Ultrashort bowel syndrome (USBS) is a group of heterogeneous disorders where the length of small bowel is less than 10 cm or 10% of expected for the age. It is caused by massive loss of the gut which in the neonatal period can be a result of vanishing gastroschisis or surgical resection following mid-gut volvulus, jejunoileal atresia and/or extensive necrotising enterocolitis. The exact prevalence of USBS is not known although there is a clear trend towards increasing numbers because of increased incidence and improved survival. Long-term parenteral nutrition (PN) is the mainstay of treatment and is best delivered by a multidisciplinary intestinal rehabilitation team. Promoting adaptation is vital to improving long-term survival and can be achieved by optimising feeds, reducing intestinal failure liver disease and catheter-related bloodstream infections. Surgical techniques that can promote enteral tolerance and hence improve outcome include establishing intestinal continuity and bowel lengthening procedures. The outcome for USBS is similar to patients with intestinal failure due to other causes and only a small proportion of children who develop irreversible complications of PN and will need intestinal transplantation. In this review, we will summarise the available evidence focusing particularly on the epidemiology, management strategies and outcome.
One hundred and forty four questionnaires relating to bladder and bowel control were sent to a random selection of patients with spina bifida throughout the United Kingdom. One hundred and seventeen questionnaires were returned, ofwhich 109 were usable. Twenty eight out of 109 responders had undergone some form of urinary diversion, of whom 20 (710%) were reliably dry. The surgical treatment of spina bifida and associated hydrocephalus ensures long term survival in most patients selected for treatment. The rapid realisation of the importance of appropriate management of the neuropathic bladder has led to most patients surviving with normal renal function.' The goals of ongoing treatment are to enable patients to achieve their full potential, within the limits of their handicap, become fully integrated into society, and to be as independent as possible. A multidisciplinary approach from healthcare professionals, psychologists, educationalists, and other allied professions is required to achieve this end.Incontinence is one of the major stigmata affecting their quality of life and producing dependence on others. Major advances have been made in the non-operative and operative management of urinary incontinence2-4 and faecal incontinence.5-8 These specialist centres report excellent results, but it seems that only a minority of patients have access to this treatment and most continue to suffer the socially isolating stigma of incontinence.This study has attempted to assess the extent of the problem and the reasons underlying it by surveying a randomly selected group of patients with spina bifida in the community.Patients and methods Questionnaires were sent to 144 patients with spina bifida who were randomly selected from the computerised database of the Association for Spina Bifida and Hydrocephalus (ASBAH), which at the time contained just over 2000 names. The questionnaire addressed details of demography, medical care, and the methods and results of bladder and bowel management. Previous and planned specialist investigations and operative interventions were also assessed. Wherever possible the questionnaires were completed by the patients themselves, but if this was not possible, by their carers. The ASBAH fieldworkers explained the questionnaires and assisted in completion when required, but the answers always reflected the patient's views.
ResultsOne hundred and seventeen (81%) of the 144 questionnaires were returned, 104 with all sections completed correctly and a further five with usable data, giving a study population of 109. The mean (range) age was 23-5 (9-47 8) years with 67 females and 42 males. Sixty eight (62%) patients were confined to a wheelchair and a further 27 (25%) used one on occasions. Seventy six (70%) patients had had a shunt fitted for hydrocephalus.
Despite being recognised for over two millennia and having an increasing incidence in many countries, the management of childhood empyema remains controversial. This review examines the recent literature on its causes and investigation then focuses on its treatment. Following a trial of appropriate intravenous antibiotics, the evidence would currently support the use of chest drain insertion with urokinase instillation as first line treatment with video-assisted thoracoscopic surgery to be used for failure of medical management. A treatment algorithm is proposed to guide clinical practice.
This is the largest reported series of general neonatal surgical procedures performed on NICU. Operating on NICU is feasible and safe, and a full range of neonatal operations can be performed. It removes risks associated with neonatal transfer and is likely to reduce physiological instability. We recommend this approach for all ventilated neonates and urge neonatal surgeons to operate at the cotside of unstable infants.
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