Journal of medical imaging and radiation oncology, Dec 3, 2013
Introduction: Duodenojejunal flexure (DJF) orientation is often examined routinely during contras... more Introduction: Duodenojejunal flexure (DJF) orientation is often examined routinely during contrast swallow studies, including those performed for purely oesophageal queries. We examine the radiation burden and the incidence of malrotation in patients undergoing contrast swallow, without clinical suspicion for malrotation. Methods: Two hundred eighteen consecutive contrast swallow studies were reviewed. Patients whose history may potentially suggest malrotation were identified (n = 90), and remaining children were grouped based on whether DJF was examined (Group 1; n = 88) or not (Group 2; n = 40). Data extracted include demographics, radiographic parameters (dosage, screening time, number of images obtained) and examination findings. Outcome measures comprised: (i) prevalence of clinically incidental malrotation; and (ii) influence of additional evaluation of DJF on patient dosage (mean ± SEM). Results: Malrotation was identified in 2 of 90 patients (2.2%) examined with clinical indications for possible malrotation, but none in Group 1 (13% already had normal DJF confirmed on previous examinations). Groups 1 and 2 were comparable with respect to age and gender (P = ns). Additional evaluation of DJF (Group 1) meant that 54% more images were acquired (48.5 ± 2.9 vs. 31.4 ± 3.4 images in group 2; P = 0.0002) and 24.9% increased screening time (130.8 ± 9.3 vs. 104.7 ± 13.0 seconds in group 2; P = 0.089), resulting in 32.6% increased patient dosage (1.36 ± 0.21 vs. 1.02 ± 0.16 microGym 2 / kg in group 2; P = 0.19). Conclusions: This study highlights the increased radiation exposures involved with routine screening for DJF position in those patients without clinical suspicion of malrotation, and raises questions about the validity of this practice; however, further research is needed.
The purpose of this prospective study was to determine if a connecting bar prevented mechanical f... more The purpose of this prospective study was to determine if a connecting bar prevented mechanical failure of hip spicas. Eighty-two hip spicas were applied to 70 patients between April 2000 and June 2001 following open or closed reduction for developmental dysplasia of the hip. Bilateral hip surgery was undertaken in 12 patients. Thirty-six spicas were applied with a bar whilst 46 were without. The technique of application was similar in all patients. Overall nine (11%) hip spicas failed (mechanically) prematurely and had to be replaced in hospital under general anaesthesia. All nine were inpatients whose spica did not have a connecting bar (P < 0.005). The rate of spica revision increased with the age of the patient. All parents of failed spica cases (nine cases) preferred the new spica with a bar to the previous one without, because they agreed that the bar made the spica more secure. The bar did not hamper toileting or handling.
In 1950, Norman Rupert Barrett, an Australian-born thoracic surgeon (Fig. 1; 1903–1979), describe... more In 1950, Norman Rupert Barrett, an Australian-born thoracic surgeon (Fig. 1; 1903–1979), described ulcers in the lower esophagus, previously attributed to gastroesophageal reflux (GER) by Allison [3], as in fact “chronic peptic ulcers“ within an intrathoracic stomach assuming a tubular form secondary to a “short esophagus“ [10]. Three years later it was Allison [4] that corrected Barrett’s misinterpretation and described the condition as we now understand it, namely columnar metaplasia replacing the normally squamous epithelium of the esophagus, and termed this “Barrett’s Esophagus.“ Over the last 50 years this definition of Barrett’s esophagus (BE) has continued to evolve, and in spite of his original erroneous description, to this day the condition remains eponymous to Norman Barrett. We describe the advances that have been made over these 50 years that have contributed to our understanding of the pathophysiology and management of this very difficult condition in adults and then focus on aspects of the disease specific to the pediatric population.
The recognition of neonatal intestinal perforation relies on identification of free gas in the pe... more The recognition of neonatal intestinal perforation relies on identification of free gas in the peritoneum on plain abdominal radiographs and the associated clinical signs. The neonatal bowel takes several hours to fill with gas, potentially obscuring one of the radiological signs of bowel perforation in the neonate. We describe the case of a male, Caucasian neonate, born prematurely at 35 +2 weeks of gestation, who was suspected before birth to be at risk of intestinal perforation, based on antenatal ultrasound signs of bowel obstruction. However, the diagnosis of intestinal perforation after birth was initially delayed because the first abdominal radiograph, requested by the neonatal team, was taken too early in the clinical progression of the neonate's condition. As a consequence, this delayed referral to the paediatric surgical team and definitive management. This case illustrates how consideration of the timing of abdominal radiographs in suspected intestinal perforation in the neonate may avoid misinterpretation of radiographic signs, thereby avoiding delays in referral and treatment in the crucial first few hours of life.
The surgical treatment of neonates has enjoyed rapid development during the last 50 years. Neonat... more The surgical treatment of neonates has enjoyed rapid development during the last 50 years. Neonatal surgery has now become an independent branch of general surgery, which requires the expertise of dedicated paediatric surgeons. Much of the development of neonatal surgery is due to the close collaboration between paediatric surgeons, neonatologists, anaesthetists, pathologists, radiologists, biochemists, and nurses. There has been a steady improvement in the outcome of most neonatal diseases requiring surgery. For example at Great Ormond Street Hospital for Children, London, the mortality for the most common congenital intestinal obstructions has declined from 50% in the 1950s and 1960s to 25% in the 1960s and 1970s to a current mortality of less than 5%. The reasons for this improvement can be ascribed to a better understanding of the physiology of surgical neonates, to the advances in fluid management, nutrition, mechanical ventilation, and not least to refinements in surgical techniques. There is still considerable work to be done to improve the survival of neonates with severe conditions such as necrotizing enterocolitis (NEC). Surgery of the gastro-intestinal tract is required for congenital abnormalities and acquired lesions. In this article the authors focus on the most common congenital anomalies of the gastro-intestinal tract requiring surgery. In addition they discuss two acquired conditions requiring surgery in neonates: NEC and hypertrophic pyloric stenosis. It is beyond the scope of this article to discuss anomalies of the abdominal wall, gastro-oesophageal reflux, and anomalies of the pancreato-biliary system.
Poster: "RANZCR-AOCR 2012 / R-0056 / A Pitfall in the Interpretation of Plain Abdominal Radi... more Poster: "RANZCR-AOCR 2012 / R-0056 / A Pitfall in the Interpretation of Plain Abdominal Radiographs in Neonatal Intestinal Perforation" by: "M. Chowdhury, M. Gillies, K. Lakhoo; Oxford/UK"
Background and methods: Volume of surgery and specialization may affect patient outcome. Articles... more Background and methods: Volume of surgery and specialization may affect patient outcome. Articles examining the effects of one or more of three variables (hospital volume of surgery, surgeon volume and specialization) on outcome (measured by length of hospital stay, mortality and complication rate) were analysed. Reviews, opinion articles and observational studies were excluded. The methodological quality of each study was assessed, a correlation between the variables analysed and the outcome accepted if it was significant. Results: The search identified 55 391 articles published between 1957 and 2002; 1075 were relevant to the study, of which 163 (9 904 850 patients) fulfilled the entry criteria. These 163 examined 42 different surgical procedures, spanning 13 surgical specialities. None were randomized and 40 investigated more than one variable. Hospital volume was reported in 127 studies; high-volume hospitals had significantly better outcomes in 74•2 per cent of studies, but this effect was limited in prospective studies (40 per cent). Surgeon volume was reported in 58 studies; high-volume surgeons had significantly better outcomes in 74 per cent of studies. Specialization was reported in 22 studies; specialist surgeons had significantly better outcomes than general surgeons in 91 per cent of studies. The benefit of high surgeon volume and specialization varied in magnitude between specialities. Conclusion: High surgeon volume and specialization are associated with improved patient outcome, while high hospital volume is of limited benefit.
Poster: "RANZCR-AOCR 2012 / R-0210 / Embolisation or Resection of Pulmonary Sequestrations ?... more Poster: "RANZCR-AOCR 2012 / R-0210 / Embolisation or Resection of Pulmonary Sequestrations ? A Meta-analysis of the Evidence for Best Practice" by: "M. Chowdhury, A. Pierro, K. McHugh; London/UK"
A pitfall in the interpretation of plain abdnominal radiographs in neonatal intestinal perforatio... more A pitfall in the interpretation of plain abdnominal radiographs in neonatal intestinal perforation: a case report
Poster: "RANZCR-AOCR 2012 / R-0039 / The Utility of Ultrasound in the Diagnosis and Manageme... more Poster: "RANZCR-AOCR 2012 / R-0039 / The Utility of Ultrasound in the Diagnosis and Management of Trochanteric Burisitis" by: "M. Chowdhury, S. Nazir, R. Syed, D. Wilson; Oxford/UK"
Poster: "RANZCR-AOCR 2012 / R-0064 / Utility of CT Pulmonary Angiography in Identification o... more Poster: "RANZCR-AOCR 2012 / R-0064 / Utility of CT Pulmonary Angiography in Identification of Alternative and Concurrent Diagnoses in Patients Suspected with Pulmonary Thromboembolism" by: "M. Chowdhury, F. MacLeod, B. Barry; Oxford/UK"
Poster: "RANZCR-AOCR 2012 / R-0066 / Is Routine Chest X-ray Necessary Following Percutaneous... more Poster: "RANZCR-AOCR 2012 / R-0066 / Is Routine Chest X-ray Necessary Following Percutaneous Central Venous Catheter Insertion in Children ?" by: "M. Chowdhury, H. Gordon, E. Nicholls; London/UK"
Journal of medical imaging and radiation oncology, Dec 3, 2013
Introduction: Duodenojejunal flexure (DJF) orientation is often examined routinely during contras... more Introduction: Duodenojejunal flexure (DJF) orientation is often examined routinely during contrast swallow studies, including those performed for purely oesophageal queries. We examine the radiation burden and the incidence of malrotation in patients undergoing contrast swallow, without clinical suspicion for malrotation. Methods: Two hundred eighteen consecutive contrast swallow studies were reviewed. Patients whose history may potentially suggest malrotation were identified (n = 90), and remaining children were grouped based on whether DJF was examined (Group 1; n = 88) or not (Group 2; n = 40). Data extracted include demographics, radiographic parameters (dosage, screening time, number of images obtained) and examination findings. Outcome measures comprised: (i) prevalence of clinically incidental malrotation; and (ii) influence of additional evaluation of DJF on patient dosage (mean ± SEM). Results: Malrotation was identified in 2 of 90 patients (2.2%) examined with clinical indications for possible malrotation, but none in Group 1 (13% already had normal DJF confirmed on previous examinations). Groups 1 and 2 were comparable with respect to age and gender (P = ns). Additional evaluation of DJF (Group 1) meant that 54% more images were acquired (48.5 ± 2.9 vs. 31.4 ± 3.4 images in group 2; P = 0.0002) and 24.9% increased screening time (130.8 ± 9.3 vs. 104.7 ± 13.0 seconds in group 2; P = 0.089), resulting in 32.6% increased patient dosage (1.36 ± 0.21 vs. 1.02 ± 0.16 microGym 2 / kg in group 2; P = 0.19). Conclusions: This study highlights the increased radiation exposures involved with routine screening for DJF position in those patients without clinical suspicion of malrotation, and raises questions about the validity of this practice; however, further research is needed.
The purpose of this prospective study was to determine if a connecting bar prevented mechanical f... more The purpose of this prospective study was to determine if a connecting bar prevented mechanical failure of hip spicas. Eighty-two hip spicas were applied to 70 patients between April 2000 and June 2001 following open or closed reduction for developmental dysplasia of the hip. Bilateral hip surgery was undertaken in 12 patients. Thirty-six spicas were applied with a bar whilst 46 were without. The technique of application was similar in all patients. Overall nine (11%) hip spicas failed (mechanically) prematurely and had to be replaced in hospital under general anaesthesia. All nine were inpatients whose spica did not have a connecting bar (P < 0.005). The rate of spica revision increased with the age of the patient. All parents of failed spica cases (nine cases) preferred the new spica with a bar to the previous one without, because they agreed that the bar made the spica more secure. The bar did not hamper toileting or handling.
In 1950, Norman Rupert Barrett, an Australian-born thoracic surgeon (Fig. 1; 1903–1979), describe... more In 1950, Norman Rupert Barrett, an Australian-born thoracic surgeon (Fig. 1; 1903–1979), described ulcers in the lower esophagus, previously attributed to gastroesophageal reflux (GER) by Allison [3], as in fact “chronic peptic ulcers“ within an intrathoracic stomach assuming a tubular form secondary to a “short esophagus“ [10]. Three years later it was Allison [4] that corrected Barrett’s misinterpretation and described the condition as we now understand it, namely columnar metaplasia replacing the normally squamous epithelium of the esophagus, and termed this “Barrett’s Esophagus.“ Over the last 50 years this definition of Barrett’s esophagus (BE) has continued to evolve, and in spite of his original erroneous description, to this day the condition remains eponymous to Norman Barrett. We describe the advances that have been made over these 50 years that have contributed to our understanding of the pathophysiology and management of this very difficult condition in adults and then focus on aspects of the disease specific to the pediatric population.
The recognition of neonatal intestinal perforation relies on identification of free gas in the pe... more The recognition of neonatal intestinal perforation relies on identification of free gas in the peritoneum on plain abdominal radiographs and the associated clinical signs. The neonatal bowel takes several hours to fill with gas, potentially obscuring one of the radiological signs of bowel perforation in the neonate. We describe the case of a male, Caucasian neonate, born prematurely at 35 +2 weeks of gestation, who was suspected before birth to be at risk of intestinal perforation, based on antenatal ultrasound signs of bowel obstruction. However, the diagnosis of intestinal perforation after birth was initially delayed because the first abdominal radiograph, requested by the neonatal team, was taken too early in the clinical progression of the neonate's condition. As a consequence, this delayed referral to the paediatric surgical team and definitive management. This case illustrates how consideration of the timing of abdominal radiographs in suspected intestinal perforation in the neonate may avoid misinterpretation of radiographic signs, thereby avoiding delays in referral and treatment in the crucial first few hours of life.
The surgical treatment of neonates has enjoyed rapid development during the last 50 years. Neonat... more The surgical treatment of neonates has enjoyed rapid development during the last 50 years. Neonatal surgery has now become an independent branch of general surgery, which requires the expertise of dedicated paediatric surgeons. Much of the development of neonatal surgery is due to the close collaboration between paediatric surgeons, neonatologists, anaesthetists, pathologists, radiologists, biochemists, and nurses. There has been a steady improvement in the outcome of most neonatal diseases requiring surgery. For example at Great Ormond Street Hospital for Children, London, the mortality for the most common congenital intestinal obstructions has declined from 50% in the 1950s and 1960s to 25% in the 1960s and 1970s to a current mortality of less than 5%. The reasons for this improvement can be ascribed to a better understanding of the physiology of surgical neonates, to the advances in fluid management, nutrition, mechanical ventilation, and not least to refinements in surgical techniques. There is still considerable work to be done to improve the survival of neonates with severe conditions such as necrotizing enterocolitis (NEC). Surgery of the gastro-intestinal tract is required for congenital abnormalities and acquired lesions. In this article the authors focus on the most common congenital anomalies of the gastro-intestinal tract requiring surgery. In addition they discuss two acquired conditions requiring surgery in neonates: NEC and hypertrophic pyloric stenosis. It is beyond the scope of this article to discuss anomalies of the abdominal wall, gastro-oesophageal reflux, and anomalies of the pancreato-biliary system.
Poster: "RANZCR-AOCR 2012 / R-0056 / A Pitfall in the Interpretation of Plain Abdominal Radi... more Poster: "RANZCR-AOCR 2012 / R-0056 / A Pitfall in the Interpretation of Plain Abdominal Radiographs in Neonatal Intestinal Perforation" by: "M. Chowdhury, M. Gillies, K. Lakhoo; Oxford/UK"
Background and methods: Volume of surgery and specialization may affect patient outcome. Articles... more Background and methods: Volume of surgery and specialization may affect patient outcome. Articles examining the effects of one or more of three variables (hospital volume of surgery, surgeon volume and specialization) on outcome (measured by length of hospital stay, mortality and complication rate) were analysed. Reviews, opinion articles and observational studies were excluded. The methodological quality of each study was assessed, a correlation between the variables analysed and the outcome accepted if it was significant. Results: The search identified 55 391 articles published between 1957 and 2002; 1075 were relevant to the study, of which 163 (9 904 850 patients) fulfilled the entry criteria. These 163 examined 42 different surgical procedures, spanning 13 surgical specialities. None were randomized and 40 investigated more than one variable. Hospital volume was reported in 127 studies; high-volume hospitals had significantly better outcomes in 74•2 per cent of studies, but this effect was limited in prospective studies (40 per cent). Surgeon volume was reported in 58 studies; high-volume surgeons had significantly better outcomes in 74 per cent of studies. Specialization was reported in 22 studies; specialist surgeons had significantly better outcomes than general surgeons in 91 per cent of studies. The benefit of high surgeon volume and specialization varied in magnitude between specialities. Conclusion: High surgeon volume and specialization are associated with improved patient outcome, while high hospital volume is of limited benefit.
Poster: "RANZCR-AOCR 2012 / R-0210 / Embolisation or Resection of Pulmonary Sequestrations ?... more Poster: "RANZCR-AOCR 2012 / R-0210 / Embolisation or Resection of Pulmonary Sequestrations ? A Meta-analysis of the Evidence for Best Practice" by: "M. Chowdhury, A. Pierro, K. McHugh; London/UK"
A pitfall in the interpretation of plain abdnominal radiographs in neonatal intestinal perforatio... more A pitfall in the interpretation of plain abdnominal radiographs in neonatal intestinal perforation: a case report
Poster: "RANZCR-AOCR 2012 / R-0039 / The Utility of Ultrasound in the Diagnosis and Manageme... more Poster: "RANZCR-AOCR 2012 / R-0039 / The Utility of Ultrasound in the Diagnosis and Management of Trochanteric Burisitis" by: "M. Chowdhury, S. Nazir, R. Syed, D. Wilson; Oxford/UK"
Poster: "RANZCR-AOCR 2012 / R-0064 / Utility of CT Pulmonary Angiography in Identification o... more Poster: "RANZCR-AOCR 2012 / R-0064 / Utility of CT Pulmonary Angiography in Identification of Alternative and Concurrent Diagnoses in Patients Suspected with Pulmonary Thromboembolism" by: "M. Chowdhury, F. MacLeod, B. Barry; Oxford/UK"
Poster: "RANZCR-AOCR 2012 / R-0066 / Is Routine Chest X-ray Necessary Following Percutaneous... more Poster: "RANZCR-AOCR 2012 / R-0066 / Is Routine Chest X-ray Necessary Following Percutaneous Central Venous Catheter Insertion in Children ?" by: "M. Chowdhury, H. Gordon, E. Nicholls; London/UK"
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