Browsing by Department "Division of Paediatric Surgery"

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    Open Access
    Advantages of MesoRex shunt compared with distal splenorenal shunt for extrahepatic portal vein occlusion in children
    (2023) Khamag, Omer; Numanoglu, Alp
    Background: Portal hypertension (PH) is a common complication of chronic liver or portal vein pathology in children. It is defined as a pathological increase in the pressure of the portal venous system. There are two leading causes for PH in children, pre and post sinusoidal liver disease and pre-hepatic non-cirrhotic portal vein obstruction, also referred to as extrahepatic portal vein obstruction (EHPVO). Management of EHPVO is primarily surgical, with surgical portosystemic shunting representing a safe and effective method for the long-term management of portal hypertension in the paediatric population. Although different shunts have been proposed for EHPVO, both the MesoRex shunt and distal splenorenal shunt have shown the most promising results as effective and definitive approaches to alleviating EHPVO. Aim: To review surgical management of extrahepatic portal vein obstruction (EHPVO) at Red Cross War Memorial Children's Hospital (RXH) and compare MesoRex shunt (MRS) with distal splenorenal shunt (DSRS). To determine and compare the shunt success rate, defined as longterm patency at 24 months of the MesoRex shunt and distal splenorenal shunt, the factors that could have influenced the patency of the Rex vein and the effect of these procedures on the long-term synthetic liver function. Methods: This study followed a retrospective study design, conducted at a single centre documenting pre- and post-operative data in 21 children, 14 MRS and 7 DSRS, All patients presented to RCWMCH with EHPVO over an 18-year period (2001-2019) were eligible for inclusion either for MRS or DSRS. Exclusion criteria included patients lost to follow up, patients who had atypical shunts not falling into either the DSRS or MRS operation and those with insufficient or missing clinical records over 18 years. Details of patient demographics included age, gender, aetiology, preoperative symptomatology, Rex vein patency, history of neonatal umbilical vein catheterization (UVC), age at shunt surgery and shunt patency were compiled over an average follow up period of 11 years (2-18). Bloodwork analysis included albumin, prothrombin time (PT), partial thromboplastin time (PTT), International normalized ratio (INR), fibrinogen, total bilirubin, liver enzymes and platelets prior to and two-years-post shunt surgery. Rex vein patency was assessed preoperatively. Statistical significance was determined at P<0.05 following a two-tailed t-test. Results: Out of 23 patients presenting with EHPVO, two children lost follow up immediately after diagnosis and were excluded. Twenty-one patients were operated on and followed up long term, with 14 patients (66%) in the MesoRex shunt group and seven patients (33%) in the distal splenorenal shunt group. Fourteen of the 15 MesoRex procedures (93%) were deemed successful in comparison to five out of seven (71%) in the distal splenorenal shunt group. Significant improvements were seen in MesoRex shunt recipients regarding the levels of Albumin, PT, PTT, and platelets. The other liver functions measured, including INR, fibrinogen, total bilirubin, ALT, AST, GGT, and ALP, were within the normal physiological range. The distal splenorenal shunt cohort only yielded a significant improvement in the platelet count, increasing from a mean value of 100 to 149.83 (P = 0.02). Out of those who showed successful surgical intervention in the long term (14 in MRS and 5 in DSRS cohorts), only one child with MRS experienced 2 episodes of variceal bleeding despite having patent shunt with adequate flow (more than 20cm/second). However, no further surgical intervention was needed, and the bleeding resolved spontaneously. Conclusion: This study highlights that MesoRex shunt has a better long-term outcome in extra hepatic portal vein obstruction and improves liver synthetic function and must be considered as the primary definitive intervention. DSRS does control variceal bleeding due to extra hepatic portal hypertension but may have a negative effect on liver function on long term and is only considered when MRS is not technically feasible or as a salvage procedure when MRS fails.
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    Birth prevalence of ano-rectal malformations for the Western Cape Province, South Africa
    (2016) Theron, André Pieter; Numanoglu, Alp
    Background: Anorectal malformations (ARMs) are a major birth anomaly worldwide. South Africa has ethnically and geologically diverse populations. A recent publication indicated an increased birth prevalence of ARMs in the Witwatersrand referral area between 2005 and 2010. The purpose of this study was to determine the birth prevalence of ARM and its various sub - types in the Western Cape referral district over an 8 year period Methods: For an eight year period from 01 January 2005 to 31 December 2012; retrospective data was collected from the Paediatric Surgical Departments of Red Cross War Memorial Children's Hospital, Tygerberg Children's Hospital as well as the private sector health registries. The number of live births per year for a specific municipal district was obtained from the National Department of Health. The Chi square for trend test was used to determine statistical significance. Results: The birth prevalence for ARM in the Western Cape Province in 2012 was shown to be 1:5572 live births (1.79/10 000 live births). The West Coast Municipality district had the highest average birth prevalence rate of 1:3063 (3 .26/10 000) live births for years studied. There was a male predominance (1.6:1), the most common ARM was the vestibular fistula (19.2%) and in 26% of the patients there was an initial delay in the diagnosis. Conclusion: This study has provided some recent data for ARMs for the Western Cape Province. There was no statistical significant change in the prevalence of ARMs over the eight year period for the Western Cape Province as well as in any of the individual six municipal health districts. ( χ2 for trend p=0.52) . The number of delayed diagnosis of ARM is of concern.
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    Correction to: Better recognition, diagnosis and management of non-IgE-mediated cow’s milk allergy in infancy: iMAP—an international interpretation of the MAP (Milk Allergy in Primary Care) guideline
    (BioMed Central, 2018-01-25) Venter, Carina; Brown, Trevor; Meyer, Rosan; Walsh, Joanne; Shah, Neil; Nowak-Węgrzyn, Anna; Chen, Tong-Xin; Fleischer, David M; Heine, Ralf G; Levin, Michael; Vieira, Mario C; Fox, Adam T
    Abstract In the original version of this article [1], published on 23 August 2017, an incorrect version of Additional file 4 has been used. The corrected version of Additional file 4 is given in this correction.
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    Correlation of 99mTc Sucralfate scan and endoscopic grading in caustic oesophageal injury: An observational analytic study at Red Cross War Memorial Children’s Hospital
    (2018) Nondela, Babalwa Bukeka; Numanoglu, Alp
    Introduction: Technecium (Tc) 99m Sucralfate scan has been shown to be a reliable and non-invasive screening modality after caustic substance ingestion, followed by oesophagoscopy under general anaesthesia to grade the extent and severity of injury. Aim: To determine a correlation between the 99mTc Sucralfate scan and the endoscopy findings in children presenting with caustic oesophageal injury. Methods: An observational analytic study of children who had both 99mTc Sucralfate scan and endoscopy after caustic substance ingestion at Red Cross War Memorial Children’s Hospital in a period between January 2009 and September 2016. The oesophageal injury was classified into low grade and high grade according to the degree of adhesion on 99mTc Sucralfate scan and modification of Zargar endoscopic grading. Approval of the study by the University of Cape Town Faculty of Health Sciences Human Research Ethics Committee was obtained, REF. 049/2017. Results: Out of a total of 197 children, 40 children were identified who had both investigations done on average 26hours post injury. Low grade adhesion on 99mTc Sucralfate scan was found in 27 children (68%), and all had low grade Zargar’s oesophageal injuries. None of these subsequently developed residual pathology. Thirteen had high grade adhesion and five of these had high grade injury on endoscopy. Three (23%) developed oesophageal strictures. Correlation of 99mTc Sucralfate and endoscopic findings reached statistical significance with a p-value of 0.0014. No morbidity was associated with either the scan or endoscopy. Conclusions: Low grade Sucralfate scan finding has potential to successfully eliminate the need for invasive endoscopy under general anaesthesia and thereby reducing procedure related morbidity, hospitalization and associated costs. However, mandatory endoscopy is required in children with high grade adhesion seen on 99mTc Sucralfate scan. This requires confirmation using a larger prospective study.
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    Extrinsic bronchial compression by primary tuberculous adenopathy, simulating foreign-body aspiration
    (2005) Pitcher, Richard; Hewitson, John
    A 5-month-old boy was well until the day before admission, when he developed a cough. On the morning of admission he was irritable and his mother noticed a blue tinge to his lips during episodes of crying. This prompted her to bring him to the emergency unit at Red Cross Children's Hospital, where he was found to be distressed and cyanosed, with a respiratory rate of 60 beats per minute, a heart rate of 200/minute and alar flaring. His left chest showed decreased air entry, bronchial breathing and dullness to percussion. Oxygen saturation was 66%, improving to 88% on face-mask oxygen. His weight was on the 50th percentile. He was well hydrated, well perfused and had no significant background medical history. A mobile chest radiograph (Fig. 1) showed complete opacification of the left hemithorax, mediastinal deviation to the left and overexpansion of the right lung, which had herniated across the midline. A penetrated anteroposterior (AP) chest radiograph (Fig. 2) showed abrupt 'cut-off' of the left main bronchus.
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    Four decades of conjoined twins at Red Cross Children's Hospital - lessons learned
    (Health and Medical Publishing Group, 2006) Rode, H; Cywes, S; Lawrenson, J; Numanoglu, A; Fieggen, A G; Brown, R A; Davies, M R Q; Hewitson, J P; Hoffman, E B; Jee, L D; Mann, M D; Matthews, L S; Millar, A J W; Peter, J C; Thomas, J; Wainwright, H
    Conjoined twins represent a rare but fascinating congenital condition, the aetiology of which remains obscure. Over the past four decades, the paediatric surgeons at Red Cross Children's Hospital have been involved in the management of 46 pairs of conjoined twins, of which 33 have been symmetrical and 12 asymmetrical. Seventeen symmetrical twins have undergone separation with 22 children (65%) surviving; all of the live asymmetrical twins survived separation. We describe the important features of this unique cohort, outline our approach to management and present the results of this approach. We consider some of the ethical and moral dilemmas we have confronted, and discuss the prenatal diagnosis, obstetric implications and postnatal care of these children, including the relevant investigations and anaesthetic and surgical management. Specific aspects related to the cardiovascular system, hepatobiliary and gastrointestinal tracts, urogenital tract, central nervous system and musculoskeletal system are highlighted.
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    The history of paediatric trauma care in Cape Town
    (Health and Medical Publishing Group, 2006) van As, A B (Sebastian); Rode, Heinz
    Trauma is a leading cause of morbidity, mortality and disability in childhood. In most developed countries where 18% of the population are in the age group 0 - 15 years, injury exceeds all other causes of childhood mortality. In the developing countries of Africa, however, children aged 0 - 15 years constitute 43% of the population and trauma has an even bigger impact on child health.There is an erroneous perception that trauma is not a major health problem in Africa, derived from undue emphasis on mortality statistics alone. Yet, the impact of trauma ought to be measured not only in terms of death, but also the tremendous morbidity and disability caused by injuries, and their socioeconomic consequences.
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    The history of paediatric trauma care in Cape Town
    (Health and Medical Publishing Group, 2006) van As, A B; Rode, Heinz
    Trauma is a leading cause of morbidity, mortality and disability in childhood. In most developed countries where 18% of the population are in the age group 0 - 15 years, injury exceeds all other causes of childhood mortality. In the developing countries of Africa, however, children aged 0 - 15 years constitute 43% of the population and trauma has an even bigger impact on child health.There is an erroneous perception that trauma is not a major health problem in Africa, derived from undue emphasis on mortality statistics alone. Yet, the impact of trauma ought to be measured not only in terms of death, but also the tremendous morbidity and disability caused by injuries, and their socioeconomic consequences.
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    Iatrogenic pneumatosis intestinalis and pneumatosis hepatis
    (2007) Bickler. W S; Alexander, A; Pitcher, R D; Wieselthaler, N; Rode, H
    A term male fetus with meconium-stained liquor was delivered at a peripheral hospital. He developed abdominal distension and bile-stained vomiting shortly after birth. Meconium ingestion was suspected. Gastric lavage was attempted using inappropriately high volumes and concentrations of sodium bicarbonate in this newborn with undiagnosed jejunal atresia. Subsequent abdominal radiographs documented the presence of the jejunal atresia and pneumatosis intestinalis (PI), together with air in both the porta hepatis and liver parenchyma (Figs 1 - 3). The latter features were interpreted as representing necrotising enterocolitis. The child was transferred to Red Cross Children’s Hospital, Cape Town, for corrective surgery.
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    Inhalational burns in children
    (1996) Whitelock-Jones, Linda; Rode, Heinz
    This study began in 1990 in the Burn Unit of The Red Cross War Memorial Children's Hospital (RCWMCH) in Capetown. It came to our attention that children in the Burn Unit developed respiratory problems. These were complications of fireburns, smoke inhalation, explosions and even hot water scalds. They presented with a wide and confusing array of symptoms and many failed to improve with the symptomatic treatment given. Greater understanding of the pathology was needed in order to investigate and manage these problems correctly. The ultimate aim of this study was to establish a treatment protocol that could be followed by junior staff.
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    Local anesthetic wound infusion versus standard analgesia in paediatric post-operative pain control : a randomised control trial
    (2015) Machoki, Mugambi Stanley; Millar, Alastair; Numanoglu, Alp
    Post-operative analgesia currently relies on multimodal therapy including epidural analgesia, intravenous morphine and/or paracetamol (Perfalgan ®) infusion. Local wound infusion has been effectively utilized in adults with promising results but has not been prospectively tested in children undergoing different abdominal operations. The aim of this study was to compare continuous local anesthetic wound infusion to the current standard of care in post-operative pain control in children. Methods: We conducted a prospective randomized, pain assessor blinded trial comparing Bupivacaine wound infusion {Continuous Local Anaesthetic Wound Infusion - CLAWI) in addition to intravenous paracetamol (Perfalgan®) and morphine for rescue analgesia. This was compared to: (a) epidural bupivacaine plus intravenous morphine and Perfalgan® [EPI] for children undergoing open abdominal surgery and (b) intravenous morphine and Perfalgan® infusion alone [standard post-operative analgesia - SAPA] in children undergoing Lanz incision laparotomy for complicated appendicitis. Patients aged between 3 months and 12 years undergoing laparotomy or open appendectomy were randomly selected for local anesthetic wound infusion (CLAWI) versus EPI or CLAWI versus (SAPA) respectively. Exclusion criteria were neurological impairment, post-operative ventilation and history of adverse reaction to bupivacaine. Consent from the guardian, assent from patients above the age of 7 years and ethics approval from the University of Cape Town Human Ethics Research Committee was obtained. The wound infusion catheter ('lnfiltralLong', PANJUNK®) was placed sub-fascially after suture of the peritoneum and 0.2 % bupivacaine 2mls/kg infused on anesthetic reversal followed by 0.2ml/kg/hour thereafter for 48 hours. Pain assessments were performed for each patient at regular intervals by a single assessor who had training in pediatric pain management and who was blinded to the group allocation. The duration of surgery, length of incision, perioperative antibiotics, wound class risk of surgical site infection, time to return to full feeds, drug reactions; hospital stay, surgical site infection and wound catheter and epidural catheter complications were recorded for each patient. Primary outcome measure was total morphine used in the appendectomy-SAPA vs appendectomy-CLAW! group and rescue morphine requirements in the laparotomy-EPI vs laparotomy-CLAWI group. The secondary outcomes were pain control as measured using the FLACC scale, time to full feeds, mobilization and requirement for urinary catheter.
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    Outcome of HIV-exposed uninfected children undergoing surgery
    (BioMed Central Ltd, 2011) Karpelowsky, Jonathan; Millar, Alastair; van der Graaf, Nelleke; van Bogerijen, Guido; Zar, Heather
    BACKGROUND:HIV-exposed uninfected (HIVe) children are a rapidly growing population that may be at an increased risk of illness compared to HIV-unexposed children (HIVn). The aim of this study was to investigate the morbidity and mortality of HIVe compared to both HIVn and HIV-infected (HIVi) children after a general surgical procedure. METHODS: A prospective study of children less than 60 months of age undergoing general surgery at a paediatric referral hospital from July 2004 to July 2008 inclusive. Children underwent age-definitive HIV testing and were followed up post operatively for the development of complications, length of stay and mortality. RESULTS: Three hundred and eighty children were enrolled; 4 died and 11 were lost to follow up prior to HIV testing, thus 365 children were included. Of these, 38(10.4%) were HIVe, 245(67.1%) were HIVn and 82(22.5%) were HIVi children.The overall mortality was low, with 2(5.2%) deaths in the HIVe group, 0 in the HIVn group and 6(7.3%) in the HIVi group (p = 0.0003). HIVe had a longer stay than HIVn children (3 (2-7) vs. 2 (1-4) days p = 0.02). There was no significant difference in length of stay between the HIVe and HIVi groups. HIVe children had a higher rate of complications compared to HIVn children, (9 (23.7%) vs. 14(5.7%) (RR 3.8(2.1-7) p < 0.0001) but a similar rate of complications compared to HIVi children 34 (41.5%) (RR = 0.6 (0.3-1.1) p = 0.06). CONCLUSION: HIVe children have a higher risk of developing complications and mortality after surgery compared to HIVn children. However, the risk of complications is lower than that of HIVi children.
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    Paediatric brain tumours: The University of Cape Town experience from 1996 - 2017
    (2019) Arnold-Day, Christel; Figaji, Anthony
    Brain tumours are the second most common malignancy in children(1) (2), and despite some advancements being made over the last 2 decades, patient outcomes in general remain poor when compared with other childhood cancers. Optimal treatment of children with brain tumours is challenging and expertise and resources are not widely available in South Africa. This is important because the outcomes of children with brain tumours depend critically on the expertise and resources of a multidisciplinary team tasked with their treatment. Despite the importance of paediatric brain tumours though, little is known about childhood brain tumours in South Africa as limited data have been published and there have been no funded studies to support research in this area. In addition, we know very little about the resources available across the country to treat these children. In international centres of excellence the best outcomes are achieved by combining good epidemiological data, strong multidisciplinary teams, centralization or regionalization of services, available resources, and a research foundation. To start, we need to know more about the patients presenting to us with brain tumours. PURPOSE The overall aim of this project was to collect epidemiological data for childhood brain tumours at a tertiary paediatric hospital in South Africa with a dedicated multidisciplinary team. METHODS Study design: A retrospective review of records of patients diagnosed with a primary brain tumour and who presented to Red Cross Children’s Hospital (RCCH) system from 1 January 1996 to 31 December 2017. 2 Patient selection & data collection: Patients were identified by combining databases and admission logs from paediatric neurosurgery, oncology, radiotherapy, histopathology and radiology. Data collected included: age at diagnosis, sex, province of referral, tumour site and diagnosis. RESULTS A total of 554 paediatric patients with primary brain tumours were identified over the study period. Tumours were more common among males (55.4%) and were located in the supratentorial compartment in 52%. The median age at diagnosis was 5.92 years. The commonest tumours were astrocytomas (n=114 patients; 20.3%), followed by medulloblastomas (incl. PNETs) (n=107 patients; 19.1%), and craniopharyngiomas (n=55; 9.8%). As expected, most patients referred and seen at RCCH/GSH were from the expected drainage area in the Western Cape (73%), but a significant number of referrals (27%) were from outside the province referrals, especially in the last 10 years. CONCLUSION Our findings were largely consistent with the published literature in terms of histological diagnosis, sex profile and age ranges for children diagnosed with brain tumours with some small differences possibly related to referral bias. More patients than expected were referred from outside of the province, which emphasizes the need for establishing an ongoing tumour database registry and co-ordinating patient care across institutions. A follow-up study to assess patient management and outcomes is of critical importance to assess resource availability and patient outcomes.
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    Protocol for the ROSE sustainment (ROSES) study, a sequential multiple assignment randomized trial to determine the minimum necessary intervention to maintain a postpartum depression prevention program in prenatal clinics serving low-income women
    (BioMed Central, 2018-08-22) Johnson, Jennifer E; Wiltsey-Stirman, Shannon; Sikorskii, Alla; Miller, Ted; King, Amanda; Blume, Jennifer L; Pham, Xuan; Moore Simas, Tiffany A; Poleshuck, Ellen; Weinberg, Rebecca; Zlotnick, Caron
    Background More research on sustainment of interventions is needed, especially return on investment (ROI) studies to determine cost-benefit trade-offs for effort required to sustain and how much is gained when effective programs are sustained. The ROSE sustainment (ROSES) study uses a sequential multiple assignment randomized (SMART) design to evaluate the effectiveness and cost-effectiveness of a stepwise approach to sustainment of the ROSE postpartum depression prevention program in 90 outpatient clinics providing prenatal care to pregnant women on public assistance. Postpartum depression (PPD) is common and can have lasting consequences. Outpatient clinics offering prenatal care are an opportune place to provide PPD prevention because most women visit while pregnant. The ROSE (Reach Out, Stay Strong, Essentials for mothers of newborns) program is a group educational intervention to prevent PPD, delivered during pregnancy. ROSE has been found to reduce cases of PPD in community prenatal settings serving low-income pregnant women. Methods All 90 prenatal clinics will receive enhanced implementation as usual (EIAU; initial training + tools for sustainment). At the first time at which a clinic is determined to be at risk for failure to sustain (i.e., at 3, 6, 9, 12, and 15 months), that clinic will be randomized to receive either (1) no additional implementation support (i.e., EIAU only), or (2) low-intensity coaching and feedback (LICF). If clinics receiving LICF are still at risk at subsequent assessments, they will be randomized to either (1) EIAU + LICF only, or (2) high-intensity coaching and feedback (HICF). Additional follow-up interviews will occur at 18, 24, and 30 months, but no implementation intervention will occur after 18 months. Outcomes include (1) percent sustainment of core program elements at each time point, (2) health impact (PPD rates over time at each clinic) and reach, and (3) ROI (costs and cost-effectiveness) of each sustainment step. Hypothesized mechanisms include sustainment of capacity to deliver core elements and engagement/ownership. Discussion This study is the first randomized trial evaluating the ROI of a stepped approach to sustainment, a critical unanswered question in implementation science. It will also advance knowledge of implementation mechanisms and clinical care for an at-risk population. Trial registration Clinicaltrials.gov, NCT03267563 . Registered June 14, 2018.
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    Surgical complications of bacille Calmette-Guérin (BCG) infection in HIV-infected children: Time for a change in policy?
    (Health and Medical Publishing Group, 2008) Karpelowsky, J S; Alexander, A G; Dix Peek, S; Millar, A J W; Rode, H
    AIM: Bacille Calmette-Guérin (BCG) immunisation is well established as part of the South African national expanded programme for immunisation (EPI). The World Health Organization (WHO) currently recommends that BCG be given to all asymptomatic infants irrespective of HIV exposure at birth but does not recommend BCG vaccination for children with symptomatic HIV infection. This approach, however, has led to HIV-infected neonates who are asymptomatic at birth, developing severe vaccine-related complications. We present a surgical case series, representative of a minority of the cases in circulation, in support of a change to the timing of BCG administration to HIV-exposed neonates. METHODS: A case series of 17 HIV-infected patients with surgical complications of BCG vaccination. RESULTS: Seventeen patients are presented. The first two illustrate disseminated systemic BCG infection, resulting in BCG infection of the lymph nodes, liver, spleen and tibia, and the second with gastrointestinal involvement causing bowel obstruction. The other 15 patients represent a series of severe ulcerating lymphadenitis secondary to BCG. CONCLUSION: The risks of BCG in HIV-infected infants are significant. Current recommendations are not satisfactory, and a change in policy is required to prevent the harmful effects of this vaccine in a high-risk group of patients. We believe that there is sufficient need to adequately stratify patients and vaccinate them according to a protocol that takes impaired immunity into consideration.
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    Surgical treatment for 'brain compartment syndrome' in children with severe head injury
    (Health and Medical Publishing Group, 2006) Figaji, A A; Fieggen, A G; Argent, A; Peter, J C
    OBJECTIVES: Traumatic brain injury accounts for a high percentage of deaths in children. Raised intracranial pressure (ICP) due to brain swelling within the closed compartment of the skull leads to death or severe neurological disability if not effectively treated. We report our experience with 12 children who presented with cerebral herniation due to traumatic brain swelling in whom decompressive craniectomy was used as an emergency. DESIGN: Prospective, observational. SETTING: Red Cross Children's Hospital. SUBJECTS: Children with severe traumatic brain injury and cerebral swelling. OUTCOME MEASURES: Computed tomography (CT) scanning, ICP control, clinical outcome. RESULTS: Despite the very poor clinical condition of these children preoperatively, aggressive management of the raised pressure resulted in unexpectedly good outcomes. CONCLUSION: Aggressive surgical measures to decrease ICP in the emergency situation can be of considerable benefit; the key concepts are selection of appropriate patients and early intervention.