African Journal of Paediatric Surgery

Indications and outcome of childhood preventable bowel resections in a developing country

UO Ezomike

Background: While many bowel resections in developed countries are due to congenital anomalies, indications for bowel resections in developing countries are mainly from preventable causes. The aim of the following study was to assess the indications for, morbidity and mortality following preventable bowel resection in our centre.

Patients and Methods: Retrospective analysis of all cases of bowel resection deemed preventable in children from birth to 18 years from June 2005 to June 2012.

Results: There were 22 preventable bowel resections with an age range of
7 days to 17 years (median 6 months) and male:female ratio of 2.1:1. There were 2 neonates, 13 infants and 7 older children. The indications were irreducible/gangrenous intussusceptions (13), abdominal gunshot
injury (2), gangrenous umbilical hernia (2), blunt abdominal trauma (1), midgut volvulus (1), necrotizing enterocolitis (1), strangulated inguinal hernia (1), postoperative band intestinal obstructions (1). There were
16 right hemicolectomies, 4 small bowel resections and 2 massive bowel resections. Average duration of symptoms before presentation was 3.9 days (range: 3 h-14 days). Average time to surgical intervention was 42 h for survivors and 53 h for non-survivors. Only 19% presented within 24 h of onset of symptoms and all survived. For those presenting after 24 h, the
cause of delay was a visit to primary or secondary level hospitals (75%) and ignorance (25%). Average duration of post-operative hospital stay is 14 days and 9 patients (41%) developed 18 complications. Seven patients died (31.8% mortality) which diagnoses were irreducible/gangrenous intussusceptions (5), necrotising enterocolitis (1), midgut volvulus (1). One
patient died on the operating table while others had overwhelming sepsis.

Conclusion: There is a high rate of morbidity and mortality in these cases of preventable bowel resection. Typhoid intestinal perforation did not feature as an indication for bowel resection in this series. Original Article

Key words: Childhood, developing country, indications, outcome, preventable bowel resection

Renal cell carcinoma in children and adolescence: Our experience

S Kumar, P Sharma, J Pratap, P Tiwari, MK Bera, AK Kundu

Background: Literature on renal cell carcinoma (RCC) in children is lacking. Occasional case report has been mentioned. Aims and objective of our study are to evaluate the clinical presentation and outcome in children with RCC.

Patients and Methods: Records of 11 children and adolescence, from January 2007 to June 2011, who were treated for RCC were retrospectively analysed. Age, clinical presentation, any paraneoplastic symptom or sign, haematological, bio-chemical investigations, radiological imaging’s, operative details, pathological reports and treatment details were taken from hospital records and results were analysed. All patients were followed-up with complete haemogram, biochemical investigations, ultrasonography - whole abdomen and chest X-ray at 6 months interval and patients with stages 2 and 3 were also followed-up with contrast enhanced computed tomography - whole abdomen. They were followed-up for 2-5 years.

Results: All had undergone open radical nephrectomy with eight hilar lymph node dissection and three formal lymphadenectomy. None had received adjuvant therapy. Four patients with stage 1 were well at 5, 4, 2.5 and 2 years. One patient with stage 1 was lost to follow-up. Three patients with stage 2 were well at 4, 3 and 2 years of follow-up while three with stage 3 were well at 5, 4 and 2 years of follow-up.

Conclusions: Lymph node dissection not only improves the survival, but it guides one the exact pathological staging and one can adopt the more aggressive follow-up in advanced pathological staging and strict follow-up is mandatory.

Key words: Childhood, lymphadenectomy, radical nephrectomy, renal cell carcinoma

Dorsal inlay inner preputial graft for primary hypospadias repair

RB Nerli, AK Guntaka, RA Patil, PB Patne

Background: The most commonly performed operation to repair distal hypospadias is the Tubularised incised plate (TIP) repair. The key step is midline incision of the urethral plate, which widens a narrow plate and converts a flat into a deep plate groove, ensuring a vertical, slit neomeatus
and a normal-calibre neourethra. At times in cases of proximal hypospadias, the urethral plate is very narrow and needs to be augmented or substituted for further tubularisation. We report our experience
with primary single stage dorsal inlay urethroplasty using preputial skin grafts.

Patients and Methods:Children with proximal hypospadias with a narrow urethral plate formed the study group. Children needing transection of the urethral plate, having undergone circumcision/hypospadias repair previously or having an inadequate prepuce was excluded.

Results: Twelve children with a mean age of 48.83 months underwent primary dorsal inlay preputial graft urethroplasty for proximal hypospadias with a very narrow urethral plate. At an average follow-up of 42.16 months, 2 (16.66%) children had a breakdown of ventral shaft skin. None of the children had meatal stenosis, and none of these 12 children developed urethrocutaneous fistula.

Conclusion: Primary dorsal inlay inner preputial graft urethroplasty successfully fulfills all traditional hypospadias repair criteria. It offers a viable, safe, rapid and easy option in the management of proximal hypospadias with a narrow urethral plate.

Key words: Hypospadias, primary repair, urethra, urethroplasty

Complicated appendicitis: Analysis of risk factors in children

M Singh, YS Kadian, KN Rattan, B Jangra

Background: Acute appendicitis (AA) is the most common surgical emergency in childhood. The risk of rupture is negligible within the first 24 h, climbing to 6% after 36 h from the onset of symptoms. Because of difficulty in accurate diagnosis of AA a significant number of children still are being managed when it is already perforated. There is always a need to make an early diagnosis of AA and to find out the risk factors associated
with development of complication in this condition.

Patients and Methods: A total of 102 patients with a clinical diagnosis of AA were admitted during the study period. On admission, a good clinical history and proper physical examination was performed. All the eligible patients who finally diagnosed clinically as having AA were planned for emergency open appendectomy. The removed appendix was sent for histopathological examination in all the study subjects.

Results: Out of 102 cases, 93 cases were histopathologically appendicitis, rest nine cases showed no evidence of inflammation so the rate of negative appendectomy was around 9%. On histopathology normal appendix was found in nine patients (8.9%), AA in 71 patients (69.6%), complicated appendicitis (CA) which includes perforated and gangrenous appendicitis was present in 22 patients (21.5%). Perforations were more common in patients who were younger than 5 years. >60% patients presented with CA when the duration of pain was >72 h. Presence of appendicolith increased the probability of CA.

Key words: Acute appendicitis, children, complication

A survey of current practices in management of Hirschsprung’s disease in Nigeria

AA Nasir, EA Ameh

Background: Although there are several modalities of treatment for Hirschsprung’s disease (HD), there are presently no clear guidelines on treatment of the condition by paediatric surgeons in Nigeria. This survey determines the current approach to treatment among Nigerian paediatric surgeons and should help in establishing a consensus and guidelines for care in this and similar setting.

Materials and Methods: An online questionnaire was designed using survey Monkey® to determine current clinical and operative management of patients with HD by consultant paediatric surgeons practicing in the Nigeria. The paediatric surgeons were notified by E-mail, which included a link to the survey on survey Monkey®. The survey was also administered at the 12th annual meeting of Association of Paediatric Surgeons of Nigeria in September, 2013, to capture those who did not complete the online survey. Thirtyone paediatric surgeons from 21 different tertiary paediatric surgery centres completed the survey.

Results: Sixteen (52%) respondents see up to 20% of their patients with HD in the neonatal period. Twentysix (84%) respondents do routine barium enema. Twenty six (84%) respondents do full thickness rectal biopsy under general anaesthesia (GA). There was no consistency in operative techniques, with transabominal Swenson’s operation being practiced
by 17 (57%) respondents and 11 (37%) transanal endorectal pull through. 14 (45%) do pull through at any age. 12 (39%) respondents do more than half of their patient as primary pull through.

Conclusion: Full thickness rectal biopsy under GA is still the vogue with variations in the surgical technique for management of Hirshsprung’s disease in Nigeria. Primary pull through procedures is becoming increasingly popular. There’s a need for Paediatric Surgeons in Nigeria to Original Article come up with a guideline on management of HD, to guide trainees and other surgeons in the care of these patients.

Key words: Hirschsprung’s disease, management, primary pull through, rectal biopsy

Late-presenting congenital diaphragmatic hernia

R Hamid, AA Baba, AH Shera, SA Wani, T Altaf, MH Kant

Background: This study was undertaken to highlight the clinical profile, misdiagnosis, surgical treatment,and prognosis of late-presenting congenital diaphragmatic hernia (CDH) cases in a tertiary level hospital.

Patients and Methods: This retrospective study included all the babies and
children >1 month of age with CDH who were admitted in our Hospital (Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India) during the period between January 2008 and December 2013. Babies with age <1 month were excluded from the study. Data regarding clinical profile, operative records, and follow-up was reviewed and analysed statistically.

Results: A total of 20 patients were included in this study. The clinical picture ranged from respiratory distress (13 patients) to non-specific gastrointestinal complaints (5 patients). In two patients, CDH was misdiagnosed as pneumothorax and had got chest tube inserted in other hospitals before referral to this tertiary care centre. In 14 patients chest, X-ray revealed the diagnosis of CDH and in remaining five patients (including the two patients with misdiagnosis) further investigations were
undertaken to establish the diagnosis. Age ranged from 45 days to 17 years with an average age of 58.9 months. There were 12 male and 8 female patients. In all the 20 patients, surgical procedures were undertaken with the retrieval of herniated contents from the thoracic cavity and repair of the diaphragmatic defect. There was no mortality in our series. All the 20 patients were followed-up for a period ranging from 6 months to 5 years (median 3.1 years).

Conclusions: Late-presenting CDH can have diverse clinical presentation. Late diagnosis and misdiagnosis can result in significant morbidity and potential mortality if these cases Original Article are not managed properly at an appropriate stage. Outcome is favourable if these patients are expeditiously identified and surgically repaired.

Key words: Congenital diaphragmatic hernia, late presentation, misdiagnosis

High drain amylase and lipase values predict post-operative pancreatitis for choledochal cyst

S Honda, T Okada, H Miyagi, M Minato, A Taketomi

Background: Post-operative pancreatitis is a severe complication after cyst excision with hepaticoenterostomy (CEHE) for choledochal cysts. The aim of this study was to examine the dynamic post-operative changes in drain amylase and lipase values after CEHE for choledochal cysts, and then compare these values with the clinical outcomes in order to identify risk factors for post-operative pancreatitis after CEHE.

Patients and Methods: A total of 19 patients with choledochal cysts were retrospectively examined in the period between 2005 and 2012. The amylase and lipase values in the drainage and the serum, and the output of the effluent were measured post-operatively. The associations between their values and the clinical outcomes were evaluated.

Results: Six were found to have a pancreatic leak according to an international study group definition. In two of them, who developed post-operative pancreatitis, both amylase and lipase values in drainage were markedly elevated at 1 post-operative day (1 POD). The drain amylase value seemed to elevate rather specifically dependent on
the occurrence of post-operative pancreatitis, whereas the drain lipase value tended to elevate regardless of the presence/absence of post-operative pancreatitis.
Conclusion: It was indicated that amylase and lipase values in drainage at 1 POD could be effective predictors of post-operative pancreatitis after CEHE.

Key words: Child, choledochal cyst, drain amylase, drain lipase, post-operative pancreatitis

Spectrum of colorectal surgery operations performed in a single paediatric surgery unit in sub-Saharan Africa

TA Lawal, DI Olulana, OO Ogundoyin

Background: Colorectal surgery is a budding subspecialty of paediatric surgery and typifies the advances in the management of surgical conditions in children. The colorectal burden in resource poor settings, though reported to be challenging, remains undocumented. The aim of the present study was to review the typical operative paediatric colorectal caseload in a single centre in sub-Saharan Africa.

Materials and Methods: A retrospective review of the operative records of the division was conducted between 2009 and 2013. Data were obtained on the demography, diagnosis, procedure performed and type of anaesthesia used; entered into a computer using SPSS (IBM Corp; Armonk, NY) and analysed.

Results: A total of 120 colorectal operations were performed in 90 patients with age ranging from 1 to 13 years. The major diagnoses were anorectal
malformations (64.4%) and Hirschsprung disease (HD) (31.1%). The most often performed operations were colostomy (45.0%), posterior sagittal anorectoplasty (17.5%) and pull through (17.5%). The number of colorectal operations performed each year ranged from 12 in 2009 to 36 in 2012. A higher proportion of patients with anorectal malformations (46.6%)
presented within the neonatal period compared with those with HD (17.9%), P = 0.005. The age at definitive surgery was less in patients with anorectal
malformations compared to patients with HD (P = 0.003).

Conclusions: Congenital malformations represent the bulk of the caseload in paediatric colorectal surgery in sub-Saharan Africa and patients typically present late; although patients with anorectal malformations present and are operated upon significantly earlier than those with HD.

Key words: Anorectal malformation, Hirschsprung disease, paediatric colorectal, spectrum of cases, subspecialty

Correlation of radiological investigations with clinical findings in cases of abdominal mass in the paediatric age group

N Sharma, V Dutt, M Sharma

Background: The aim of the following study is to find out the accuracy of clinical examination and radiological investigations in determining the organ of origin and diagnosis in cases of abdominal mass.

Patients and Methods: This prospective study included patients presenting with a palpable abdominal mass. Complete detailed history and clinical examination were done prior to any investigation to find out the possible
clinical diagnosis and determine the organ of origin. Radiological investigations were done by blinded senior radiologist to form a radiological diagnosis and determine the organ of origin. Final diagnosis was used to see the accuracy of both the pre-operative modalities.

Results: There were 50 cases which formed the study group. Male to female ratio was 2:1. Prepubescent age was the most common age group at presentation. Right hypochondrium was the most commonly affected quadrant (18%). Most of these masses were hepatobiliary in origin. The
overall accuracy of ultrasound with respect to the final diagnosis was 45/50 (90%). Ultrasonography findings correlated with a clinical diagnosis in 91% of those who were operated and in 88% in those confirmed by biopsy or other modalities. Radiological investigations in total had accuracy of 94%, which was similar to the clinical examination. Both radiological diagnosis
and clinical diagnosis were correct in 47/50 (94%) cases.

Conclusions: Most of the cases of abdominal mass can be well evaluated clinically in terms of the diagnosis and organ of origin. Both radiological investigation and a good clinical examination have equal sensitivity. Radiological investigations are thus only adjuvant to a good clinical examination. Original Article

Key words: Abdominal mass, accuracy, clinical examination, radiological investigations, ultrasonography

Complications of total implantable access ports and efficacy of Taurolidine-citrate lock solution against catheter-related infections

E Ince, P Oguzkurt, A Temiz, SS Ezer, HÖ Gezer, N Yazici, A Hiçsönmez

Background: Totally, implantable access ports (TIAPs) are used for long standing venous catheterization. This study was designed to present our experiences of the TIAPs applications and efficacy of Taurolidinecitrate
lock solution (TCLS) against catheterrelated infections.

Materials and Methods: We evaluated records of the 108 patients implanted with 112 TIAPs, which had been performed using heparin solution or TCLS between 2005 and 2013.

Results: Duration of exposure to TIAPs was 17-2051 days (median: 411 days). The primary diagnoses were solid tumours (n = 57), lymphoma (n = 23), haematologic diseases (n = 23), nephrotic syndrome (n = 4), Hirschsprung disease (n = 1). The right external jugular vein was most frequently used vascular access route (72.3%). Mechanical complications were observed in four cases. TIAPs were removed due to remission in
19 cases and infection in 19 cases. Median time from implantation and to the development of infection was 60 days. Heparin solution had been used for care in 33 ports, whereas heparin and TCLS had been used in 79 ports. Based on statistical comparison, use of TCLS was considered to be an important factor for preventing infection (P = 0.03).

Conclusion: We consider that TCLS reduces infection prevalence so TIAPs would be used more extensively and effectively to prevent infections.

Key words: Catheter, infection, malignancy, port, Taurolidine-citrate

Single high scrotal incision orchidopexy for unilateral palpable testis: A randomised controlled study

AA Eltayeb

Background: Bianchi and Squire introduced single high trans-scrotal incision for mobilisation of palpable undescended testes to decrease the potential morbidity of the traditional inguinal approach. This incision has not gained widespread acceptance and there is still a considerable debate about its efficacy. This study evaluated the outcome of high single scrotal incision in comparison to the classic inguinal exploration for unilateral palpable testes regardless to its pre-operative location to assure its validity and safety.

Patients and Methods: This was a randomised controlled study conducted on seventy males with palpable unilateral undescended testicles from November 2009 to October 2013. They were divided into two equal groups; group I had high single scrotal incision and group II had the classic inguinal approach. The comparative parameters between both groups were the operative time, intra-and post-operative complications, postoperative
pain and scar.

Results: There was statistical significant difference between both groups regarding the operative time (P < 0.001). The high scrotal approach (Group I) was not completed in three cases and were converted to the classic inguinal approach. No statistical significant difference between both groups regarding the post-operative complications.

Conclusions: Single high scrotal incision orchidopexy for palpable undescended testis is safe, has shorter operative time but may not be
suitable for proximally lying testis.

Key words: Scrotal orchidopexy, palpable undescended testes, single scrotal incision

Intractable chronic constipation in children: Outcome after anorectal myectomy

SA Mousavi, H Karami, AA Rajabpoor

Background: Many children with constipation fail to respond with conventional medical therapy. Surgery can produce a good result in dysfunction of the colon secondary to aganglionosis. However, its role in treating idiopathic constipation is more controversial.

Patients and Methods: A consecutive series of 44 patients with chronic idiopathic intractable constipation were included in this study. All children
were investigated by barium enema and anorectal manometry. Due to inadequate response to medical therapy, all of these patients were selected for internal sphincter myomectomy. Patients were followed-up from 3 to 12 months.

Results: Short-term (3 months) and long-term (6 months) follow-up was available for all patients. The histology examinations showed normal ganglion cells in 32, hypoganglionosis in eight and aganglionosis in four patients. In short-term, regular bowel habits, without the need for laxatives or low dose drugs were recorded in 35 patients (79.5%). Overall there was an improvement in 68.2% of the children after 6 months follow-up. There was not any correlation between histopathological findings, duration of
symptoms, age and sex of operation and response to myectomy.

Conclusion: anorectal myectomy is an effective procedure in patients with intractable idiopathic constipation. It relieves symptoms in 68.2% of patients with chronic refractory constipation.

Key words: Anorectal myectomy, children, idiopathic constipation

Do geography and resources influence the need for colostomy in Hirschsprung’s disease and anorectal malformations? A Canadian association of paediatric surgeons: Association of paediatric surgeons of Nigeria survey

LO Abdur-Rahman, A Shawyer, R Vizcarra, K Bailey, BH Cameron

Background: This survey compared surgical management of Hirschsprung’s disease (HD) and anorectal malformations (ARM) in high and low resource settings.

Materials and Methods: An online survey was sent to 208 members of the Canadian Association of Paediatric Surgeons (CAPS) and the Association of Paediatric Surgeons of Nigeria (APSON).

Results: The response rate was 76.8% with 127 complete surveys (APSON 34, CAPS 97). Only 29.5% of APSON surgeons had frozen section available for diagnosis of HD. They were more likely to choose full thickness rectal biopsy (APSON 70.6% vs. CAPS 9.4%, P < 0.05) and do an initial colostomy for HD (APSON 23.5% vs. CAPS 0%, P < 0.05). Experience with transanal pull-through for HD was similar in both groups (APSON 76.5%, CAPS 66.7%). CAPS members practising in the United States were more likely to perform a one-stage pull-through for HD during the initial hospitalization (USA 65.4% vs. Canada 28.3%, P < 0.05). The frequency of colostomy in females with vestibular fistula varied widely independent of
geography. APSON surgeons were less likely to have enterostomal therapists and patient education resources.

Conclusions: Local resources which vary by geographic location affect the management of HD and ARM including colostomy. Collaboration between
CAPS and APSON members could address resource and educational needs to improve patient care.

Key words: Africa, anorectal malformation, colostomy, Hirschsprung’s, North America, paediatric surgery

Risk of surgical site infection in paediatric herniotomies without any prophylactic antibiotics: A preliminary experience

D Vaze, R Samujh, KLN Rao

Background: Different studies underline the use of pre-operative antibiotic prophylaxis in clean surgeries like herniotomy and inguinal orchiopexy. But, the metaanalyses do not recommend nor discard the use of prophylactic pre-operative antibiotics. The scarcity of controlled clinical trials in paediatric population further vitiates the matter. This study assessed the difference in the rate of early post-operative wound infection cases in children who received single dose of pre-operative antibiotics and children who did not receive antibiotics after inguinal herniotomy and orchiopexy.

Materials and Methods: This randomised prospective study was conducted in Paediatric Surgery department of PGIMER Chandigarh. Out of 251 patients, 112 patients were randomised to the case group and 139 were ascribed to the control group. The patients in control group were given a standard regimen of single dose of intravenous antibiotic at the time of induction followed by 3-4 days of oral antibiotic. Case group patients underwent the surgical procedure in similar manner with no antibiotic
either at the time of induction or post-operatively.

Results: The incidence of surgical site infection in case group was 3.73 % and that in control group was 2.22%. The observed difference in the incidence of surgical site infection was statistically insignificant (P value = 0.7027). The overall infection rate in case and control group was 2.89%.

Conclusions: Our preliminary experience suggests that there is no statistically significant difference in the proportion of early post-operative wound infection between the patients who received single dose of pre-operative antibiotics and the patients who received no antibiotics after inguinal herniotomy and orchiopexy. The risk of surgical site infection in paediatric heriotomies does not increase even if the child’s weight is less than his/her expected weight for age.

Key words: Antibiotic prophylaxis, clean surgeries, herniotomy, orchiopexy, surgical site infections

Post-operative pain management in paediatric surgery at Sylvanus Olympio University Teaching Hospital, Togo

HD Sama, AFOB Maman, M Djibril, M Assenouwe, M Belo, K Tomta, M Chobli

Background: The aim of this study was to evaluate pain management in paediatric surgery at Sylvanus Olympio University Teaching Hospital, Lome.

Patients and Methods: A prospective descriptive study was conducted in the Department of Anaesthesiology and Intensive Care at Sylvanus Olympio teaching hospital from 1 January to 30 June 2012. Data collected include:
demography, type of surgery, American Society of Anaesthesiologists (ASA) classification, anaesthetic protocol, analgesia technique, post-operative complications and cost of analgesia.

Results: The study includes 106 post-operative children. Abdominal surgery was performed in 41.5% and orthopaedic surgery in 31.1%. A total of 75% of patients were classified ASA 1. General anaesthesia (GA) was
performed in 88%. Anaesthetists supervised postoperative care in 21.7% cases. Multimodal analgesia was used in every case and 12% of patients received a regional block. The most frequently unwanted effects of analgesics used were nausea and/or vomiting in 12.3%. At H24, child under 7 years have more pain assessment than those from 7 to 15 years (46% vs 24%) and this difference was statistically significant (chi-square = 4.7598; P = 0.0291 < 0.05). The average cost of peri-operative analgesia under loco regional analgesia (LRA) versus GA during the first 48 h postoperative was US $23 versus $46.

Conclusion: Our study showed that post-operative pain management
in paediatric surgery is often not well controlled and paediatric loco regional analgesia technique is under practiced in sub Saharan Africa.

Key words: Paediatric anaesthesia, post-operative pain, Togo

Comparing the analgesic effect of caudal and ilioinguinal iliohypogastric nerve blockade using bupivacaine-clonidine in inguinal surgeries in children 2-7 years old

M Seyedhejazi, D Sheikhzadeh, Z Adrang, FK Rashed

Background: We compared the analgesic effects of caudal and ilioinguinal-iliohypogastric nerve block using bupivacaine-clonidine performed in children undergoing inguinal hernia repair. The ilioinguinal-iliohypogastric nerve block provides excellent pain relief for operations on the inguinal region, including emergency procedures (e.g. strangulated inguinal hernia with intestinal obstruction). It should be preferred to caudal block for these procedures.

Materials and Methods: After local ethics committee approval and written parental consent, 67 ASA class I - II patients aged between 2-7 years old scheduled for elective inguinal hernia repair were allocated randomly into two groups after general anesthesia with same drugs in both groups. Group C received caudal block with 1 ml/kg bupivacaine 0.25% combined with 1 µg/kg clonidine, and group I received ilioinguinal- iliohypogastric nerve block with 0.3 ml /kg bupivacaine 0.25% combined with 1 µg/kg clonidine. Blood pressure and heart rate were documented every 5 minutes. Post-operative analgesia, analgesic use and side-effects were assessed during first 24 hours.

Results: In group C, 7 / 34 and in group I, 12/33 patients required post-operative analgesia (P = 0.174). Five patients (15.5%) in group I and one patient (2.94%) in group C had severe pain after operation. Systolic and diastolic blood pressure decreased during operation, but the differences between two groups were not significant (P = 0.176, P = 0.111). Heart rate changes between two groups were insignificant (P = 0.182).

Conclusion: It seems that in children, caudal epidural block and ilioinguinal – iliohypogastric nerve block using bupivacaine-clonidine have comparable effects on analgesia, severity of pain and hemodynamic changes during and after surgery on inguinal region.

Key words: Bupivacaine, caudal anaesthesia, children, clonidine, ilioinguinal-iliohypogastric nerve block

Outcomes of conservative treatment of giant omphaloceles with dissodic 2% aqueous eosin: 15 years’ experience

Background: The surgical management of giant omphalocele is a surgical challenge with high mortality and morbidity in our country due to the absence of neonatal resuscitation. This study evaluates conservative management of giant omphalocele with dissodic 2% aqueous eosin.

Materials and Methods: In the period from January 1997 to December 2012, giant omphaloceles were treated with dissodic 2% aqueous eosin. The procedure consisted of twice a day application of dissodic 2% aqueous eosin (sterile solution for topical application) on the omphalocele sac. The
procedure was taught to the mother to continue at home with an outpatient follow-up to assess epithelialization. We studied the duration of the hospital stay, the learning curve of the procedure by the mother, the complications, the duration and the percentage of complete epithelialization and the mortality.

Results: A total of 173 giant omphaloceles had a conservative treatment with dissodic 2% aqueous eosin. The average hospital stay was 21 ± 6 days. The learning curve by the mother of the procedure was 10 ± 3 days. Complications of treatment were intestinal functional occlusion 22% and omphalocele sac infection 18%. The complete epithelialization of the omphaloceles sac after application of dissodic 2% aqueous eosin was 68.5%. Mortality was observed in 25.5%.

Conclusion: Conservative treatment of giant omphaloceles by dissodic 2% aqueous eosin is a simple, efficient and a good alternative to surgery.
The mother can easily learn its procedure which reduces the duration of hospital stay.

Key words: Conservative treatment, dissodic
aqueous eosin, new-born, omphalocele

Longterm outcome of Macroplatique injection for treatment of vesicoureteral reflux in children

EA Mohamed, FH Shehata, EA Abdelbaset, MA Abdelkhalek, AH Abdelatif, HA Galal

Background: This study examined our experience with one year follow-up of 20 cases of vesicoureteric reflux in children after treatment with Macroplastique® injection.

Patient and Methods: A total of 20 children (31 ureters) with primary grades II to V vesicoureteral reflux were treated with subureteral Macroplastique® injection from 2010 to 2011 and followed for an average of 12 months (range 3 to 24). Vesicoureteral reflux was grade II in 3, III in 7, IV in 9 and V in 12 ureters. Each child underwent pre-operative voiding
cystourethrography, abdominopelvic ultrasound, urine analysis/culture, S. creatinine and CBC. Dimercapto-succinic acid scan (DMSA scan) and magnetic resonance urography (MRU) were done in some patients. Voiding cystourethrography at 3 months was done to rule out persistent reflux.

Results: Overall, reflux was corrected in 11 (35.5%) ureters and 9 (45%) children after a single injection. With repeat injection, reflux was corrected in 16 (51.6%) ureters and 11 (55%) children, reflux improved/downgrade in 4 (12.9%) ureters and 2 (10%) children. Correction by grade was 100%, 100%, 9.7%, 9.7% for grades II to V, respectively. There were no surgical complications. None of the cured patients had recurrent reflux during follow-up. There were 9 (45%) children who required open ureteral re-implantation for failed injection.

Conclusion: Sub-ureteral Macroplastique® injection therapy could be a
primary treatment for low grade VUR (grade III or less) in children because it is simple, safe, effective, less invasive, decreased.

Key words: Children, injection, Macroplastique®, polydimethylsiloxane, vesico-ureteral reflux

Ten years experience with a novel modification of plastibell circumcision

A Hammed, AE Helal, R Badway, SH Goda, M Razik, A Elshamy, O Elsamahy

Background: Plastibell device is a satisfactory method of circumcision in infants. However the most common post-operative complication was bleeding (especially from the frenulum site). As a result, we introduce a novel modification of the device to prevent this complication.

Patients and Methods: A prospective comparative study of Plastibell circumcision in infants up to the age of 12 months was conducted, using conventional Plastibell device and modified Plastibell device circumcision.
In The first group (1000 infants), circumcision was performed with conventional Plastibell device while in the second group (4500 infants), circumcision was done with modified Plastibell device.

Results: The mean age was 8 weeks. The mean operating time were 8.5 min and 5.9 min for conventional Plastibell ring and modified Plastibell device circumcision respectively. The most common postoperative complication in first groups was bleeding.

Conclusion: This modified Plastibell device, prevents the most series complication of bleeding. It is fast and ensures excellent cosmoses compared with the standard Plastibell template circumcision. Also it is easy
to perform and allows the paediatric surgeon to achieve consistently excellent cosmetic results. Moreover, the shorter operating time makes circumcision by the modified Plastibell device a more practical method. The
technique will be described in detail.

Key words: Circumcision, Plastibell, Children

A comparison of manual versus hydrostatic reduction in children with intussusception: Single-center experience

S Ocal, M Cevik, ME Boleken, E Karakas

Objective: In recent years several techniques have been recommended for intussusception treatment. In this study, an evaluation was made of intussusception cases that presented at our clinic and had reduction applied together with saline under ultrasonography (USG) and cases, which were surgically treated.

Patients and Methods: A retrospective evaluation was made of the records of 72 cases treated for a diagnosis of intussusception between January 2010 and July 2012. Patients were evaluated demographics, clinical presentation, management strategy, during the hospitalisation and outcome.

Results: A total of 72 cases which consists of 44 male and 28 female with age range between 5 and 132 months were treated with a diagnosis of intussusception. USG was applied to all cases on initial presentation. As
treatment, hydrostatic reduction (HR) together with USG was applied to 47 cases. Of these, the HR was unsuccessful in 13 cases. Surgical treatment
was applied to 38 cases. Of these cases, ileocolic intussusception was observed in 30 cases, ileoileal in seven cases and colocolic in one case. Meckel diverticulum was determined in five of these cases, polyps in two cases, lymphoma in two cases, lymph nodule in one case and 28 cases were observed to be idiopathic. There was no mortality in any case.

Conclusion: HR together with USG is a safe technique in the treatment of intussusception, which also shortens the duration of hospitalisation and
significantly reduces the treatment costs.

Key words: Hydrostatic reduction, intussusception, treatment, ultrasonography

Paediatric penetrating thoraco-abdominal injury: Role of minimallly invasive surgery

J Donati-Bourne, MI Bader, D Parikh, I Jester

We report two cases of penetrating thoraco-abdominal injuries who presented to our trauma centre. One with stab to lower left chest and the other one had
pallet injury to right upper abdomen. The clinical presentation, radiological investigations and operative intervention are reviewed.

Key words: Laparoscopy, minimally invasive, penetrating injuries, thoraco-abdominal

Stone ingestion causing obstructed inguinal hernia with perforation

We report a rare case of obstructed right inguinal hernia caused by ingested stones. A 2 year-old boy from Northern Thailand was transferred to our hospital with low-grade fever, vomiting, and acute painful swelling at his right hemiscrotum for one day. The physical examination revealed marked enlargement with inflammation in his right hemiscrotum. The radiological findings showed huge number of stones in the right hemiscrotum. At surgery, the content of hernia sac was ascending colon, which was full of hard masses. With the help of additional lower transverse abdominal incision, the obstructed segment was successfully reduced and revealed a perforation. Most of the stones were removed through the perforation. The colonic wound was primarily repaired and both incisions were primarily closed. Although he developed post-operative wound infection, the boy had uneventfully recovered. The psychological exploration in this “stone pica” revealed no other psychological disorders.

Key words: Inguinal hernia, pica, stone ingestion

Child abdominal tumour in tropical context: Think about schistosomiasis!

Schistosomiasis presenting as an abdominal mass with chronic pain in a child is not common. This report presents case of child presenting with schistosomiasis presenting as an abdominal mass with chronic pain. Abdominal ultrasonography did not particularly contribute to definitive pre-operative diagnosis. However, pathological examination of surgical specimen confirmed Schistosoma mansoni eggs in the biospy. A decrease in the mass volume was noticed under medical treatment (Biltricide). The aim of this report was to intimate clinicians on possible abdominal schistosomiasis as
differential diagnosis of childhood abdominal mass. This is a clarion call for a high index of suspicion of childhood abdominal schistosomiasis in children presenting with abdominal mass in a tropical setting.

Key words: Abdominal mass, abdominal schistosomiasis, child

Ultrasound- guided placement of double catheter in the right internal jugular vein: Two case reports

Central vascular access in critically ill paediatric patients is, many times, a challenge for physicians due to the number of lines needed for multiple infusions. We present ultrasound-guided placement of a double catheter in the right internal jugular vein in two patients that required multiple central lines for management.

Key words: Double catheter, jugular vein, ultrasound-guided