Fibroepithelial polyps causing ureteropelvic junction obstruction in children--a case report and review article

Fibroepithelial polyps are extremely rare benign mesodermal tumours in children that can cause ureteropelvic junction (UPJ) obstruction. We report on a 10-year-old boy presenting with UPJ obstruction due to a fibroepithelial polyp, and review 28 similar published paediatric cases.

The management of renal conditions in the perinatal period

Most urogenital abnormalities are now diagnosed antenatally on high resolution ultrasound scans. This has enabled recognition of those that are not compatible with survival and these are managed with termination of pregnancy. Renal anomalies that require surgical intervention continue to pose challenges. Conditions such as multicystic dysplastic kidney can be easily recognised and managed based on the experience gained with long-term studies of its natural history. Polycystic kidney on the other hand while not posing a diagnostic problem remains beyond the reach of therapeutic intervention and postnatal supportive measures are the only available means of dealing with this entity at present. The major difficulty is with the management of antenatally diagnosed pelvicalyceal dilatation. The goal of intervention is to preserve renal function when dilatation is the consequence of obstruction. Unfortunately, by the time ultrasound evidence of significant obstruction is apparent renal damage is already established. Fetal intervention should be considered in those cases where severe oligohydramnios is associated with hydronephrosis, especially in the presence of a solitary kidney or in bilateral disease. Postnatally, all neonates with renal tract dilatation should be managed according to a protocol which mandates serial measurements of renal pelvis diameter and correlates this with data from radionuclide scans. This will enable recognition of kidneys that are at risk of losing function while at the same time avoiding unnecessary surgical intervention in those which remain dilated but are functionally stable.

Acute retention of urine due to prolapsing stoma in a case of anorectal malformation with bladder neck fistula

This case report describes an extremely premature infant who was born with a high anorectal malformation requiring a colostomy soon after birth. He later developed multiple episodes of acute urinary retention complicated by bilateral hydronephrosis and acute renal failure. The cause of the retention was found to be the prolapsing stoma, which was kinking the bladder neck.

When is a mediastinal mass critical in a child? An analysis of 29 patients

The aims of this study were to determine the pattern of presentation of childhood mediastinal masses in our community and to identify factors associated with the development of acute airway compromise. The authors retrospectively reviewed the records of 29 consecutive patients with mediastinal masses managed at their institution between January 1995 and December 2001. Demographic data, mass characteristics, clinical presentation, and surgical procedures were recorded. Seven patients (24.1%) were asymptomatic at presentation. Eight (27.6%) were classified as having acute airway compromise at presentation. Respiratory symptoms and signs were the most common mode of presentation (58.6% and 55.2%, respectively). The most common histological diagnosis was neurogenic mass (37.9%), followed by lymphoma (24.1%). Most masses were located in the superior mediastinum (41.1%). Factors associated with the development of acute airway compromise were (1) anterior location of the mediastinal mass (P=0.019), (2) histological diagnosis of lymphoma (P=0.008), (3) symptoms and signs of superior vena cava syndrome (P=0.015 and 0.003, respectively), (4) radiological evidence of vessel compression or displacement (P=0.015), (5) pericardial effusion (P=0.015), and (6) pleural effusion (P=0.033). Clinical presentation of childhood mediastinal masses is often nonspecific or incidental. Yet they have the propensity of developing acute airway compromise, which is closely associated with superior vena cava obstruction. Such patients should be managed as a complex cardiorespiratory syndrome, termed "critical mediastinal mass syndrome", by an experienced multidisciplinary team.

Pleuropulmonary blastoma with a large embolic cerebral infarct

We report on a 3-year-old girl who developed a large embolic cerebral infarct 1 day after an uneventful thoracotomy to remove a large pleuropulmonary blastoma. The tumour had encased the heart and great vessels and ruptured into the left hemithorax. Pleuropulmonary blastoma is a rare, but unique, primary thoracic neoplasm in young children and, to our knowledge, the development of a secondary large embolic cerebral infarct is also uncommon and has not been reported in this tumour.

Carbon dioxide laser circumcisions for children

The carbon dioxide laser for circumcision was introduced by our department in 1989. This study aims to review our experience with laser circumcision for children and to evaluate its cost effectiveness as compared to conventional methods. A retrospective study of 30 patients who underwent conventional circumcision in 1985 and another 30 patients who underwent laser circumcision in 1995 was undertaken. The operating times in both groups were compared. The total cost of use of the laser machine was calculated, taking into account maintenance costs, estimated life span of laser machines (10 years) and costs of disposables used during each circumcision. This was weighed against the cost savings from shorter operating times and reduced operating theatre facility charges. Also, morbidity data from 2781 laser circumcisions done between May 1997 and April 2000 was collected. There was a significant decrease of 5 minutes in operating time for the group of patients who underwent laser circumcision. Calculated cost savings per laser circumcision from the reduced operating theatre time was S dollars 31/-. Of the 2781 cases of laser circumcision performed, there was an overall complication rate of 1.15%. Twenty-nine cases (1.04%) had post circumcision bleeding, of which 10 cases (0.36%) required unplanned return to operating theatre for hemostasis. Three cases (0.11%) had wound infection, requiring admission to hospital. Laser circumcision is a simple method with reduced operative time translating into cost effectiveness. Morbidity rates of laser circumcision compare favourably to those of conventional circumcision based on reports from other institutions.

One-stage surgical correction of proximal hypospadias

INTRODUCTION

Proximal hypospadias poses major problems in surgical correction owing to the complexity and severity of the abnormalities, leading to the use of staged repairs to correct this condition. However, with precise definition of the components of this deformity a single-stage operation can be developed and applied successfully for surgical correction of this condition.

MATERIALS AND METHODS

Twenty-six patients with severe proximal hypospadias were subjected to a one-stage repair. Excision of proximal fibrotic dartos tissue and removal of dysplastic urethral plate tissue corrected chordee completely. Urethral reconstruction was then performed by tubularising a flap of dorso-lateral preputial skin which was then anastomosed to the proximal urethra. The glandular part of the urethra was reconstructed using the distal part of the flap as an onlay graft over the meatal groove. The suture lines were covered with a layer of dartos tissue and skin closure was completed by transposing dorsal skin to surface the ventral penile shaft. A urethral catheter was left in for 10 days.

RESULTS

All patients have been followed up after surgery from 1 to 5 years with a median period of 2 years. There were no fistulas. Two patients had mild stenosis at the meatus which responded to dilatation. One patient developed a stricture at the proximal anastomosis which required secondary correction. All other patients achieved satisfactory correction, both in terms of voiding and in the cosmetic appearance of the genitalia.

CONCLUSION

Single-stage repair of hypospadias can be successfully applied in the correction of severe proximal hypospadias. It requires meticulous dissection and careful design of reconstructive techniques. The end results are comparable to staged procedures and morbidity is significantly lower.

Comparing wound closure using tissue glue versus subcuticular suture for pediatric surgical incisions: a prospective, randomised trial

Tissue adhesives have gained favour for quicker and painless closure of lacerations. To compare the tissue adhesive 2-octylcyanoacrylate with our current standard subcuticular suture for closure of surgical incisions in children, looking at outcome measures of time efficiency, cosmesis, and wound complications, a prospective, randomised, controlled trial was conducted at our institution's ambulatory surgery centre. All healthy patients undergoing unilateral or bilateral herniotomies were recruited prospectively with informed consent and randomly allocated to suture or glue. The exclusion criteria were neonates or children with allergy to tissue glue. Time of wound closure was measured from the subcutaneous layer to application of the dressing. An independent, blinded observer assessed cosmesis at 2 to 3 weeks using a validated wound scale ranging from worst (0) to best (6). Parent satisfaction with wound appearance was recorded on a 100-mm visual analogue scale (VAS). A total of 59 patients were recruited into the study with 26 in the glue group and 33 in the suture group. There was no difference in mean time of closure (glue 181 +/- 62 s vs suture 161 +/- 45 s, P = 0.18). Two patients in each group had a suboptimal Hollander wound score of 5 (7.7% glue, 6.1% suture). There was also no difference in parent satisfaction (VAS: glue 78 +/- 19 mm vs suture 81 +/- 15 mm, P = 0.68). No patient reported any rash, wound infection, or dehiscence. Tissue glue is easy to use with no complications and has equivalent cosmetic results, but is not faster than a subcuticular suture.

Clinics in diagnostic imaging (61). Left primary megaureter with lower ureteric stone

Megaureter is infrequently diagnosed in adulthood. A 27-year-old man who presented with recurrent left loin pain was found to have megaureter on intravenous urography. His symptoms did not resolve after balloon dilatation of the 3 cm stenotic aperistaltic segment of the lower ureter. He eventually underwent ureteric re-implantation with satisfactory symptomatic relief. The resolution of obstruction was demonstrated radiologically. The role of imaging in the diagnosis and surveillance of megaureter, as well as indications for intervention, are discussed.

Experience with video-assisted thoracoscopic surgery in the management of complicated pneumonia in children

PURPOSE

The aim of this study was to assess the impact of video assisted thoracoscopic surgery (VATS) in the management of empyema in children.

METHODS

This report involves cases of complicated pneumonia in children requiring surgical intervention after failure of medical treatment with antibiotics, with or without drainage from November 1997 to October 1999. The impact of VATS has been studied prospectively from October 1998 when VATS was introduced. The results have been compared with the previous year when similar cases were dealt with open thoracotomy. These 2 groups of patients with VATS (V) or without VATS (O) were studied for their progress in hospital and the final outcome.

RESULTS

A total of 39 immunocompetent children with community-acquired pneumonia were studied. There were 17 cases in O and 22 in V. There were 2 conversions to open thoracotomy in V. Both of these cases required resection of the lung parenchyma for severe necrosis and bronchopleural fistula. The mean age in years was 5.3 (O) and 4.9 (V). Parameters that were significantly less in V compared with O include timing of referral (O, 13.6 days; V, 5.3 days), number of lung resections (O, 8; V, 2), blood transfusion (O, 14; V, 2), analgesia requirements (O, 7.8 days; V, 2.9 days), postoperative length of stay in hospital (O, 10.4 days; V, 4.6 days), time to become normothermic (O, 5.6 days; V, 1.7 days); and time to removal of chest drains (O, 6.0 days; V, 2.7 days). Cosmesis is superior in cases of VATS compared with open thoracotomy. All the children recovered well on follow-up with resolution of symptoms and no recurrences.

CONCLUSIONS

(1) VATS has ushered in a new era of hope for patients with complicated pneumonia. (2) Thoracotomy, lung resections, and the attending morbidity rate have decreased. (3) Patients are being referred earlier by the physicians because the management protocol is changing.

Salmonella typhimurium: a rare cause of colonic ulceration and perforation in infancy

A rare case of a healthy infant with colonic ulcers caused by Salmonella typhimurium infection that presented with colonic perforation, hypovolemic, and septicemic shock is discussed. It stresses the importance of considering an infective process such as salmonellosis in the differential diagnosis of colonic ulceration in an infant and illustrates the unique histologic finding of colonic inflammatory changes with sparing of the small intestine.

A combined tubularized/onlay graft technique for total correction of severe hypospadias

BACKGROUND/PURPOSE

A combined tubularized/onlay graft technique is described for the complete correction of chordee with urethroplasty in a single stage in cases of severe hypospadias.

METHODS

Twenty-two patients with severe hypospadias ranging in age from 9 months to 11 years underwent single-stage correction using a technique developed by the author. In this method, chordee is first completely excised by removing all fibrotic tissue both proximal and distal to the urethral orifice, preserving the meatal groove. A dorsolateral preputial flap is then raised and tubularized to form the neourethra. The proximal end of this tube is anastomosed to the urethral opening using a continuous absorbable suture. Two parallel incisions are made in the glans on either side of the meatal groove. The distal part of the neourethral flap is laid over the groove and sutured on either side to create the glanular part of the urethra, after which the glans is reconstructed with the new meatal opening at the tip. The neourethral suture line is covered with a layer of vascularized subcutaneous tissue to protect against fistula formation, and the rest of the preputial skin is transferred ventrally to provide cover for the penile shaft.

RESULTS

There were no major complications with minimum follow-up of 20 months. Meatal stenosis developed in two patients, and one had stricture at the proximal anastomosis. These were treated successfully with minor corrective procedures. All other patients had good results, and there were no cases of fistula.

CONCLUSIONS

The method described has proved successful in the surgical correction of severe hypospadias in a single stage. It is easily adapted to permit urethral reconstruction after varying degrees of tissue excision required to obtain satisfactory correction of chordee. Patients do not need to undergo multiple procedures, and no major complications were encountered in this series.

The viability of liver graft for transplantation after prolonged warm ischaemia

Maximum duration of warm ischaemia within which the liver graft is viable for transplantation remains undefined. Published data on porcine allogeneic liver transplantation (LTx) using non heart beating donors (NHBDs) are conflicting because technical details like the hepatic artery status, systemic heparinisation of donor animals and duration of rewarming were not addressed. We described a novel porcine model which simulate conditions of transplantation from NHBDs. The pigs were divided into three groups of 6 each. Groups I, II and III were subjected to 60, 90 and 120 minutes of warm ischaemia, respectively. Liver viability was assessed using four parameters: serum liver function tests (serum bilirubin and transaminase), dynamic liver function test i.e. the monoethylglycinexylidide (MEGX) formation test, morphological assessment and animal survival. All animals in groups I and II (90 minutes of warm ischaemia or less) survived but 50% of animals in group III died of massive liver failure. Given that rewarming period required in actual allogeneic LTx is about 60 minutes, the safe period for intervention in NHBDs is determined to be about 30 minutes. Allogeneic porcine LTx using NHBDs with 30 minutes of cardiac arrest were performed in 5 animals. All of them survived.

Pudendal-thigh flap vaginoplasty in the reconstruction of genital anomalies

Children with abnormal genitalia associated with intersex anomalies or cloacal malformations require vaginal reconstruction. Although many procedures using skin grafts, skin flaps, and intestinal segments have been described, they all have disadvantages. In the present study 12 patients with genital defects who required vaginoplasty underwent surgery using a new technique using bilateral pudendal-thigh flaps based on the posterior labial artery. There were six patients with congenital adrenal hyperplasia (CAH), three with vaginal atresia, two with cloacal deformities, and one with testicular feminizing syndrome. Four of the CAH patients and the two with cloaca underwent vaginoplasty as second-stage procedures. All other cases were treated with one-stage operations. This method of vaginoplasty can be combined with correction of other associated abnormalities, and it has proved to be simple and reliable with satisfactory functional and cosmetic results.

Mortality among infants with high-risk congenital diaphragmatic hernia in Singapore

Several factors suggested to predict mortality in congenital diaphragmatic hernia (CDH) have not always been applicable in different centers. A retrospective review was conducted of 19 consecutive neonates in Singapore in whom CDH was diagnosed within 12 hours of birth to identify factors associated with mortality. Of the 19 cases, 15 (79%) were diagnosed using antenatal ultrasonography. Eight (42%) underwent primary repair at a median age of 23 hours (range, 12 to 50 hours). Of the 19 infants, 15 died (mortality rate, 79%). Survivors until hospital discharge were compared with nonsurvivors. Antenatal diagnosis and stomach position in left-sided defects had no effect on outcome, although polyhydramnios tended to be associated with nonsurvival. Significant postnatal factors associated with mortality included a low arterial pH level, low initial arterial-alveolar oxygen ratio, high initial alveolar-arterial oxygen gradient, as well as high oxygenation and ventilation indices. These results reflect difficulty in oxygenation because of pulmonary hypoplasia despite evidence of adequate ventilation. There was no difference between survivors and nonsurvivors in either their initial or best postductal blood gases. The "Bohn quadrants" did not aid in predicting survival of infants who underwent repair because all eight such infants had best postductal carbon dioxide values of less than 40 mm Hg and ventilation indices of less than 1,000. Yet only four (50%) survived until hospital discharge. Large-scale evaluation of these factors may be required in the future to demonstrate their validity and reliability because of changing management strategies for CDH.

A new approach to the surgical correction of buried penis

Buried penis has been variously attributed to obesity with excessive suprapubic fat, severe phimosis with trapping of the penis within the prepubic tissues, and inadequate fixation of the penile shaft skin at the base resulting in tenting. Previous attempts at surgical correction, by excising suprapubic fat, fixing penile shaft skin to the base of the penis, and circumcising, have failed to give satisfactory results and, indeed, procedures like circumcision will make the condition even worse. The technique developed by the author is based on the recognition that this condition exists because of the displacement of the root of the penis below its normal position, resulting in the surrounding fat and dartos tissues enveloping the penile shaft. In this procedure, dissection at the root of the penis is carried out deep down to the corporal bodies. All fibrotic tissue that binds the penile shaft is excised. The lengthened penile shaft is anchored at its base by suturing the surrounding tissue onto the tunica. This technique has been applied in 22 patients ranging in age from 5 months to 11 years. Apart from two technical problems, all other patients had satisfactory correction with good functional results.

Single stage excision of preauricular sinus

A total of 44 patients with preauricular sinus underwent one-stage surgical treatment. There were 32 unilateral and 12 bilateral cases giving a total of 56 sinuses. Of these 16 were infected at the time of presentation. Based on the observation that preauricular sinus represents the duct of a preauricular gland which is closely adherent to the fibrocartilage of the ear, the authors propose a method for the complete cure of this lesion by excising the whole gland and duct together. This technique was used in all cases including 16 patients with infected sinuses. There were three recurrences, two of which were due to incomplete excision of the gland. The third case was found to have a fistula leading to an atretic external auditory canal. All other patients have shown no evidence of recurrence on follow up of six months or longer. Our experience has shown that preauricular sinus can be effectively treated at any stage by a simple surgical technique based on a clear understanding of the underlying anatomy of the lesion.

Congenital tracheobiliary fistula

A case of congenital tracheobiliary fistula with absent common bile duct is reported. The patient presented with repeated aspiration pneumonia, and the diagnosis was established during bronchoscopy. Excision of the fistula and cholecystoduodenostomy were successful. This is the fourth reported case of its type and the first one to survive surgical treatment. The condition is a rare cause of respiratory distress in neonates and should be considered in the differential diagnosis of intractable aspiration pneumonia.

Surgical techniques and long-term results in the treatment of choledochal cyst

A personal follow-up of 52 cases of choledochal cyst managed over a 28-year period has provided a unique opportunity to review the long-term problems and outcome. Eleven patients had internal drainage procedures and at least four have developed cholangitis more than 10 years later, with three requiring reoperation and cyst excision. Of the 41 patients who had cyst excision, 34 were performed personally by the author; 33 have remained completely well, whereas one died subsequently of cholangiocarcinoma. Complete cyst excision can be successfully achieved provided the dissection of the distal part of the cyst is carried out in a clear, bloodless field obtained by working directly on the cyst wall beneath the overlying loose areolar tissue. Partial excision, mucosectomy, and operative cholangiograms have not been found necessary. This study provides conclusive evidence that any anastomosis of cyst wall to the gastrointestinal tract will ultimately result in stricture and cholangitis.

Chemotherapy for hepatoblastoma in children

Hepatoblastoma is an uncommon but highly malignant liver tumour found in childhood. It is associated with high mortality with overall survival of only 35%. Two cases of hepatoblastoma are described. Both had surgical excision of tumour with microscopic residual tumour at the resected margins. They were given adjuvant chemotherapy. Both patients are living well, disease-free and off treatment six years and two years since diagnosis.

Accuracy of anorectal manometry in the diagnosis of Hirschsprung's disease

The value of anorectal manometry as a diagnostic tool for Hirschsprung's disease (HD) was assessed in 50 children presenting with chronic constipation. Anorectal manometric studies and rectal biopsy were performed on all children. Biopsy specimens were stained with hematoxylin and eosin and serial sections were examined for ganglion cells. Forty-five children had concordant manometric and histologic results, 15 of whom were positive for HD and 30 negative. In five children, the results were discordant. Using histologic aganglionosis as the reference point for the final diagnosis of HD, the overall accuracy of anorectal manometry as a discriminative test was 90.0%. The sensitivity, specificity, and positive and negative predictive values of manometric studies for the diagnosis of HD were 0.79, 0.97, 0.94, and 0.88, respectively. Factors responsible for the inaccuracies of manometric studies are discussed.

A new technique of vaginal reconstruction using neurovascular pudendal-thigh flaps: a preliminary report

The blood supply to the skin of the perineum, medial groin, and upper thigh was studied in fresh female cadavers. The pudendal-thigh flap was designed as a result to reconstruct the vagina. The flaps are raised bilaterally in the groin crease just lateral to the labia majora and then are transposed toward the midline and sutured together to form a skin-lined cul-de-sac which opens at the introitus. The technique has been used successfully in three patients to reconstruct the vagina. The first patient, an adult, was reconstructed after total pelvic exenteration for malignancy, while two children had reconstructions for congenital vaginal anomalies. This technique is superior to currently available methods because it is simple and reliable. No stents or dilators are needed. It is safe technique without complications in our hands. The reconstructed vagina has a natural angle for intercourse and is sensate. The donor scars in the groin are well hidden.

Acute appendicitis in Singapore children--some clinical aspects

This retrospective study of 132 patients less than 12 years of age with Appendectomy done for Acute Appendicitis showed histological confirmation in 106 patients (80.3%) and a "negative appendix" rate of 19.7%. The appendix was perforated in 31 patients (23.5%). In those patients with confirmed Acute Appendicitis, males predominate (1.7 males: 1 female) and the peak incidence was in those 9 years of age or more. Abdominal pain was present in all patients except a 13 month old infant. Abdominal tenderness was also elicited in all patients except one. Fever was present in 83 patients (78.3%), vomiting in 82 patients (77.4%) and diarrhoea in 19 patients (17.9%). There were 2 deaths in this review, giving a mortality rate of 1.9%. Postoperative complications include wound infection (13.2%), pelvic abscess (0.9%), ileus (0.9%) and adhesion obstruction (0.9%).

Problems and pitfalls in the management of Hirschsprung's disease

A study of 126 patients with histologically proven Hirschsprung's disease revealed various problems associated with the surgical management of these cases. Complications such as prolapse, stricture, and cuff abscess were noted in patients undergoing endorectal pull-through (ERPT). These complications were not always obvious, and in some cases, the diagnosis became apparent only several years after definitive surgery. Specific technical aspects of the procedure probably play an important role in the pathogenesis of these problems. Ultrashort-segment Hirschsprung's disease remains a problem in treatment. Rectal myectomy gives good results in some cases and unsatisfactory results in others.

Experiences in the treatment of neuroblastoma

The clinical presentation, diagnosis and treatment of a series of 18 cases of neuroblastoma is reviewed. About half the patients were below the age of 2 years. Fever, loss of weight and appetite appeared to be the common manifestations, underscoring the vague and non-specific symptomatology of such a grave childhood disorder. Unusual presentations included paraplegia, chronic diarrhoea, lower limb edema and respiratory distress. Management consisted of radical surgery with adjunctive chemotherapy where indicated. It is emphasised that in resectable lesions every attempt must be made to remove tumour involved tissue as thoroughly as possible. With this approach 50% of patients followed up to 4 years have survived. Comparison of characteristics of survivors against non-survivors showed that the only significant difference was in the state of the disease--survivors having generally earlier state tumours.

Experience in the surgical management of Hirschsprung's disease

The clinical presentation, surgical treatment and results in a group of 126 patients with histologically proven Hirschsprung's disease are presented. This study has enabled the authors to identify various problems and complications associated with the management of this condition. The typical clinical picture in the neonate has been observed in only 45.2% of our cases. In the long segment Hirschsprung's, especially those presenting with bowel perforation, the precise localisation of the aganglionic segment has been difficult. The standard surgical procedure in our department has been the mucosal-stripping endorectal pull-through operation. The problems of prolapse, stricture and cuff abscess associated with this procedure are, related to specific technical aspects of the operation which we believe have not been emphasised previously. Our current experience with this type of procedure has enabled us to carry out definitive surgery in early infancy without preliminary colostomy. The results justify our confidence that this approach to the surgical management of neonatal Hirschsprung's disease will become the standard procedure in our practice. An unusual feature has been the relatively common occurrence of the short segment type of Hirschsprung's disease--30.2% with rectal aganglionosis and 7.1% with ultrashort segment disease. This group has posed a dilemma as to the selection of the most appropriate surgical procedure. Rectal myectomy, which was the operation of choice, has given excellent results in some cases and yet in other cases it has been unsatisfactory, leading to the development of very gross megacolon.

Anorectal malformations and their associated anomalies

Congenital malformation of the rectum and anus is a problem frequently encountered in the neonatal period. 88 patients presenting with anorectal malformations were analysed and physical, operative, radiological and autopsy findings were reviewed to determine the types and incidence of associated lesions. Genitourinary malformations form the major group of associated lesions and contribute a significant degree of morbidity in the overall management of the anorectal deformities.

Estimation of glomerular filtration rate in children using 99m-technetium DTPA. A comparison with 51-chromium EDTA clearance

The usefulness of radionuclide imaging studies with 99m-technetium diethylenetriaminepentaacetic acid (Tc-DTPA) for quantitating the glomerular filtration rate (GFR) in children was studied. This was compared to the conventional methods for measuring GFR using 51-chromium-EDTA clearance (Cr-EDTA), creatinine clearance and a height/plasma creatinine formula. In the 22 children studied, the correlation coefficient between renal uptake of DTPA and Cr-EDTA was 0.90 (p less than 0.001). In contrast, there was a poorer correlation between Cr-EDTA and creatinine clearance (r = 0.69) or the derived GFR using height/creatinine formula (r = 0.83). The regression line between Tc-DTPA uptake and Cr-EDTA clearance was used to derive a formula for calculating the predicted GFR. This was tested in 10 additional children, and the correlation between the predicted GFR and measured GFR (using Cr-EDTA clearance studies) was 0.92 (p less than 0.001). Quantitative estimation of the GFR during renal imaging studies is a feasible and convenient method of assessing renal function.

Endoscopic surgery of posterior urethral valves

Although posterior urethral valves were described more than sixty years ago, the surgical treatment of this condition has only recently been technically feasible. This paper is a review of 15 cases of posterior urethral valves treated over a 3 year period in the Department of Paediatric Surgery, Singapore General Hospital. The commonest clinical presentation was urinary tract infection. The upper urinary tract was normal in only six cases. In 14 out of the 15 cases primary surgical treatment of the valve was carried out with satisfactory results in 13 patients.

Pelvi-ureteric junction obstruction in Singapore children--a retrospective study

Thirty-two cases of hydronephrosis caused by pelvi-ureteric junction obstruction, presenting to the Department of Paediatric Surgery in the last 6 years were reviewed. In both infants and older children a palpable abdominal mass was the most common mode of presentation. Anderson-Hynes pyeloplasty was performed in a total of 31 kidneys. In 4 children, whose kidneys were severely hydronephrotic and with hardly any renal parenchyma present a primary nephrectomy was performed. Of the two children who required further operation on the same kidney, a repeat pyeloplasty for persistent obstruction was required in 1 patient, the other patient underwent nephrectomy subsequent to pyeloplasty as a severe pyonephrosis had developed. Twenty-nine of the 31 kidneys were assessed postoperatively by tube nephrogram, intravenous pyelogram (IVP), or diuretic renography. Four kidneys were found to be non-functional or severely damaged.

Vesico-ureteric reflux in Singapore children--a survey of surgically treated children

A survey of 29 cases of vesico-ureteric reflux treated surgically at the Department of Paediatric Surgery, Singapore General Hospital, between 1974 and 1981 was carried out to assess the Singapore experience with the disease. There was a 2:1 female predominance but proportionately more males presented before 6 months of age (sex ratio 1:1). In contrast to Caucasian children, the peak incidence is below one year of age, and demonstrates the importance of recognising the condition early in infancy. Correspondingly, the most frequently presenting symptom is fever, as a result of urinary tract infection. In contrast, enuresis is uncommon (unlike in Caucasian children, where the peak incidence is at a later age). There is no predilection to unilateral, bilateral or side of involvement. Ectopia lateralis and patulous ureteric orifices were the most commonly identified structural defects. E. Coli and Klebsiella were the most commonly occurring organisms among those with urinary tract infections, and Ampicillin or Bactrim was adequate for most cases.

Neonatal total gastrectomy

A 2-day-old, female infant underwent total gastrectomy for spontaneous gastric gangrene and perforation. She developed the following complications: growth retardation, vitamin B12 deficiency, post-gastrectomy dumping syndrome, and occasional bile regurgitation. Nutritional management is described. The two previously reported survivors of total gastrectomy in the neonatal period are reviewed.

Early gastric cancer in Singapore

Gastric cancer is one of the commonest malignancies in Singapore. 330 to 350 new cases are reported annually. Only about 8% of these cases undergo curative resection and the rest receive some form of palliative surgery. Early gastric cancer (i.e., cancer limited to mucosa and submucosa) is rarely diagnosed in Singapore. This paper presents 11 cases of early gastric cancer treated successfully by various Departments of Surgery over the past 5 years. All patients are well and free of tumour to date. The aim of this presentation is to remind clinicians of the importance of detecting early gastric cancer which has more than 90% 5 year survival rate.

One stage repair of hypospadias

The surgical repair of hypospadias has evolved from the multi-staged procedures of the previous decade to single stage urethroplasty. A number of techniques have been described and this report is a study of the experience in 44 cases using 4 different types of repair. All patients were Chinese and their ages ranged from 1 year to 23 years, with about half the cases below 5 years of age. The most commonly used method of repair was the transverse preputial flap technique of Duckett (25 out of 44 cases). The overall results indicate a fistula rate of 20%. The detail correlation of complications with age, type of hypospadias and type of repair illustrate the general principle that while age is not a significant factor, with the more severe types of hypospadias, the complication rate is definitely increased.

Undescended testis: a study of 212 cases treated surgically

Two hundred and twelve of undescended testes were operated on in the Department of Surgery, Singapore General Hospital between the years 1974 through 1980. There was a 51.9% incidence of right undescended testis, 34.9% left undescended testis and 13.2% were bilateral. The method of treatment was surgical exploration with orchidopexy wherever technically feasible or orchidectomy if the testis was found to be severely hypoplastic. Of the total series, 42% were operated on before the age of 5 years. The oldest patient undergoing orchidopery was aged 40. Failure of orchidopexy to secure the scrotal position for the testis was noted in 14 cases. This was probably due to inadequate mobilisation at the first operation. There was no mortality and no significant morbidity following surgical treatment in this series.

Adenomyoma of the pylorus presenting as intestinal obstruction with pseudomyxoma peritonei--a case report

Adenomyoma of the stomach is an exceedingly rare and benign tumour. We report here what we believe to be the first documented case in Singapore. Our patient is unique in three respects; an eight-week old infant presented with signs and symptoms of intestinal obstruction. Operative findings showed a small tumour in the pylorus of the stomach. The abdominal contents were covered with a colourless mucous slime, giving an appearance of pseudomyxoma peritonei. This is a feature which has not been hitherto reported. Microscopically, the lesion was consistent with adenomyoma of the pylorus. The interesting feature is an abundant production of mucin, with rupture and spillage of mucin in some of the glandular structures. We believe that this may account for the appearance of a pseudomyxoma peritonei seen in our patient.

Infantile hypertrophic pyloric stenosis: surgical experience of 24 cases

Twenty-four patients with infantile hypertrophic pyloric stenosis were admitted to the University Department of Paediatrics, Singapore General Hospital, from 1974 to 1980 were reviewed. The male to female ratio was 2.4:1. The age of onset of vomiting ranged from birth to 7-week. All except 2 had palpable pyloric tumour. Barium meal studies were required in these two patients to confirm the diagnosis preoperatively. Significant abnormal laboratory findings on admission were: metabolic alkalosis (71%), hypochloraemia (63%), hyponatraemia (54%), hypokalaemia (21%), haemoconcentration (39%) and pre-renal azotaemia (17%). Two-thirds of the patients were operated within 24 to 48 hours after intravenous correction of fluid deficit and electrolyte imbalance. Common complications after Ramstedt's pyloromyotomy were vomiting and fever which were, however, mild and subsided in two to three days. Serious complications were uncommon and there was no mortality in this series. Majority of the patients were discharged well after one to two weeks of hospitalization.

Surgical experience with lymphangioma in infants and children

Twenty-nine consecutive cases of lymphangioma seen and managed at the Department of Surgery, Singapore General Hospital, between August 1974 and January 1981 are reviewed here. More than half the lesions (58.6%) were noted at birth and about 90% presented during the first year of life. All patients were treated by surgical excision soon after recognition, in order to prevent extensive local growth and expansion which can encroach on vital structures such as nerves, major vessels and the trachea. Surgical resection was complete where possible, with preservation of vital structures. There were no deaths. Morbidity was confined to wound infection and haematoma, respiratory distress and in one case, a facial palsy. Eight patients required two or more operations for complete excision.

Malignant tumours of the undescended testis: a report of three cases

Three cases of testicular malignancies arising in undescended testes were treated in the Department of Surgery, Singapore General Hospital. The patients were all adult Chinese male who presented with tumours arising in unilateral, intra-abdominal undescended testes. Two of the tumours were seminomas while the third was a choriocarcinoma. In all 3 cases, the tumours were large and at an advanced stage at the time of presentation. The treatment in these cases was surgical excision of the primary lesion followed by radiotherapy or chemotherapy. The patient with choriocarcinoma died soon after chemotherapy was initiated while the other two cases are alive, one for over 6 years with no recurrence.