0.983 to 0.995. The most striking finding was a logarithmic periodicity in bone length moving from distal to proximal up the limb (upper limb λ = 0.72, lower limb λ = 0.93). These novel data suggest that human limb bone lengths and volumes follow fundamental and highly conserved mathematical relationships, which may contribute to our understanding of normal and disordered growth, stature estimation, and biomechanics.

Does senescence affect lymph node number and morphology? A systematic review

BACKGROUND

Immunosenescence may contribute to an observed increase in infections and specific cancers in the elderly. Lymph nodes play a key role in the body's immune system. A systematic review was undertaken to investigate the effects of senescence on lymph node number and morphology.

METHODS

Electronic databases Ovid MEDLINE, Embase and Google Scholar were searched for relevant articles examining normal lymph node number and morphology with senescence. Data on lymph node number, gross anatomy and histo-architecture were collated and analysed.

RESULTS

A total of 20 articles (15 human and 5 animal studies) were eligible for inclusion; many were limited by poorly standardized methods and relatively small sample sizes. However, there is evidence to suggest both a decrease in lymph node number and histological lymph node degeneration with senescence, at least in some lymph node basins. Degenerative changes include loss of lymphoid tissue from both the cortex and the medulla of lymph nodes, a reduction in the number and size of germinal centres, and changes such as hyalinization, fibrosis, fat deposition, a decrease in high endothelial venules and 'transparency'.

CONCLUSION

In this first systematic review to examine changes in lymph nodes with senescence, evidence was accrued to suggest a decline in lymph node number and morphological degeneration in older age groups. These changes might adversely affect immune function and the prognosis of infections and selected cancers in the elderly. Further research is required to confirm these morphological changes and to explore their potential immunological and functional effects.

CT morphology and morphometry of the normal adult coccyx

PURPOSE

Lack of data on the in vivo morphology and morphometry of the normal adult coccyx hampers understanding of radiological abnormalities in idiopathic coccydynia. The aim of this study was to investigate normal adult sacrococcygeal morphometry.

METHODS

Retrospective analysis of 112 adult CT scans (mean age 63 ± 14.6 years, 50 males) evaluated the following: number of coccygeal segments; joint fusion; coccygeal spicules, subluxation, sacralization, and scoliosis; sacrococcygeal straight and curved lengths and curvature indices; sacrococcygeal and intercoccygeal angles; and lateral deviation of the coccyx tip.

RESULTS

Four coccygeal segments were present in 76 % of scans. Sacrococcygeal fusion was present in 57 % and intercoccygeal fusion was increasingly common more caudally; there was no significant association with age or gender. A bony spicule was present in 23 %. Subluxation was rare. Nine of 12 coccyges with a retroverted tip were female. Mean coccygeal curved length was 4.4 ± 0.8 cm in men and 4.0 ± 0.8 cm in women (P < 0.01). Mean angle between first and last coccygeal segments was 138° ± 25° in men and 147° ± 25° in women (P = 0.08). There was no significant correlation between coccygeal length or curvature and stature, age or BMI.

CONCLUSIONS

In this first detailed study of the CT morphology and morphometry of the adult coccyx, sacrococcygeal and intercoccygeal joint fusion was common. Female coccyges were shorter, straighter, and may be more prone to retroversion, factors that may be relevant to the markedly higher prevalence of idiopathic coccydynia in women.

Cervical fascia: a terminological pain in the neck

Although understanding the cervical fascia and its arrangement is an important part of anatomical, surgical and radiological training, it is inconsistently described in textbooks, which makes its study challenging and interdisciplinary communication confusing. This review examines the recommended textbooks for trainees of these disciplines in order to identify areas of agreement and controversy. Not only were the terms used variably between texts, but also key aspects of the anatomical descriptions associated with similar terms differed, contributing further to the confusion.