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BACKGROUND: Currently, there are two well-established methods of bowel lengthening in patients with short bowel syndrome (SBS)-longitudinal intestinal lengthening and tailoring (LILT) and serial transverse enteroplasty (STEP) [1-4]. Both procedures may carry a high reported morbidity and mortality of 30.2% and 14.4%, respectively [5]. We report the outcomes of a novel technique: double barrel enteroplasty (DBE) for autologous intestinal reconstruction. METHODS: We performed a retrospective review of all ten patients who underwent DBE at our institution since 2011. All patients have SBS and were dependent on parenteral nutrition (PN) at the time of surgery. Etiologies were gastroschisis (n = 4), bowel atresia (n = 3), necrotising enterocolitis (n = 1), volvulus (n = 1), and near-total intestinal aganglionosis (n = 1). Patient survival, complications, and subsequent enteral autonomy were evaluated. RESULTS: All patients are alive with normal liver function. Five children achieved enteral autonomy, while the remaining are on weaning PN. There was no bleeding, anastomotic leak, perforation, infective complications, or intestinal necrosis. No patient has required a liver and/or intestinal transplant. CONCLUSIONS: Double barrel enteroplasty is technically feasible and safe. It has similar efficacy and may have fewer complications when compared with other methods of autologous intestinal reconstruction.

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OBJECTIVES: Scalds involving toddlers commonly involve the torso and are frequently mid-dermal in depth. Initial management of a mid-dermal burn is conservative, progressing to grafting if healing has not been achieved in 10-14 days. Historically BiobraneTM (UDL Laboratories, Inc., Sugar Land, TX) is thought to have more favourable clinical outcomes compared to Acticoat TM (Smith and Nephew, St. Petersburg, Fl, USA). The Burns Unit at The Children's Hospital at Westmead (CHW) uses both dressings on a regular basis, providing the opportunity to compare the results of the dressings in a cohort of patients with mid-dermal torso burns. METHOD: A retrospective review was undertaken of all paediatric mid-dermal torso burns admitted to CHW between 2015 and 2017. The primary outcomes analysed were: time to complete healing and the need for grafting. Secondary outcomes included: operating theatre time, clinic visits, length of stay in hospital and positive wound swab colonisation. RESULTS: 78 children met the study criteria, 64 (82%) in the Acticoat group and 14 (18%) in the Biobrane group. 36 out of 78 children (56%) in the Acticoat group had their burns spontaneously healed without the need of skin graft surgery, compared with 10 out of 14 children (71%) in the Biobrane group. The days to complete healing were quicker in the Acticoat group (13 days) compared to the Biobrane group (17 days), although this was not statistically significant (P = 0.3). Overall patients managed with the Biobrane dressing required more operative sessions under general anaesthesia, a longer hospital stay, more clinic visits and a higher number of positive wound swab colonisation with heavy growth compared to the Acticoat group. CONCLUSION: This study suggests that the use of the Biobrane dressing does not significantly improve the clinical outcomes of mid-dermal torso burns in children compared to the Acticoat dressing. Acticoat reduced healing time, decreased the requirements for a general anaesthesia, reduced inpatient hospital stay and risk of infection.

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OBJECTIVES: The management of pediatric mid-dermal burns is challenging. Anecdotal evidence suggests Biobrane™ (UDL Laboratories, Inc., Sugar Land, TX) may expedite epithelization, reducing the requirement for skin grafting. Our standard management for burns of this depth is Acticoat™ (Smith and Nephew, St. Petersburg, Fl, USA). No publications are known to compare Biobrane™ to Acticoat™ for treatment of mid-dermal burns. METHODS: A prospective, randomised controlled pilot study was conducted, comparing Biobrane™ to Acticoat™ for mid-dermal burns affecting ≥ 1% Total Body Surface Area (TBSA) in children. Mid-dermal burns were confirmed using Laser Doppler Imaging within 48 hours of injury. Participants were randomized to Biobrane™ with an Acticoat™ overlay or Acticoat™ alone. RESULTS: 10 participants were in each group. Median age and TBSA were similar; 2.0 (Biobrane™) and 1.5 years (Acticoat™), 8% (Biobrane™) and 8.5% TBSA (Acticoat™). Use of Biobrane™ had higher infection rates (6 children versus 1) (P = 0.057) and more positive wound swabs, although not significant (7 children versus 4) (P = 0.37). Healing time was shorter in the Biobrane™ group, this was not significant (19 days versus 26.5 days, P = 0.18). Median dressing changes were similar (5 versus 5.5) (P = 0.56). Skin grafting requirement was greater in the Acticoat™ group (7 versus 4 children, P = 0.37) and similar in % TBSA (1.75% TBSA). CONCLUSION: This pilot study suggests that the use of Biobrane™ for mid-dermal burns in children may be associated with increased risk of infection but appears to decrease the time to healing and therefore the need for skin grafting compared to Acticoat™ alone.

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There is minimal reported experience with long-range retrieval of pediatric patients receiving extracorporeal membrane oxygenation (ECMO) support. We report the case of a 10-month old boy with necrotizing staphylococcal pneumonia complicated by a bronchopleural fistula, who was successfully retrieved and transported while receiving ECMO to our unit in Sydney, Australia, from a referring hospital 2,000 kilometers away in the Pacific Islands. He was successfully weaned from ECMO to receive single-lung ventilation after 13 days, and he underwent surgical repair of his bronchopleural fistula through a thoracotomy 3 days after decannulation. He has made a full recovery.

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INTRODUCTION: Conventional surgical debridement of burn wounds consists of tangential excision of eschar using a knife or dermabrasion until viable dermis or punctate bleeding occurs. The Versajet™ (Smith and Nephew, St. Petersburg, FL, USA) hydrosurgery system has also been advocated for burn wound debridement, with the suggestion that enhanced preservation of dermal tissue might reduce subsequent scarring. METHODS: A prospective randomised controlled trial was undertaken comparing Versajet™ to conventional debridement. After excluding those with facial burns, 61 children ≤16 years of age undergoing debridement and skin grafting for partial thickness burns were recruited. Adequacy of debridement was assessed by 2mm punch biopsies taken pre- and post-debridement. Surgical time, percentage graft take at day 10, time to healing, post-operative infection and scarring at 3 and 6 months were assessed. RESULTS: Thirty-one children underwent conventional debridement and 30 debridement using Versajet™. There was a significant difference in the amount of viable dermal preservation between the two groups (p=0.02), with more viable tissue lost in the conventional group (median 325 µm) versus the Versajet™ group (median 35 µm). There was no significant difference between graft take at day 10 (p=0.9), post-operative wound infection (p=0.5), duration of surgery (p=0.6) or time to healing after grafting (p=0.6). Despite better dermal preservation in the Versajet™ group, there was no significant difference between scarring at 3 or 6 months (p=1.0, 0.1). CONCLUSIONS: These findings suggest that Versajet™ hydrosurgery appears a more precise method of burn wound debridement. Although dermal preservation may be a factor in reducing subsequent hypertrophic scarring, there were no significant differences found between scarring at 3 or 6 months after-injury.

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Local rectal application of tacrolimus in distal colitis, pouchitis and perianal Crohn's disease has previously been reported to be both effective and safe. We report a patient treated with per rectum local application of tacrolimus, who developed toxic levels of tacrolimus and acute renal injury during an episode of acute gastroenteritis. This case illustrates that local application of tacrolimus, although usually safe, may be associated with significantly raised tacrolimus levels and acute renal injury during acute gastroenteritis. It is important for physicians to be aware of this association when prescribing local rectal tacrolimus.

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OBJECTIVES: The aim of the present study was to report caregiver perceptions to antireflux surgery and gastrostomy in children with severe neurological impairment and to report the complications of the surgery. METHODS: Children were identified from a clinic database and clinical information and surgical complications were extracted from the database and hospital medical records. A cross-sectional questionnaire addressing severity of symptoms was administered to parents/caregivers and scored with a 5-point Likert scale (1 is much better to 5, much worse). RESULTS: A total of 122 children, median age 74 months (interquartile range 29-124), 63% spastic quadriplegic cerebral palsy, had antireflux surgery. Laparoscopic surgery was performed in 77 of 122 (63%) and 117 of 122 (96%) had gastrostomy insertion. Questionnaire was completed by 89 of 122 (73%) children; median duration of time from fundoplication to questionnaire was 77 months (43-89). The majority of caregivers indicated that surgery improved or greatly improved weight gain, chest infections, vomiting, and feeding tolerance. Only 2 caregivers reported that they regretted consenting to surgery. Serious surgical complications occurred in 10%. CONCLUSIONS: Serious complications were uncommon in this series of antireflux surgery in neurologically impaired children. Although gagging and retching were common following surgery, a high percentage of caregivers reported improved nutrition, reflux-related symptoms, and high levels of satisfaction.

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The current Australia and New Zealand Burn Association recommended burns first aid treatment is to place the burn under cool running water for 20 minutes. Immediate cooling of a burn wound has been shown to reduce the depth of the injury. Cooling has also been recommended as beneficial for up to 3 hours after the burn. No scientific data currently exist to support this recommendation. The aim of this study was to identify the effect of delayed cooling of an acute scald contact burn wound in a porcine model. Four partial-thickness contact scald burn injuries were induced in 12 piglets each. First aid treatment consisting of cool running water for 20 minutes was instituted randomly to each wound at different time points: immediately and at time delays of 5, 20, and 60 minutes. The group receiving immediate first aid with cool running water for 20 minutes served as the control group. At day 1 and day 9, biopsies were obtained and assessed in a blinded manner. Histologic analysis of burn depth on days 1 and 9 demonstrated no significant difference in the depth of the burn in the various treatment groups in comparison to the control group receiving immediate first aid. No significant differences in the surface areas of each burn were noted between the various treatment groups on day 9. Core body temperature did not fall below 35 degrees C throughout the cooling process. This study provides scientific evidence that in an animal model delayed cooling for up to 60 minutes postacute contact scald burn is still effective compared with immediate cooling at reducing burn depth.

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Transverse testicular ectopia (TTE) is an uncommon condition with different clinical presentations. A significant proportion of cases are diagnosed only during surgery and it is important to define the precise anatomy and associated anomalies in every case of TTE. Laparoscopy is being increasingly adopted in the treatment of undescended testis, especially in cases where the testis is impalpable. We hereby report a child with a variant of TTE wherein laparoscopy proved enormously beneficial in diagnosis and treatment and where a routine groin exploration was likely to have yielded an incorrect diagnosis. We also review the available literature on the use of laparoscopy in the management of TTE and its impact on the ability of surgeons to diagnose and treat TTE and its associated conditions.

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Pyogenic liver abscesses are rare in children but relatively common in those with chronic granulomatous disease (CGD). We present a case of a 2 year old boy who initially presented with BCGitis and Staphylococcus aureus cervical adenitis, and then subsequently developed liver abscesses. A diagnosis of X-linked CGD was confirmed. This case demonstrates the typical radiological features of liver abscesses in CGD, its management without surgical intervention, and the increasingly recognised complications of BCG vaccination in CGD.

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The Australian and New Zealand Burn Association recommend 20 minutes of cold running tap water as burn first aid. Scientific evidence for the optimal duration of treatment is limited. Our aim was to establish the optimal duration of cooling using cold running tap water to treat the acute burn. Partial thickness contact scald burns were induced at five sites in each of 17 pigs. Treatments with cold running tap water for 5, 10, 20, and 30 minutes were randomly allocated to different sites together with an untreated control site. In the running water 5 and 10 minute treatments intradermal temperatures rose by 1 degrees C per minute when cooling was stopped, compared with 0.5 degrees C per minute for 20 and 30 minutes duration. No differences in the surface area of each burn were noted between the five treatments on day 9. Histological analysis of burn depth on days 1 and 9 revealed that a higher proportion of burns treated for 20 and 30 minutes showed improvement compared with those treated for 5 and 10 minutes only. This difference reached statistical significance (P < .05) only in the cold running water for 20 minutes treatment arm. There was a statistically significant (P < .05) improvement in burn depth in a porcine acute scald burn injury model when the burn was treated with cold running tap water for 20 minutes as opposed to the other treatment durations. This study supports the current burn first aid treatment recommendations for the optimal duration of cooling an acute scald burn.

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The current Australian and New Zealand Burn Association (ANZBA) recommended Burns First Aid Treatment is place the burn under cool running water for 20 minutes. Wet towels and water spray also have been used frequently. No scientific data exist to compare the effectiveness of these methods of cooling. This study sought to determine experimental evidence for current Burns First Aid Treatment recommendations and the optimal mode of cooling. Four partial-thickness scald burn injuries were induced in 10 piglets each. First aid was then applied for 20 minutes via cool running water, wet towels, or water spray, with no treatment as a control. At day 1 and day 9, biopsies and clinical photographs were assessed in a blinded manner. The control group showed worsening or no change of depth over the course of 9 days. The outcomes with wet towels and water spray were variable. Cool running water consistently demonstrated improvement in wound recovery over the course of 9 days (P < .05). This study demonstrated that cool running water appeared the most effective first aid for an acute scald burn wound in a porcine model compared with wet towels and water spray.

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Minimally invasive surgery has a role in planning the resection of malignant chest wall tumors in the pediatric population. We studied the role of thoracoscopy in both the diagnosis and definitive surgery of chest wall Ewing's sarcoma tumors.

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OBJECTIVE: To identify the adequacy of first aid care following minor burns in children. DESIGN: Prospective case series. SETTING: Emergency Department and Acute Wound Clinic, the Children's Hospital at Westmead (CHW), Sydney. PARTICIPANTS: 109 children who presented with minor burns (10% body surface area or less) to CHW over the five months from 2 November 1998 to 23 March 1999. MAIN OUTCOME MEASURES: Comparison of the adequacy of first aid delivered by parents and carers, general practitioners, local hospitals, and CHW. RESULTS: Burns included scalds, contact, flame, chemical or electrical burns. Adequate initial first aid had been given by parents or carers in only 24 of 109 cases (22%). The 85 children who presented to medical care after inadequate initial first aid was given by parents or carers included 14 of 14 (100%) who had presented to their general practitioner (GP), 22 of 31 (71%) who had presented to their local hospital, 22 of 38 (58%) who had presented to CHW, and 2 of 2 (100%) who had had first contact with other health professionals. CONCLUSIONS: This study shows that there is a need to educate parents and health professionals regarding appropriate first aid for burns.

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