Notat om omskæring af drenge - Sundhedsstyrelsen

FROM THE AMERICAN ACADEMY OF PEDIATRICScircumcised primarily by trained, ritualproviders in nonmedical settings,and reported similarly low complicationrates. The overall complicationrate was 0.34%, including bleeding in0.08% and infection in 0.01%. 183 Approximatelyone-third of the identifiedcomplications were immediate (ie,bleeding, infection, penile injury),whereas two-thirds occurred later (ie,excess foreskin, penile torsion, shortageof skin, phimosis, inclusion cyst).There is fair evidence of a more frequentcomplication rate of 3.1% ina study based on abstraction of 1951hospital medical (rather than billing)records on newborn circumcision inAtlanta. 184 In this study, complicationswere found to be much more common,with bleeding occurring in 2.1%,although most reports of bleedingwere mild in nature. Likewise, a reviewwith fair evidence of 1000 newborncircumcisions by using theGomco clamp in a hospital setting inSaudi Arabia found an overall complicationrate of 1.9%. 185 Bleeding occurredin 0.6%, infection in 0.4%, andredundant prepuce in 0.3%.Late complications of newborn circumcisioninclude excessive residualskin (incomplete circumcision), excessiveskin removal, adhesions (naturaland vascularized skin bridges),meatal stenosis, phimosis, and epithelialinclusion cysts. These complicationsare considered “late,” asopposed to “acute” (or immediate)complications such as bleeding orinfection, which may still presentduring infancy but not during the immediatepostprocedural time frame.In 1 outpatient-based study of 214boys with poor evidence, the complicationsseen included adhesions (observedin 55 boys [25.6%]), redundantresidual prepuce (44 boys [20.1%]),balanitis (34 boys [15.5%]), skinbridge (9 boys [4.1%]), and meatalstenosis (1 boy [0.5%]). 76Outside the United States, a crosssectionalstudy from Nigeria of 370consecutive male infants (322 ofwhom had been circumcised) attendingan infant welfare clinic forimmunization with fair evidencereported an overall complication rateof 20.2%. 186 Complications includedredundant prepuce (12.9%), excessiveskin removal (5.9%), skin bridge(4.1%), and buried penis (0.4%). Themajority of the procedures (81%)were performed in the hospital; 19%were performed at home. Nursesperformed 56% of procedures (n =180), physicians performed 35% (n =113), and traditional circumcisersperformed 9% (n = 29). The Israelistudy noted earlier with fair evidencereported a late complicationof redundant prepuce in 0.2% of the19 478 male infants studied. 183There is good evidence that circumcisionof a premature infant isassociated with an increased risk oflater-occurring complications (ie, poorcosmesis, increased risk of trappedpenis, adhesions). There is also goodevidence that circumcision of a newbornwho has a prominent suprapubicfat pad or penoscrotal webbing hasa higher risk for the same long-termcomplications. 187 One prospectivestudy with fair evidence examined thenatural course of penile adhesionsafter circumcision and found thatadhesions disappeared at some point6 months postcircumcision withoutintervention, except for thick adhesions(called “bridging adhesions”).The authors recommended lysis forskin bridges. 188Post-newborn CircumcisionThere have been few reports of acutecomplications after non-newborn circumcisionin the United States. Furthermore,there are no adequatestudies of late complications inboys undergoing circumcision in thepost-newborn period; this area requiresmore study.Although adverse outcomes are rareamong non-newborn circumcisions,the incidence tends to be orders ofmagnitude greater for boys circumcisedbetween 1 and 10 years of age,compared with those circumcised asnewborns. 189 As noted, general anesthesia,which is used for proceduresperformed after the newborn period,confers additional risk.The most common surgical complicationis excessive bleeding (eg, bleedingthat did not stop with local pressure,perhaps requiring a suture), reportedin 0.6% of 1742 male infants. 184 Contactburns were reported with electrocauterywhen used with metal, and itshould not be used with the Gomcoclamp in newborn circumcisionsbecause it can cause devastatingburns. 184,190,191 A study with fair evidencereviewed the records of 476boys undergoing circumcision duringchildhood and found that complicationsoccurred in 8 records (1.7%), ofwhich 3 were related to anesthesia. 192The most common surgical complicationwas excessive bleeding in 0.6%.In another report with fair evidence,which examined 267 patients whohad circumcision by using topicalglue rather than skin sutures, excessivebleeding occurred in 0.75% ofcases. 193European centers report an overallcomplication rate of 1.2% to 3.8% forcircumcisions performed in boysduring the newborn or non-newbornperiod. 194–196 In a study with fair evidenceof trained medical personnel inthe United Kingdom, the rate ofbleeding was 0.8% and of infectionwas 0.3%. In this study of a historicalcohort of over 75 boys aged 0 to 14years, 0.5% required surgical repair.195In a Turkish prospective cohort studyof 700 boys with fair evidence, bleedingPEDIATRICS Volume 130, Number 3, September 2012Downloaded from pediatrics.aappublications.org by guest on June 19, 2013e773