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ABSTRACT Table of Contents   
Year : 2010  |  Volume : 7  |  Issue : 3  |  Page : 217-239
Abstracts of papers presented at PAPSA in Dar-Es-Salaam, 5-9th July 2010

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Date of Web Publication18-Sep-2010

How to cite this article:
. Abstracts of papers presented at PAPSA in Dar-Es-Salaam, 5-9th July 2010. Afr J Paediatr Surg 2010;7:217-39

How to cite this URL:
. Abstracts of papers presented at PAPSA in Dar-Es-Salaam, 5-9th July 2010. Afr J Paediatr Surg [serial online] 2010 [cited 2020 Jul 3];7:217-39. Available from:

Pre-Hospital trauma care for road traffic crash victims in Dar-Es-Salaam

Ngiloi P

Department of Pediatric Surgery, University Hospital, Dar-es-Salaam, Tanzania

Introduction : Road traffic injuries have been noted to be on the increase in Tanzania. Data from the Police records show that between 1990 and 2000, road traffic accidents rose by 44%. Dar-es-Salaam is the largest City and smallest region in Tanzania but records six times the number of road traffic injuries compared to the second highest region.

Objectives : The objectives of the study were to determine the pattern of pre-hospital trauma care among road traffic crash victims attending the five public hospitals in Dar-es-Salaam.

Methods : A structured questionnaire was used for interviewing all road traffic crashed victims / relatives /witness/ police patrol attending the five hospitals in Dar-es-Salaam namely Muhimbili Orthopaedic Institute, Muhimbili National Hospital, Mwananyamala, Amana and Temeke municipal Hospitals. An assessment of the pre-hospital trauma care was done by interviewing all the patients who were attended at the above five named hospitals. Where a patient was unable to communicate then the accompanied person was interviewed.

Results : A total of 629 road traffic crashes and fatalities were attended at five hospitals in Dar-es-Salaam, in the months of June 2009. The results showed that Muhimbili Orthopaedic Institute was the largest recipient of road traffic crash victims by 317 (50.4%) and Temeke Hospital 48 (7.6%) the least recipient. Out of the 629 victims only 248(43.2%) admitted to have received some form of first aid which entailed splinting of fractured limb (158 (63.8%) and dressing of bleeding wounds 90(32.2%). A number of patients admitted to have called a pre-hospital help from relatives mainly 187(29.7%), police 77 (12.2) including friends 27 (4.3%). No ambulance services were called to the site of crash.

Conclusion : From the findings of this study pre-hospital trauma care in Dar-Es-Salaam is not yet well structured it has been left to the discretion of public and relatives. This silent massive loss of lives due to road traffic crashes on daily basis could be saved with appropriate measures in place.


Paediatric trauma patterns in KATH

Nimako B, Amoah M, Abantanga FA

Directorate of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana

Objective : Injury is the leading cause of death among children older than 1 year. The impact of pediatric trauma on the society is often underestimated. The time, energy and financial implications of injuries to children cannot be overemphasized. There is limited data in our country about the mechanism and type of injuries in children. The objective of this study is to assess the etiology and the patterns of injuries in children below 14 years of age in KATH, Kumasi, Ghana.

Method : A retrospective review of patients under 14 years of age who were admitted from January to December 2009 was done. The mechanisms and patterns of injuries were collated and analyzed.

Results : In all there were 235 injuries recorded. Of these 37 were birth injuries, 31 head injuries, 12 abdominal injuries and 155 limb fractures and other soft tissue injuries. Fifteen children were involved in motor vehicular occupancy accidents, 92 were knocked down by moving vehicles, 51 falls from height, 31 were hit or struck by other objects and one sustained gun-shot injury.

Conclusion : Limb fractures were the commonest injuries sustained by children admitted to our hospital with abdominal injuries being least common. More children sustained injuries via knock down by moving vehicles. Falls from heights were also common but gun-shot injuries were almost non-existence. The high number of children knocked down by vehicles reflects the poor road conditions and non-existent mechanisms for traffic control and the disregard for traffic regulations in our society. The high number of fractures is consistent with the most predominant mechanism of action which is vehicular knock downs. Multi-center prospective studies over longer period of time are needed to throw more light on the extent and effect of pediatric trauma on our society.


Childhood motorcycle related injuries in a Nigerian city: Spectrum and strategies for control

Nasir AA, Bello JO, Ofoegbu CKP, Abdur-Rahman LO, Yakub S, Solagberu BA

Center for Injury Research and Safety Promotion, Department of Surgery, University of Ilorin Teaching Hospital, Ilorin, Nigeria

Introduction : Injuries claim more children's lives than birth defects, cancer and infectious diseases combined and have evolved into the number one cause of death and disability among children. Motorcycle crashes are taking up a noticeable proportion of deaths and disabilities in road traffic crashes in developing countries. This study aim to determine the spectrum of childhood motorcycle related injuries in Nigeria city and to suggest strategies for its control

Methods : A 3-year prospective study of motorcycle related injuries (MCRI) presenting at the surgical emergency room of University of Ilorin Teaching Hospital in children 15 years or less. Data obtained included patient demographic Information, use of a protective helmet, mechanism of injury, part of the body injured, injury arrival time, hospital length of stay, and outcome of management

Results : Children constitute 9% (40) of the 440 patients with MCRI. Ten children were injured in the first year and nineteen in the third year. The male: female ratio was 1.4:1. The age medial age of 3 years, range 3-15 years. Twenty-seven (67.5%) children were injured as pedestrians, 11(27.5%) as passengers and 2(5%) children, aged 10-15 years as riders. None of the passengers and the riders wore helmet. Mechanism of injury was motorcycle pedestrian collision in 28 (70%) and Vehicle-motorcycle collision in 7 (17.5%). The most commonly injured body parts were extremities (67.5%) and head (52.5%). Most of the patients arrived under 1 hour (19, 47.5 %). The median length of hospital stay was 1 day. The mean (SD) length of hospital stay of patients with PTS ≤ 8 and PTS 9-11 was 11.3 (14) and 1.6(1) respectively, P=0.002. Injury arrival time (P=0.005) and PTS (P=0.002) were significant association with length of hospital stay among the survivors. One patient with head injury died after 36hours of Intensive Care Unit (ICU) stay giving a mortality rate of 2.5%.

Conclusions : Children remain very vulnerable as pedestrians in MCRI. Strict observance of rules for road crossing, need for adult help, use of hand held traffic control signals are important measures for control including use of child helmets.


Surgical procedures for trauma in children in Northern Tanzania

Bokhari Z, Meier KJ, Msuya D, Chilonga K, Lakhoo K

Kilimanjaro Christian Medical Centre, Moshi, Tanzania & Children's Hospital, Oxford, UK

Introduction : Kilimanjaro Christian Medical Centre (KCMC) was established in 1971 as a referral hospital for Northern Tanzania, serving a population of 15 million people. Injuries account for the commonest surgical admission for children and the second commonest admission for all children at KCMC. Death from injuries is well documented in the developed world and in some developing countries .However documentation of operative needs for injured children is lacking. The aim of the study is to determine the need for surgery in children admitted for trauma.

Methods : Over a 24 month period beginning January 2008 to December 2009 data on children who required surgery for trauma was analysed. The ages ranged from birth to 16 years of age. Data was obtained from the operative database and paediatric admissions database at KCMC. Analysis detailed principle diagnosis and operative procedures. All orthopaedic patients have been excluded from this study.

Results : There were 804 children admitted for trauma over a 2 year period and these included falls 576 (72%), road traffic accidents 82 (10%), burns 139 (17%) and other 7 (poison 4,foreign body 2 non-accidental 1). Of these 804 trauma admissions 103 (12.8%) required surgery. During the same period 875 surgical procedures were performed in children and 103 (11.8%) were for trauma. The 103 operations for trauma included: head injury 33 [32%](compound skull fracture management 24, subdural haematoma 4, epidural haematoma 5), burns 32 [31%] (17 skin grafts and 15 contracture surgery),wound suture and debridement 19 [18%],intra-abdominal visceral injury 15 [14%] (11 splenic injury, 7 for bowel injury,5 liver trauma, 1 pancreatic injury,1 bladder, 2 renal and 1 for diaphragmatic rupture) 4 for haemothorax and 9 for muti-system trauma. Further analysis of the type of injury requiring surgery is reflected in [Table 1]. The mortality from trauma admissions was 29 (3.6%) of which 21 (72%) were due to road traffic accidents.[Additional file 3]

Conclusion : Road traffic accidents account for the highest mortality and need for surgery in children admitted for trauma in Northern Tanzania.


Surgery for blunt abdominal trauma in children at KCMC, Tanzania

Kayandabila J, Msuya D, Chilonga K, Lakhoo K

Kilimanjaro Christian Medical Centre, Moshi, Tanzania & Children's Hospital, Oxford, UK

Introduction : Trauma is the highest cause for admission in children requiring surgical care in many parts of Africa, especially urbanised areas with its high incidence of motor vehicle accidents. This study analyses surgery for blunt abdominal trauma in a rural setting that has no major transport route.

Methods : Data was analysed for children who underwent surgery for blunt abdominal trauma. Age, gender and type of injury was recorded. Cause of injury and mortality was documented. Data was obtained from operative records and cross checked with admission data base in casualty.

Results : Over a 5 year period beginning 2005 to the end of 2009,343 children underwent emergency abdominal surgery for non congenital causes. Eighty eight children underwent abdominal surgery for infection, 73 for appendicitis, 63 intestinal obstruction, 68 intussusception and 51 (15%) for blunt abdominal trauma. Further analysis of the children with blunt abdominal trauma surgery revealed a male to female ratio of 10:7 and a mean age of 7.9 years (range from 1 month to 12 years). Injury was caused by road traffic accidents in 46 children and fall 5 children. Of the 46 children involved in road traffic accidents 31 were pedestrians. Investigation included a combination of blood tests, abdominal radiograph and abdominal ultrasound. Laparotomy revealed splenic injury 37, bowel injury 29, liver 12, pancreas 5, bladder 2, renal 3 and diaphragm 3. In 14 (27%) patients no further surgery was required at laparotomy. Splenectomy was required in 9(24%) children out of the 37 who suffered splenic injury. Mortality from blunt abdominal trauma surgery was 14% (7 children).

Conclusion : Operative treatment may be avoided in more than a quarter of the children presenting with blunt abdominal trauma if more sensitive preoperative tests are available. Pedestrian injury and mortality are high.


Outcome for children with head injuries managed at non-neurosurgical centre

Olori S, Anyanwu PA, Salihu LJ

University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria

Introduction : Trauma is a leading cause of death in the pediatric age group. It accounts for about 10% of mortalities in children in the USA. Acute traumatic brain injuries account for high morbidity and mortality. Several outcome studies have documented varied results from different centres.

Objective : The objective of this study is to report the outcome for children with head injuries managed at our centre, and hope that our experience could add to the wealth of knowledge on paediatric head injuries especially in the non neurosurgical cetres.

Method : It is a retrospective study from May 2006- May 2010.The information extracted from the case notes included; hospital number, age, sex, diagnosis, associated injuries, mechanism of injury, treatment given, duration of admission, time taken to regain consciousness, outcome of treatment, and complications.

Result : 33 cases were analyzed.11(33.3%),10(30.3%),12(36.4%) were mild, moderate and severe head injuries respectively. Out come were death(2.9%), poor(2.9%)and good(94.1%).Pedestrian and vehicular injuries accounted for all injuries in our experience.

Conclusion : From this study we observe that attention to resuscitation and careful monitoring and support care for these patients could produce satisfactory outcome in centres that lacked high technological intensive care which are the gold standard for the head injured.


Clinical features of multiple non-contiguous spine fractures in children

Moroz PJ, Kingwell S

Division of Orthopaedic Surgery, University of Ottawa, Ottawa, Canada

Introduction : A single level spine fracture can be dangerous and even life-threatening, however a second spine fracture at a different level then the first in the same patient can add complexity to patient management, and if missed, can result in a significant adverse outcome. Higher rates of noncontiguous spinal injury have been observed in pediatric patients with traumatic death associated with spinal injury, and in pediatric patients with more unstable spinal injuries. The reported incidence in adults is 1.6-34%, and to our knowledge there are no studies specifically examining multiple spine injuires and their outcomes in a pediatric population.

Methods : A retrospective review of charts at an academic pediatric level 1 trauma center over a 15 year period identified a population with noncontiguous spinal injuries.

Results : Twenty five (11.8%) out of 211 patients were identified with noncontiguous spinal injuries and complete charts and radiographs. The mean age was 10.7 years old. MVC (motor vehicle collision) was the most common mechanism of injury for ages 0-9, while a fall was most common for ages 10-17. The mean number of vertebral levels injured was 3.2 and the most common region was the thoracic spine. Patients had a mean of 5.4 (range 1 to 22) intact vertebral levels between injuries. Twenty-four percent of patients with noncontiguous spinal injuries had a neurologic deficit compared to 9.7% in patients with single level or contiguous injuries. This was statistically significant; risk ratio was 2.48 (1.09, 5.65). Seven (78%) of 9 patients aged 0-9 suffered an associated injury; most commonly a visceral injury. The mortality rate was 8.0% in patients with noncontiguous spinal injury compared to 2.7% in patients with single level or contiguous injury.

Discussion : Front line emergency workers need to know about the possibility of multiple level fractures at different levels in traumatized children. These children were more likely to suffer serious neurologic injury than with single level or contiguous spinal injury. Injured spinal segments tended to occur at a greater distance in patients with neurologic injury or death. Younger patients with NCSI's had a high rate of associated injuries. A higher mortality rate was seen in patients with NCSI. NCSI's can also occur in conjunction with SCIWORA's in the flexible pediatric spine. Clinicians must be aware of the incidence of NCSI's in children, and be aware of emergency transport techniques of injured children.


The Lodox: A revolution in paediatric trauma assessment

Van As AB, Douglas T, Beningfield S, Millar AJW

Trauma Unit, Red Cross War Memorial Children's Hospital, Department of Paediatric Surgery, School of Child and Adolescent Health, University of Cape Town, South Africa

Introduction : Trauma is the leading cause of childhood deaths. In our Level 1 trauma unit we have annual patient load of approximately 9500 patients (all children under the age of 13 years). The majority of severe child trauma occurs as a result of traffic related injuries. Typically these patients have more than one injury and fall in the category of "poly-trauma" patients. Polytraumatized patients require multiple radiographs that can take up to 60 minutes before they are finalized. The Lodox Stat-Scan is a newly developed digital total-body scanner, able to accomplish a total body image within 13 seconds at lower radiation levels than conventional radiographs.

Aim : To assess the use of the Lodox Stat-Scan in trauma.

Materials and Methods : A new whole-body Lodox Stat-Scan was installed in our Trauma Unit in October 2004. We conducted an initial assessment of the use of the Stat-Scan in paediatric trauma. A new protocol was developed for the use of the Stat-Scan and only patients with multiple injuries were included in the study. An antero-posterior whole-body image as well as a lateral image cervical spine image was performed on all patients. A number of parameters were assessed, including procedure time, radiation levels, diagnostic capacity and user friendliness. A total of 893 patients were analysed.

Results : Initial training of staff proved to be crucial for successful application of the new imaging device. After an initial steep learning curve staff adapted rapidly to the new device, located in the Resuscitation room (ER room). The Stat-Scan has performed well in a number of areas, particular in (1) picking up clinically missed fractures, (2) shortening the radiographic diagnostic time significantly, (3) reducing the total amount of radiation, (4) preventing complications by limiting transport of the patients out of the emergency room and (5) picking up life-threatening conditions within seconds after arrival.

Conclusion : The Lodox Stat-Scan is an ideal radiographic diagnostic tool for trauma units. It is of particularly benefit in busy trauma units with a high patient load.


Plusses and minuses of routine computerized tomography scanning in children with blunt abdominal injury

Arnold M, Moore SW

University of Stellenbosch, Cape Town, South Africa

Introduction : Blunt abdominal trauma is more frequent in children than penetrating abdominal trauma. Routine computerized tomography (CT) scanning in children with blunt abdominal injury, is reported to minimize negative abdominal exploration and facilitate better management of extra-abdominal injuries as even complex liver injuries are increasingly being treated conservatively. However, missed hollow viscus injuries and the high radiation exposure remain a problem.

Method : We investigated 136 patients aged 0-12 years referred with blunt abdominal trauma to tertiary care. Data were analyzed retrospectively with details of injury, treatment, transfusion requirements, mortality and method of imaging reviewed.

Results : Adequate data was available for 96 patients were seen in the period from 2003 to March 2009, and compared to 40 patients seen since the introduction of a multi-slice CT scanner within the trauma unit over the subsequent 1 year period from April 2009. The most frequent injuries involved the liver (54; 40%), spleen (20;15%) and kidney (16;12%). Associated injuries were head injuries (major: 12%; minor: 8%; skull fractures in 6%); chest injuries (16%); pelvic fractures (11%); soft tissue injuries (minor: 13%; major 13%); long bone fractures (14%) and spine injuries (1%). 4% were recorded as unstable at admission, with 1 death. Despite the majority of patients being stable, a transfusion threshold on laboratory haemoglobin measurements (Hb) of 7.8g/dL was noted, with a mean admission Hb of 10.2 g/dL and a nadir of 8.6g/dL overall during admission. Before the introduction of a spiral CT scanner within the trauma unit, 11% were observed only, ultrasound was used in 30%, with a 4% negative sonar rate, and CT scanning used in 51%, with a 4% negative CT rate. Post-introduction of the trauma-unit multi-slice spiral CT scanner, US was used in 8% of patients, CT in 98%, with a 35% negative CT scan rate. 15 patients (11%) required surgery for complications of the blunt abdominal trauma, of which most were for bowel injuries, but 1 each for liver and spleen injuries respectively. CT scanning aided pre-operative diagnosis of only 2/10 bowel injuries, being a duodenal perforation and intramural colonic haematoma respectively.

Discussion : For solid viscera injuries, over 95% were managed non-operatively, aided by sophisticated imaging. Clinical parameters remain the most important in detecting hollow viscera injuries due to blunt abdominal trauma. A high blood transfusion threshold in otherwise stable patients was noted, prompting concerns about unnecessary exposure to blood products due to reliance on bedside Hb monitoring. A high negative CT scan rate after improving access to this imaging modality also prompts concerns about radiation exposure and inadequate emphasis on clinical evaluation, as well as poor cost-benefit ratio.


Review of dog bites in small children

Van As AB, Du Toit N, Nyakaza P, Millar ALW

Department of Paediatric Surgery, University of Cape Town; Childsafe South Africa

Introduction : Dog bites are a major cause of preventable traumatic injury in the paediatric population. To accurately determine the epidemiology of dog bite injuries in children in view of developing potential preventative strategies, we conducted a 13.5-year retrospective review of patients with dog bite injuries presenting to our tertiary paediatric trauma unit.

Aims/Objective : To perform an analysis of dog bites in our community in order to develop preventative strategies.

Materials/Methods : Retrospective study of paediatric patients who suffered dog bite injuries presenting to the Trauma Unit of the Red Cross War Memorial Children's Hospital (RCH) in Cape Town, South Africa, from March 04, 1991 to October 25, 2004.

Results : A total of 2025 dog bite injuries were sustained by the 1871 children. The majority of injuries (n=1626, 80%) were classified as minor. Children less than six years of age were more likely to sustain injuries to the head, face or neck (n=421, 49%), whereas children greater than six years of age more commonly received injuries to the thigh or leg (n=560, 48%). The most frequent injuries were superficial lacerations and only 38 (2%) of children required major surgery.

Conclusions : This is one of the largest epidemiological studies of dog bite injuries in children reported. The causes were found to be multifactorial and possible preventative strategies should adopt a multidisciplinary approach aiming to modify behavioural patterns of the pet owner, child and dog. Health practitioners should actively contribute to responsible dog ownership and provide evidence-based dog bite prevention information.


Giant encephaloceles and meningomyeloceles: Our experience in a poor resource environment

Musa I, Mohammad AM

Murtala Mohammed Specialist Hospital and Aminu Kano Teaching Hospital, Kano, Nigeria

Introduction : Encephalocele is the protrusion of the cranial contents beyond the normal confines of the skull through a defect in the calvarium. It is a serious congenital anomaly characterized by herniation of brain and meninges through a defect along the mid line of the cranial vault or at the base of skull. These neural tube defects continue to be a challenge in our environment due to parental low educational level and extreme poverty in conjunctions with socio-traditional believes attached towards such anomalies.

Aim : Our aim is to highlight the challenges we are facing with children with congenital encephalocele and meningomyelocele in our set up.

Material and Method : From the year 2007 to April, 2010, there were 74 admissions into our children surgical unit of Murtala Moh'd Specialist Hospital, Kano of children with different types of encephalocele and meneingomyeloceles. The age ranges from 2hrs after delivery to 3 yrs old. Male to female ratio is 2:3 with female predominance in our set up. 16 (21.6%) parents declined surgical intervention due to financial problems while 6 (8%) died due to accidental rupture and acute drainage of CSF. Out of the 74 patient, 52 (70.2%) had successful repair of the different types of the lesions. 36 (48.6%) of the patients had simultaneous VP-shunt insertion with resections of the encephalocele and meningomyelocele. While a patient (1.35%) had a primary medium pressure VP-shunt insertion followed by resection after the hydrocephalus regressed. 13 (17.5%) had partial resection of the dysplastic brain tissue within the contents of the encephaloceles. 5 (6.7%) of the patients operated upon without VP-shunt insertion primarily developed hydrocephalus with subsequent insertion of the medium pressure VP-shunts. 2 (2.7%) of the patients died 74 and 86 hours post-operatively.

Conclusion : Giant to medium size encephaloceles and meningomyelocels are common within our set up. Surgical resection and VP-shunt insertion gives satisfactory results while poverty and low socio-economic class constitute to the denial of medical advice and interventions.


Quality of life of African children with spina bifida: Results of a validated instrument

De Jong- De Vos Van Steenwijk CCE, Blokland E, Jansen HE, Poenaru D

BethanyKids At Kijabe Hospital, Kijabe, Kenya

Aim : Ethical issues in treating children with spina bifida (SB) often center on quality of life (QoL) issues - yet there are no objective QoL studies from Africa to date. We purposed to determine their QoL and correlate it to patient characteristics.

Methods : SB children from one sub-Saharan institution and its mobile clinics were interviewed regarding QoL using the validated Schedule for the Evaluation of Individual Quality of Life - Direct Weight (SEIQoL-DW). This instrument uses open questions clustered in 6 domains chosen based on study group responses. Other patient characteristics were obtained from medical records, including SB type, motor level, hydrocephalus, urinary incontinence, clean intermittent catheterization (CIC), and fecal incontinence. The same instrument was applied also to a group of age-matched healthy controls.

Results : There were 166 children: 102 SB patients and 64 controls, aged 6 months - 18 years. Forty-four parents were also interviewed. Myelomeningocele was present in 68%, 59% had hydrocephalus, and CIC was used by 67% of 49 incontinent children over 2.5 years. The SEIQoL score of children with SB was 65.1 (scale 0 - 100), as compared to 78 in controls (P<0.001). SB children scored significantly lower than healthy controls in three domains: "health and disease", "development" and 'basic needs'; yet both groups identified "self-actualization" and "development" as the most important domains. There was no significant difference in total SEIQoL scores weather interviewing children or their parents, and no single SB-related determinant made a significant difference in the score.

Conclusions : As expected, QoL of African children with SB is lower than that of health controls, but remains surprisingly acceptable. No SB-related clinical factors significantly influenced QoL. These results are useful in counseling and advocacy for children with SB and their families.


The spectrum of operative surgery in Sub-Saharan Africa

Grossman O, Meiler KJ, Bokhari Z, Msuya D,

Chilonga K, Lakhoo K

Kilimanjaro Christian Medical Centre, Moshi, Tanzania & Children's Hospital, Oxford, UK

Introduction : Most paediatric surgery in sub Saharan Africa is performed by general surgeons with assistance from paediatricians for perioperative care. We describe the spectrum of operative surgery in children, performed by adult general surgeons in a Sub-Saharan Hospital in Africa.

Methods : The operative database was examined and information extracted on children from birth to 16 years of age over a 24 month period beginning October 2007 to September 2009. The age distribution was divided into four groups namely <1 year, 1-5 years, > 5-10 yrs and >10- 16 years. The operative procedures were analysed into subgroups: abdominal, thoracic, limb, neurological, head + neck, skin and other. The data was further analysed into congenital, acquired and traumatic procedures.

Results : A total of 3092 procedures were performed by general surgeons in adults and children of which 875 were performed in children alone. The analysis of children's data showed a gender distribution of 364 (42%) female to 511(58%) male and an age distribution of 30% <1 yr, 37% 1-5 yrs, 15% > 5-10 yrs and 18% > 10 yrs. The type of procedures include abdominal 50%, neurosurgical 25%, head/neck 9%, skin 8%, limb 3%, thorax 2% and other 3% (scrotal lesions, circumcision, perineal mass). Stoma related surgery accounted for 48% of abdominal surgery and surgery for spina bifida and hydrocephalos accounted for 82% of neurosurgical procedures. Surgery for trauma was performed in 11% of children. Congenital abnormalities requiring surgery were noted in 54% of infants in whom hydrocephalos, anorectal malformations and hernias accounted for almost 50% of congenital causes. In the 46% of non congenital group the 3 commonest conditions needing surgery were bowel obstruction (25%), tumours (16%) and wound debridement (11%). Intussusception accounted for 38% of bowel obstruction. Cleft lip repair was required in 32 (76%) children, 6 (14%) required cleft palate repair and 4 (10%) required both cleft lip and palate operation.

Conclusion : In the absence of specialist paediatric surgeons, targeted training in stoma related abdominal surgery and surgery for hydrocephalos and spina bifida for adult surgeons may benefit the child with surgical needs.


The association between peri-operative nutritional status in infants and surgery outcome in Kenya

Renkema-Mills N, Poenaru D, Heij HA

Bethany Kids at Kijabe Hospital, Kijabe, Kenya & University Hospital, Vrije Universiteit, Amsterdam, The Netherlands

Background : Malnourished children have an increased risk of postoperative complications as opposed to normally nourished children. Many children in developing countries are malnourished, but little is known about the relationship between nutritional status of children in developing countries and surgery outcome. This study aims to assess the prevalence of malnutrition in infants in Kenya, the association with surgery outcome and any potential confounding factors.

Patients and Methods : Data on the nutritional status of infants up till 18 months of age undergoing surgery at Kijabe Hospital in the year 2008 was collected and reviewed retrospectively. The patients were classified into normally nourished and malnourished groups, and surgical outcome in terms of complications, duration of hospitalization, mortality and length of survival was compared between these groups.

Results : 30% of the patients were malnourished, 56% had one or more complications and the mortality rate was 4%. There was no difference between the normally nourished and the malnourished groups in terms of hospital stay, length of survival, or occurrence of complications, except for nutrition-associated complications (P<0.01) and for mortality (P=0.04). Having a clean-contaminated wound or diarrhea as a comorbidity seemed to contribute to these relationships.

Conclusion : This study has shown that in infants in a rural Kenyan setting there is no substantial association between nutritional status and surgery outcome and only a weak association for two contributing factors. Other factors must be considered when looking at an adverse surgery outcome in these patients.


Adhesions - the forgotten complication

Grossmann O, Hughes-Thomas A, Dean B, Baidwin G, Grant H

Department of Paediatric Surgery, John Radcliffe Hospital, Oxford, UK

Introduction : The purpose of this study was to review and summarise the collective literature regarding the incidence of adhesive small bowel obstruction (ASBO) following open trans-abdominal surgery in neonates and children.

Methods : The data were collected from published articles on surgery in neonates and children in which adhesions were recorded as a complication. The study used small bowel obstruction due to adhesions as the endpoint complication.

Results : In neonates the incidence of ASBO [Table 1] was highest following laparotomy for meconium ileus (25-41%), followed by gastroschisis closure (5-25%) and Ladd's procedure (8 - 24%). In children the incidence of ASBO [Table 2] was highest following colectomy (up to 40%) followed by Ileostomy formation/closure (up to 25%) and Ladd's procedure (8-24%).
Table 1 :Incidence of ASBO in neonates

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Table 2 :Incidence of ASBO in children

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Conclusions : The data from this study provide surgeons with the overall incidence of ASBO following specific operations in neonates and children. The data demonstrate that ASBO is a frequent cause of major post-operative complications in neonates and children. With this information surgeons can re-consider their operative techniques, and target the use of treatments (which have been shown to reduce adhesions) in high-risk procedures in neonates and children.


Nasogastric tube use in children after surgery - how long should it be kept In Situ?

Abantanga FA, Amoah M, Nimako B

Department of Surgery, School of Medical Sciences, College of Health Sciences, Kwame; Nkrumah University of Science & Technology; Directorate of Surgery, Komfo Anokye Teaching Hospital, Kumasi, Ghana

Background : Traditionally, nasogastric (NG) tube passage into the stomach after a laparotomy to decompress the gastrointestinal tract has been used routinely in children for 3 to 5 days in our hospital and in many centres all over the world. The use of an NG tube after laparotomy is said to prevent vomiting, abdominal distension and paralytic ileus, which are likely to complicate the postoperative course. We decided to find out if eliminating the use of NG tube within 24 hours after operations for various reasons in children will adversely affect recovery in the postoperative period.

Materials and Methods : A pro forma was developed to prospectively follow children who needed an NG tube passed after undergoing various abdominal surgical procedures from August 2006 to September 2007. Within 24 hours after the surgery, the NG tubes were removed in all but 46 children, who had the tube in situ for 3 to 5 days. If for one reason or the other the tube came out while the child was still recovering from anaesthesia, it was not repassed. Time to first and full oral feeds, length of hospital stay and complications were compared between the groups.

Results : The patients who had their NG tubes removed within 24 hours (N = 120, Group 1) were compared with those who had an NG tube in place for 3 to 5 days (N = 46, Group 2) after various abdominal surgical procedures for various conditions. The mean time to first oral sips was 1.02 ± 0.13 days for Group 1 as compared with 3.57 ± 0.66 days for Group 2 patients (P < 0.05). The mean time to full feeding was 2.22 ± 0.54 days for Group 1 as compared to 4.04 ± 0.87 days for Group 2 patients (P < 0.05). Also, the mean length of hospital stay was 8.32 ± 5.93 days for Group 1 and 12.78 ± 8.79 days for Group 2. When both groups were combined, the length of hospital stay was 9.55 ± 6.85 days. There were in all ten complications associated with the removal of the NG tube in both groups - 6 in Group 1 and 4 in Group 2.

Conclusion : We conclude from our results that keeping the NG tube in situ after recovery of a child from anaesthesia is not necessary and should be avoided as much as possible. There is an added advantage that the child can feed earlier and return to normal activities earlier than when the tube is left in situ for several days.


Laparoscopic box training assessment tool: Good correlation between surgical experience and laparoscopic accuracy and speed

Ashour K, Kubiak R, Evans C, Zilvetti M,

McHoney M, Grant HW

Paediatric Surgery Department, John Radcliffe Hospital, Oxford, UK

Introduction : Laparoscopic box training provides an alternative and complementary way of training and assessing surgical trainees. This assessment tool was devised to assess trainees, monitor their progress, and improve skills. These data demonstrate the validity of this training tool.

Methods : Thirty six candidates (ranging from junior trainees to consultants) were recruited to perform a standardised assessment of laparoscopic skills. Firstly, participants completed a questionnaire to determine previous laparoscopic surgical experience and training. These data were used to provide each candidate with a (self assessment) laparoscopic experience score. Secondly, candidates were assessed using six basic tasks (peg transfer, pattern cutting, application of endoloops, application of clips, intracorporeal and extracorporeal knot tying). All tasks were performed using a box trainer with a 10mm 30 degree scope and 5 mm instruments. Scoring was based on the time (seconds) to perform the task, combined with penalties for inaccuracies for each task. Maximum time limits were set for each task, when exceeded, more penalty points were applied. Spearman correlations and scatter plots with regression lines and 95% confidence intervals were used to assess the relation between laparoscopic experience and laparoscopic assessment scores.

Results : There was a significant correlation between the candidates' self-assessment score and their performance in terms of speed and accuracy (P<0.005), i.e. the more experienced surgeons were faster and more accurate.[Additional file 1]

Some tasks were particularly discriminating, e.g. pattern-cutting and intracorporeal sutures, (P<0.005), with a high correlation coefficient, (R), (R= 0.78 and 0.7 respectively).

Conclusions : The laparoscopic assessment model used in this study objectively correlated individual laparoscopic experience with both time to task completion, and the precision of task performance. In the future, this will help to score trainees for competency in specific Laparoscopic tasks.


Perinatal management of gastroschisis: Effect on neonatal outcome

Van Der Hoeven A, Lever F, Numanoglu A, Millar A, Brown R, Heij HA, Wilde JCH

Paediatric Surgical Centre, Amsterdam, The Netherlands; Red Cross War Memorial Childrens' Hospital, Cape Town, South Africa; Panorama Medi-Clinic, Cape Town, South Africa

Introduction : Gastroschisis is a full-thickness defect of the abdominal wall. As a consequence the small bowel and other viscera protrude from the abdominal cavity. The incidence lies between 1 in 4000 to 1 in 10,000 deliveries. Our objective was to assess the influence of time of diagnosis, delivery mode and site, gestational age, time until surgery and the method of closure on neonatal outcome.

Methods : Data were collected retrospectively by chart review from three different hospitals. These included the Paediatric Surgical Centre Amsterdam, the Netherlands (PSCA), the Red Cross War Memorial Childrens' Hospital, Cape Town (RCWMCH), South Africa and Panorama Medi-Clinic Cape Town, South Africa (PMC). The PSCA is a tertiary referral hospital with a high rate of controlled pregnancies where Caesarean Sections (CS) are reserved for obstetric indications. The RCWMCH is a public hospital with no inborn patients. The diagnosis is made mainly at birth. The PMC is a private hospital where patients are born at 34 weeks by elective CS. The preferred method of treatment for all hospitals was by primary closure. If this was not possible a silo was used. Outcome measures examined included mortality, complications, method of closure, days to full enteral feeding, duration of ventilation, total length of hospital stay.

Results : The time of diagnosis (prenatally vs. at birth) did not influence the outcome. Neither did the method of delivery or gestational age. However, when elective CS were compared to the vaginal deliveries and unplanned CS a significant difference was found in the number of days on mechanical ventilation P = 0.04) When inborn patients were compared to outborn ones, there was a significant difference in the amount of complications encountered (P = 0.00) A short time (< 6 hours) until the first surgery compared with a longer one (> 6 hours) also significantly influences (P = 0.01) the amount of complications encountered. Primary closure had a substantially better outcome on all the above measures but did not influence the mortality rate. When the three hospitals were compared there were significant differences in the length of hospital stay, time to full feeds and the number of complications whereby PMC seems to have the best results.

Discussion : Early (within 6 hours of birth) primary closure has the best neonatal outcome. There seems to be a trend towards a better neonatal outcome in the elective CS group.


Prediction of length of postoperative ventilation in CDH Survivors: Preoperative and operative variables

Khairi A, Sameh SS, Lolah M, Sherif AH

Pediatric Surgery Unit, Department of Surgery, Alexandria Faculty of Medicine; Pediatric Surgery Unit, Department of Surgery, Monofya Faculty of Medicine; Department of Pediatrics & Neonatology, Zagazig Faculty of Medicine, Egypt

Background : The period taken for complete weaning from ventilation in cases of repaired congenital diaphragmatic hernia (CDH) varies greatly. We tried to relate the endo-tracheal tube removal time (ETTRT) in these cases with the different variables; both preoperative and operative.

Methods : This is a retrospective study of cases of CDH survivors managed by the authors over the period from January 2003 till February 2010. The preoperative variables included gestational age, gender, birth weight, Apgar score, the time of intubation, the ventilation strategy, the presence of a significant PDA in the ECHO study, the time-lapse till surgery. The operative variables (all by laparotomy approach) included the side of the hernia, the herniated contents, the presence of a sac, the insertion of a chest tube and the degree of abdominal wall stretch required. The successful weaning from ventilation and ETTRT were classified into two groups; ≤ 7 days and > 7 days postoperatively.

Results : During the study period, 26 cases were included (21 Males and 5 females). The ETTRT ranged from 2 to 23 days (7.7 ± 7.15 days; mean ±SD). Among the variables studied; the statistically significant ones (P value < 0.05) were Apgar score at 1 minute (preoperatively) and the need for "vigorous" abdominal wall stretch (operatively).

Conclusions : Apgar score of less than 8 at 1 minute; preoperatively, and the need for "vigorous" abdominal wall stretch; operatively, were associated with delayed weaning from ventilation in CDH survivors. This could have a predictive value in the management of these cases.


The versatility of transumbilical approach for laparotomy in infants

Elhalaby EA, Hashish AE

Department of Pediatric Surgery, University of Tanta, Tanta, Egypt

Background/Purpose : Although the umbilical incision becomes very popular for pyloromyotmy, the approach has not been widely used in other procedures in children. The aim of this work is to evaluate the safety and versatility of this approach for laparotomy in infants.

Methods : All hemodynamically stable neonates and infants with suspected gastrointestinal surgical problems were considered candidates for this approach. Likewise, pelvic or abdominal cystic masses were also included. The umbilicus was incised nearly circumferentially, and the peritoneum was entered in the midline in a cephalic or caudal direction depending on the site of the lesion. In most cases the bowel or the mass was delivered outside the peritoneal cavity and the procedure was completed in the standard open fashion. The fascia was closed by interrupted 2/0 or 3/0 polyglactin and the wound was closed subcuticularly.

Results : 141 infants have undergone transumbilical laparotomies during the period from 2004-2010. The primary pathology was: hypertrophic pyloric stenosis (n=65), small intestinal atresia/ stricture (n=15), duodenal atresia/stenosis/web (n=7), malrotation with/without volvulus (n=10), colonic atresia (n=2), spontaneous isolated intestinal perforation (n=7), intussusception (n= 9), mesenteric cyst (n=3) ovarian cyst (n=12), primary peritonitis (n=1), intestinal ischemia/perforation of reduced bowel after surgery for a strangulated congenital inguinal hernia (n=3), patent urachus (n=3), and remnants of vitellointestinal duct (n=4) The ages ranged from one day to 22 months. The operating time ranged from 30 to 120 minutes. Three patients required transverse extension of the wound, and another 2 required conversion to a traditional incision. 2 patients had dehiscence of the wound required wound closure. Three developed wound infections.

Conclusions : Transumbilical approach is both feasible, safe approach for for a broad spectrum of surgical procedures in neonates and infant. The cosmetic results are excellent. The approach is an attractive alternative to laparoscopy in this group of patients.


Surgery for dysphagia in the neurologically challenged child: An ongoing dilemma

Moore SW, Arnold M, Tshifularo N, Sidler D

Division of Paediatric Surgery, University of Stellenbosch, Tygerberg, South Africa

Neurologically challenged children have a high incidence in developing countries. Although their most common presentation is feeding problems and dysphagia associated with failure to thrive, surgery in the neurologically challenged child poses many problems for the surgeon. These include malnutrition, orthopaedic issues as well as poor bone mineral density and related fractures, dental and jaw problems, feeding problems, nutrition-related pain and concomitant medical problems. This study was undertaken to evaluate a cohort of neurologically challenged children treated surgically at the Tygerberg children's hospital (2000-2009).

Methods : We retrospectively investigated 91 neurologically challenged patients aged 0-13 years referred with significant feeding problems and dysphagia (2001-2010). Data were analyzed with details of neurological problem, treatment, complications, and mortality and outcome.

Results : 91 neurologically challenged children were entered into the database. The M:F ratio was 1.7:1 and all ethnic groups were affected. Most related to birth-related hypoxic episodes but 12 children suffered from specific syndromes or sequelae of TB Meningitis. Mortality was low. 35 patients had documented associated Gastro-oesophageal reflux (GER).Concomitant medical problems were frequent and included severe epilepsy (9) (uncontrollable in 2 cases), HIV (4) (one of them suffering a stroke). In 63 (66%) a percutaneous gastrostomy (PEG) was performed. 21 had laparoscopic a-reflux procedure in addition to gastrostomy placement. The outcome was successful in most but postoperative gastrostomy problems were frequent. There was a failure rate with anti-reflux procedures.

Conclusion : Careful selection of Neurologically challenged patients for surgical intervention is necessary and criteria for antifeflux procedure evaluated.


Compare outcomes of management of newborn duodenal obstruction in Africa and Europe

Ashour K, Lakhoo K

Alexandria University, Alexandria Egypt, & Children's Hospital, Oxford, UK

Introduction : Neonatal duodenal obstruction's management differs in Europe when compared to Africa, being mainly attributed to lack of resources in Africa. The main difference, however, lies in the perioperative management. Antenatal diagnosis, highly equipped neonatal units, with 24-hours laboratory facilities, and readily available. Total parenteral nutrition (TPN) are amongst the main points of differences. In this study, we present different mode of neonatal management within 2 centres across both continents, Egypt and UK.

Methods : The current study included all cases of life-born neonates diagnosed with duodenal obstruction operated upon in both Alexandria (Egypt), and Oxford, (UK) in the period between 2000 and 2005. Exclusion criteria were any associated anomalies (except Down's syndrome), preoperative death, and cases of malrotation. Management in Egypt included duodenoduodenostomy with omental patch, nasogastric tube (NGT), and trans-anastomotic tube (TAT) in some cases. In Oxford, management included duodenoduodenostomy, NGT and TPN.

Results : In Alexandria, Egypt, 22 neonates presented with duodenal obstruction, with a female: male ratio of 13:9. Eight babies had annual pancreas and 14 duodenal atresia. Body weight ranged from 2.1 to 3.15 Kg (mean 2.8 Kg), and age of presentation ranged from 1 to 6 days (mean 2.4 days). None were diagnosed antenatally. All neonates underwent laparotomy, and duodenoduodenostomy with omental patch. TAT tube was inserted in 12 cases, (54.5%). Feeds were started from 2 to 7 days postoperatively, (average 4.1 days) and fully tolerated between 4 to 9 days (average 6.8 days). No TPN was used. In 16 babies, 72.7%, alternating blood and plasma transfusion technique was used. All babies survived with no significant morbidity. In Oxford, UK, there were 18 cases, with weight range from 2.1 to 3.54 Kg, (mean 2.8 Kg). Twelve out of 18 cases were antenatally diagnosed, 66.7%. Diagnosis was established on day 1 postnatally for all. All babies were operated upon by duodenoduodenostomy with no TAT tubes, nor omental patch. TPN was used for all babies. Time to full feed was 4 to 13 days (average 7.3 days). Again, all babies survived postoperatively.

Conclusion : In isolated duodenal obstruction, the outcomes in well resourced countries are comparable to countries with limited resources.


Predictor of mortality in children with typhoid intestinal perforation

Nasir AA, Abdur-Rahman LO, Adeniran JO

Division of Paediatric Surgery, Department of Surgery, University of Ilorin Teaching Hospital, Ilorin, Nigeria

Introduction : Typhoid intestinal perforation (TIP) exerts a great toll both on the patients and the surgeons in resources poor countries with reported mortality rate of 7.3-39%. To date, factors that predict mortality in patients with TIP remains controversial. The study aim to determine factors that predict mortality in Ilorin and offer strategies for improvement.

Methods : We conducted a retrospective analysis of 153 children who underwent surgery for typhoid intestinal perforation at University of Ilorin Teaching Hospital, Ilorin over a period of eight years ( January 2002 to December 2009). Data were collected using a tool that captured patient demographics, presentation, hemoglobin level (Hgb), presentation-operation interval, type of surgical procedure, nature of peritoneal collection, the number of perforations and duration of surgery. Postoperatively complications, duration of hospital stay and outcome were also examined. Data was analyzed with SPSS 16.0. logistic regression analysis was used to predict mortality. The P value for significance was set at 0.05.

Results : There were 99 (64.7%) boys and 54 (35.3%) girls aged 3 to 15 years, mean(SD) 9.4(3.6)years. Seventy-eight (51%) were 5-9 years. There were 105 single perforations and 46 multiple perforations, (range 1-32). The surgical procedure was simple closure in 128(83.7%) and segmental resection in 9(5.9%) children. The mortality was 16(10.4%). The mean(SD) age of children who survive and those who died was 9.3(3.6) and 10.1(4.0) respectively; P=0.446, the mean duration of symptom in children that survive and those who died was10.3(4.9) and 12.3(5.6); P=0.164, and the mean interval between presentation and operation in those who died and those that survive was 29.3(25) and 28.4(13.4); P= 0.896. Temperature 38.5 o C (P=0.040), anastomotic leak (P=0.029) and fistula(P=0.000) were significantly associated with mortality. Age < 5 years (P=0.675), male gender (P = 0.845), presentation-operation interval ≥24hours (P = 0.940), less than 8 g/dL Hgb (P = 0.058), feculent peritoneal collection (P=0.757), number of perforations (P=0.518) and the surgical technique (P = 0.375) were not related to mortality. Logistic regression analysis showed that fistula (P = 0.001; OR= 13.7) and temperature ≥38.5 o C (P = 0.044; OR=4.5) were the independent risk factors predicting mortality.

Conclusion : Development of fecal fistula significantly predict mortality. Prioritizing the prevention of typhoid fever than its treatment and attention to surgical details may significantly reduce mortality of typhoid intestinal perforation in children in poor resources setting.


Physiologic predictors of postoperative intra-abdominal abscess in children

Uba AF, Osagie O, Uba CS, Shitta HA

Paediatric Surgery Unit & Dept. of Surgery, Dept. of Nursing, Jos University Teaching Hospital, Jos, Nigeria

Background : Post-operative intra-abdominal abscesses are a frequent source of morbidity and mortality following open appendicectomy and repair of typhoid intestinal perforation. There are currently little data that may predict which patients are more likely to develop an abscess. The aim of this study was to determine whether there are predictors for developing a postoperative abscess.

Patients and Methods : The dataset was collected prospectively in a randomized trial among 64 paediatric patients with appendicitis and typhoid intestinal perforation. All patients underwent open surgery and received a minimum of 5 days of intravenous antibiotics. The Pearson correlation was used to evaluate the influence of patient, intra-operative, and early postoperative variables on the development of an abscess. Two-tailed P values were determined from the correlation coefficient, and significance was defined as P < 0.05.

Results : At presentation, a positive correlation for abscess formation was identified with increasing age (P = 0.003), weight (P = 0.001), body mass index (P = 0.008), and diarrhea (P = 0.005). Operative time had no influence on abscess development. After operation, there was progressively increasing positive correlation between abscess and the maximum temperature each successive postoperative day. This relationship became significant at day 3. An increased white blood cell count on day 5 was highly predictive of abscess (P < 0.001).

Conclusion : In children presenting with perforated appendicitis or intestine due to typhoid enteritis, increasing age, weight, and/or body mass index correlated with the development of a postoperative abscess. Diarrhea on presentation also poses an increased risk of abscess. Postoperatively, a fever on each successive day is incrementally more predictive of an abscess formation.


Hirschsprung's disease and the neurologically challenged child

Moore SW, Tshifularo N

Division of Paediatric Surgery, University of Stellenbosch, Tygerberg, South Africa

Hirschsprung's disease (HSCR), is not infrequently associated with neurological challenges (6,79%). In addition to associated syndromes (e.g. Trisomy 21), these include brain anomalies, mental retardation and growth, ear and hearing deformities, eye hypoplasia, and craniofacial abnormalities, suggesting an neurocristopathy. This group of patients present with special challenges in management.

Methods : We retrospectively investigated 32 HSCR patients with significant HSCR -associated neurological challenges. Data were analyzed with details of neurological problem, treatment, complications, and mortality and outcome.

Results : 32 neurologically challenged children were studied. The M:F ratio was 1.7:1 and all ethnic groups were affected. Abnormalities included Down syndrome (16), ophthalmic problems (8), CNS and brain abnormalities (8). Mortality was mostly related to Hirschsprung-associated enterocolitis, particularly in Trisomy 21. Concomitant medical problems did occur. The outcome post definitive surgery was variable, with a number of patients failing to achieve satisfactory continence.

Conclusion : The association of neurologically challenges in patients with HSCR presents many challenges, particularly in developing countries. Management may involve the exploration and evaluation of treatment choices.


The epidemiology of anorectal malformations in Malawi

Borgstein ES, Beudeker N, Heij HA

Queen Elisabeth Central Hospital, Blantyre, Malawi & AMC, Amsterdam, The Netherlands

Background : Queen Elisabeth Central Hospital (QECH) in Blantyre provides the only specialised paediatric surgical service in Malawi, a country with 15 million inhabitants. Logistics and referral patterns determine the presentation of patients with congenital malformations in Malawi. A study was performed to analyse the impact of these factors in patients with AnoRectal Malformations (ARM).

Patients and Methods : A retrospective study of the hospital records of all patients below the age of 5 years with ARM, admitted to QECH between 1 January 2006 and 31 December 2009, was done. The data of 46 patients who were identified as congenital ARM were analysed for the following characteristics: place of birth, distance to Blantyre, age at admission, sex, presence of other malformations, (treatment and outcome).

Results : The majority of the patients were female (n=30, 65%). Nearly 50% lived at a distance of more than 50 km from Blantyre. Only 8 children (17%) were admitted in the first week of life and 3 patients were above the age of 1 year at presentation. Boys were younger at presentation (mean age 5.8 days) than girls (mean age 213 days, median?)

There was a relationship between age at presentation and distance to Blantyre. The four patients living within a radius of 5 km all presented within 4 weeks after birth.

The most common type of ARM in girls was anovestibular fistula (n= 20), and in boys rectourethral fistula was the most frequent type (n=10), only two boys had no fistula. No significant associated malformations were recorded.

Discussion : The referral pattern and logistic problems determine the presentation of ARM in Malawi. Because of the delays caused by long distances, children without a fistula or with severe associated malformations do not reach the hospital. Children with a outlet vent in the form of a fistula, who have no other malformations, have a good chance of survival till admission in the hospital.

Conclusion : Greater awareness among birth attendants and midwives is necessary to detect children with ARM early. Better referral facilities are required to transport these children to the only center with expertise in congenital malformations in the country.


Management of anorectal malformations in rural Kenya

Ayele F, Poenaru D

BethanyKids at Kijabe Hospital, Kijabe, Kenya

Aim : To study the prevalence of different types of anorectal malformations (ARMs), their associated anomalies, management and follow-up bowel function at a single institution.

Methods : A retrospective chart review combined with phone questionnaire was undertaken of all children treated for ARMs at Bethany Kids at Kijabe Hospital (BKKH) between 2004 and 2009.

Results : A total of 127 children were operated for ARMs during the study, 77 female and 50 male. The mean age at definitive surgery was 2.5 years (range, 0 to 15 years). Male malformations included 11 bladder neck fistulas, 4 prostatic fistulas, 14 bulbar fistulas,12 perineal fistulas, 2 rectal stenoses & 1 imperforated anus without fistula; female anomalies included 9 persistent cloacas, 5 true vaginal fistulas (3 of them were "N" type with normal anus), 40 vestibular fistulas, 9 perineal fistulas, 3 rectal stenoses and 1 imperforated anus without fistula. Thirteen children had associated anomalies which included neurological, genitourinary, and orthopedic deformities, with one case of VACTERL association. A total of 230 operative procedures were performed in the group at our centre, including 42 colostomies (65 were done at another institution), 72 colostomy closures, 20 anoplasties, 104 posterior saggital anorectoplasties (PSARPs), and 3 posterior saggital anorectovaginourethroplasties (PSARVUPs). Follow-up was available in only 43 patients (33%) for a mean length of 26 months. Satisfactory bowel control was reported by 31 of these patients (72%), while 9 children (21%) were reported to be incontinent; the rest were indeterminate. The incontinence rate was 25% in children repaired after age 5 years and 17% in those repaired before that age of 5 (NS). Complications other than fecal incontinence were encountered in 32%, including stenosis (6%), dehiscence (7%), urinary retention (3%), wound infection (9%), anastomotic leak, bowel obstruction, and vas deferens division <1% each; there were no deaths.

Discussion : Limited resources and difficult access to care in the rural African setting results in late presentation, delayed care and poor follow-up. These results are comparable to other African reports and show relatively good outcomes after staged ARM surgery in our setting. Fecal continence does not appear to be significantly affected by age of definitive repair.

Conclusion : The staged management of ARMs with colostomy and PSARP remains a safe and effective approach in resource-poor settings with delayed presentation.


The perils of medical journal editorship in developing countries: Experience from African Journal of Paediatric Surgery

Uba FA

African Journal of Paediatric Surgery, Jos University Teaching Hospital, Nigeria

Background : Paediatric Surgery is one specialty in need of academic communication to flourish in Africa. There is currently a dearth of specialized media to communicate indigenous peadiatric problems from and within Africa. This report evaluated the performance of African Journal of Paediatric Surgery (AJPS) as it attempts to fill the void for the past 7 years.

Materials and Methods : Electronic evaluation of AJPS' performance over the last 3 years was performed. Data were analysed for article submission rate, author distribution and registration rate, performance status, article acceptance/Rejection rate, and challenges.

Result : There has been steady overall increase in article submission rate, international author distribution and registration rate; however, most of the article submissions are from overseas. Article acceptance/ rejection rate, has remained high mainly due to sustain/improve performance status. There are a battery of challenges facing AJPS editing including funds, need to raise visibility and recognition among a wider (international) audience.

Conclusion : Academic paediatric surgery in Africa needs to embrace changing global trends and respond creatively to new realities and responsibilities of communication and education, research and patient care, now, more than ever. Academic surgeons must lead the effort to awaken and renew interest in highlighting the essential role of paediatric surgery to the health of the population.


Does prior circumcision adversely affect the management and outcome of repair of anterior hypospadias ?

Okoro PE, Onoyona AU, Ossai CN

Department of Surgery, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria; Department of Surgery, Federal Medical Centre, Owerri, Nigeria; Department of Surgery, Imo State University Teaching Hospital, Orlu, Nigeria

Introduction : The teaching that patients with hypospadias should not be circumcised before repair is an old concept. However, in recent times researchers have questioned the wisdom in this teaching. While some believe that hypospadiacs should not be circumcised, others have shown in studies that prior circumcision does not affect outcome of repair of anterior hypospadias. In our environment, many hypospadiacs are already circumcised at the time of presentation.

Patients and Methods : This is a prospective study carried out in three tertiary health facilities in South east and South south regions of Nigeria between December 2005 and November 2009. All paediatric patients who were managed for anterior hypospadias in our service during the stipulated period in Federal Medical Centre, Owerri, Imo State Teaching Hospital Orlu, and University of Port Harcourt Teaching Hospital, Port Harcourt, were included in the study. Patients who were lost to follow up or who came for redo repair were excluded. A proforma was designed to guide the collection of data. Parameters assessed included age, type of hypospadias, status of prepuce, repair technique used, duration of catheterization, duration of hospitalization, outcome. Data was analysed using the SPSS version 17.0

Results : A total of 101 patients met the inclusion criteria. Thirty seven(36.6%) of these were already circumcised at presentation. Repair techniques requiring flap movement and staged procedure were more common in the circumcised patients. The circumcised patients also had significantly longer periods of hospital stay and catheterization than their uncircumcised counterparts. The fistula rate was more than twice higher than for the uncircumcised patients. We conclude that prior circumcision of patients with anterior hypospadias has adverse effect on the management and outcome of repair of anterior hypospadias.


Neonatal circumcision: Why, how, and who is to do it?

Andrawes SS

Nairobi Hospital, Nairobi, Kenya

Introduction : Circumcision is the most common procedure done on males. It is also the most common one done by non-surgeons. The procedure is often underestimated and can lead to serious complications if not done properly.

Methods : In the period between 2004 and 2009 in Nairobi Hospital 450 cases of Neonatal Circumcisions were done, the number of different ethnicity was studied, 40% was Arab/Muslim, 40% were Kenyans and 20% were others.

Results : Most of the patients recovered well and the ring fell in 5 days, and the parents were pleased with the outcome. The ring was stuck in 2% of cases and had to be assisted out. We had to convert to usual suturing because of bleeding in 8%. Part of the prepuce remains attached and cut the band of tissue attached in 1% of the cases.

Conclusion : Neonatal circumcision is safe and less of a procedure done under local anaesthesia, easy post-operative care and less traumatic to the boys. So let us encourage more people to accept it and more surgeons who are qualified, trained, and interested to do it.


One-stage feminizing genitoplasty in patients with disorders of sex development

Essam A. Elhalaby

Department of Pediatric Surgery, University of Tanta, Egypt

Background : A growing interest has been noted recently in one -stage Feminizing genitoplasty for patients with Disorders of Sex Development (DSD). The timing of surgery is currently controversial. This study was carried out to investigate the feasibility and outcome of one -stage feminizing genitoplasty at various ages.

Materials and Methods : Twenty five patients with DSD were treated during a seven year-period. All patients presented with various degrees of ambiguous genitalia. Twenty one patients had congenital adrenal hyperplasia (CAH), two had complete androgen insensitivity syndrome and two had true hermaphrodite. All patients undergone one- stage genitoplasty. Twenty cases with high or intermediate confluence of vagina and urethra underwent total urogenital mobilization (TUM). A perineal posterior flap vaginoplasty and minimal mobilization of the urogenital sinus (UGS) was adequate in 3 cases with short UGS. In two patients a loop sigmoid colon was used to reconstruct the vagina. Each patient was evaluated as regard to age at surgery, degree of virilization, preoperative diagnostic studies, operative technique, and outcome. Follow up ranged from 2 to 82 months.

Results : Patients aged 5 weeks to 11 years. Mean operative time was 180 minutes (range: 60 to 230 minutes). The dissection was technically easier, and the mean operative time was shorter in patients younger than 6 months at time of surgery compared to older children (140 versus 200 minutes). Postoperative complications included: atrophy of the clitoris (n= 2), absent labia minora (n=3), and vaginal stenosis (n=4). Fecal and urinary continence were documented in 13 of 15 children who are older than 3 years. The cosmetic and anatomic outcomes were considered good or satisfactory in 22 of the 25 patients (88%).

Conclusions : 1. One-stage feminizing genitoplasty is both feasible and safe in patients with DSD. 2. The repair is technically much easier in young infants. 3. Total urogenital mobilization technique has simplified the feminizing genitoplasty even in patients with high confluence of vagina and urethra. 4. Using a part with of the sigmoid colon with its intact blood supply proved to be an effective and safe option for vaginolplasty in patients with testicular feminization syndrome.


Intersex: Treatment at the University Hospital of Treichville

Bankole SR, Guemaleu P, Nandiolo A, Yebouet E, Coulibaly D, Mobiot L

University Hospital of Treichville, Abidjan, Cote d'Ivoire

Introduction : The diagnosis and the treatment of ambiguous genitalia or Intersex is still a challenge in developing countries, because of late presentation of the patients and no availability of essentials diagnostic procedures (as karyotype, serum 17 OHP level).

The aim of this study was to report our results of the treatment of the children with intersex and to emphasize our difficulties.

Materials and Methods : This study was conducted by a retrospective collection of data over 14 years (January 1995 - December 2008). Epidemiological, clinical, paraclinical, therapeutical characteristics, and outcome of the patients were recorded.

Results : We have seen 47 patients. The age of patients ranged from birth to 18 years. Eighteen of the patients were neonate. Among the 47 patients only 23 have been treated, the others patients did not come back for treatment. The paraclinic studies included hormonal level (17 Hydroxyl progesterone, testosterone), ultrasonographic study, and genitogram or laparoscopic diagnosis). We diagnosed 16 cases of female pseudo hermaphrodite (4 cases of CAH with one salt wasting), 4 cases of true hermaphrodite, 2 cases of male pseudo hermaphrodite and 1 case of mixed gonadal dysgesis. We have performed 21 female genitoplasty and 2 male genitoplasty. For 4 patients, the sex was changed (3 cases of female pseudo hermaphrodite were rearing as female, and 1 cases of true hermaphrodite was rearing as female).The morphologic results were good in 21 cases, one patient required psychological assistance.

Conclusion : Intersex is a social emergency which treatment is still a big challenge in developing countries because of late presentation of the patients and no availability of essential diagnostic procedures.


The management of disorders of sexual differentiation in Kenya: A single institutional experience

Mung'ong'o C, Baird R, Sutherland R, Poenaru D

BethanyKids at Kijabe Hospital, Kijabe, Kenya

Background : Disorders of sexual differentiation (DSD) are poorly understood and emotionally charged conditions. The purpose of this study was to review the management of patients with DSD at a single referral institution in rural Kenya, with particular emphasis on quality of life and the impact of their sociocultural context. We hypothesize that this context influenced their management, particularly in resource-poor settings with delayed presentation.

Methods : The study was a retrospective chart review combined with phone questionnaire of all patients diagnosed with DSD at BethanyKids at Kijabe Hospital (BKKH) between 2004 - 2010. Usual medical record data on pre- and post-operative course was collected, and an attempt was made to contact all patients by phone with a standardized questionnaire.

Results : Out of 793 paediatric urology patients operated during the study period, 27 had DSD and underwent a total of 64 procedures. In standard diagnostic procedure was mini-laparotomy with gonadal biopsy (in 23 children), which revealed ovotestes (9), immature testes (7), immature ovaries (5), fibrovascular tissues only (1) and ovo-salpingitis (1). After thorough discussions involving a multidisciplinary professional team and the families, final reconstructive procedures included 1-stage or 2-stage feminizing genitoplasty / clitoroplasty (9) or multi-stage virilizing procedures: hysterectomy and oophorectomy (4), orchidopexy (9), orchiectomy (4), hypospadias repair (15), and testicular implant (1). The mean age at first intervention was 8.3 years (range, 0 - 34 years), with more gender-reared males than females (17:10). Gender reassignment occurred in one gender-reared male and in 2 females (3%). The median number of procedures per patient was 1 for feminization and 3 for masculinization.

Early post-operative complications occurred in 7 patients (26%), including wound infection (3), sepsis (1), and urethral fistula (3). There was one mortality (2-week old child with associated myelomeningocele and hydrocephalus). Late complications included vaginal stenosis (2), and meatal stenosis (1).

Follow-up phone data was available in 20 patients (74%) after a mean period of 6 months. In this group 60% reported excellent results, 9% satisfactory, and 31% could not complete all procedures required for financial reasons.

Conclusion : The management of patients with DSD in resource-poor settings is challenging and complex. Late age of presentation and sociocultural factors limit gender-reassignment decisions. Despite multiple procedures required, DSD can be successfully managed in such settings with acceptable morbidity and good medium-term quality of life.


Augmentation colocystoplasty and incontinence surgery in patients with spina bifida: Our ongoing experience

Karmarkar S, Krishnan J

Department of Pediatric Surgery, Lilavati Hospital and Research Centre, Bandra Reclamation, Mumbai, India

Results : The dry interval of our patients preoperatively ranged from <10mins to 120 mins (mean of 45 mins) which improved to a mean dry interval of 4 hours (range of 3 to 7 hrs) postoperatively. Young-Dee-LeadBetter and bladder neck hitch showed good results, whereas results of periurethral injection of DEFLUX were not encouraging. The Mitrofanoff and MACE stomas functioned well. There were no major complications in any of our patients postoperatively.

Conclusion : With careful preoperative evaluation and urinary work up beginning 6 months to 1 year prior to the proposed date of surgery, proper CIC training, anticholinergic medication and meticulous augmentation technique, most patients with neurogenic incontinence stand to benefit significantly by augmentation colocystoplasty. Easy access continent channels such as a Mitrofanoff makes CIC a simpler task. We recommend augmentation colocystoplasty with adjunct procedures to achieve social continence in patients with neurogenic incontinence.


A review management of Wilm's tumor with intracardiac extension

Millar AJW, Abdullah MY, Karpelowsky J,

Numanoglu A

Department of Paediatric Surgery, Red Cross War Memorial Children s Hospital, University of Cape Town, South Africa

Aim : To review the management of patients with Wilms tumor with intracardiac tumor extension.

Patients and Methods : Data were collected regarding patient's presentation, operative details and outcome.

Results : From 1984 to 2009, 244 patients with Wilm's tumor were treated at Red Cross Children's Hospital. 7 patients (2.86%) had cavo-atrial extension of the tumor thrombus and 2 of these had extension into the right ventricle. Pre-operative chemotherapy was administered in 6/7 patients with complete regression of the intracardiac tumor thrombus in 2 patients. 4 patients with intracardiac tumor were operated on under cardiopulmonary bypass (CPB) with deep hypothermia and circulatory arrest (DHCA). The mean ischemic time was 30 minutes. There were no intraoperative deaths and no major complications. All tumors were favorably histology. To date, 4 patients are still alive, 3 disease free. 2 patients died from relapsed pulmonary metastases. 1 patient with intraventricular extension of a left Wilm's tumor has had a right metachronous Stage 2 tumour.

Conclusion : Intracardiac extension of Wilms' tumor is rare and the management is technically challenging. Pre-operative chemotherapy is effective. CPB and DHCA for excision of the cavoatrial tumor thrombus is safe. Distant metastases determines long-term prognosis.


Sacrococcygeal teratoma: Management and outcomes

Hashish AE, Fayad H, El-Attar A, Radwan MM,

Ismael K, Ashour MHM, Elhalaby EA

Department of Pediatric Surgery, Facullty of Medicine, Tanta University, Tanta, Egypt

Background : Sacrococcygeal teratoma (SCT) is a relatively uncommon tumor affecting neonates, infants, and children. This study was designed to determine the various pattens of clinical presentation, and factors affecting the outcome of patients with SCT.

Methods : A total of 35 patients with SCT were received during the period from January 1998 to November 2008 at Tanta University Hospital and its affiliated hospitals. A retrospective review of all recorded data concerning maternal history, mode of delivery, age at presentation, patient sex, presenting clinical features, associated anomalies, various laboratory and radiological investigations, operative details, and tumor histopathology were performed. Early and late postoperative functional results and complications were also reviewed. The patients were divided into 2 groups according to the age at presentation. Group I involved 21 patients presented at the neonatal period, while group II included 14 patients presented after the first month of life. The follow up period ranged between 3 months and 8 years.

Results : One patient died prior to surgery. Excision of the tumors was achieved in the remaining 34 patients. Living patients in group I (n=20) were operated upon at a median age of 2 days. The histology proved to be benign in all patients in this group, and no recurrence was noted during a follow period ranging between 3 months and 8 years. The mean age at surgery was 6+ 3 months in group II patients (n= 14). In this group, three patients proved to have malignant changes in the excised specimens and postoperative recurrence occurred in 4 patients.

Conclusion : A prenatal diagnosis of SCT is essential to avoid early mortality. This study stressed on the importance of: early diagnosis, early complete en-block resection of the tumor along with the coccyx, and the avoidance of intraoperative spillage of the tumor as critical factors in prognosis. Delayed presentation and the presence of malignant changes continued to be poor prognostic factors. Close follow-up of these patients is mandatory to deal with the potential postoperative sequelae of surgery.


Sacrococcygeal teratoma: A 4-year experience at Komfo Anokye teaching hospital

Amoah M, Boateng N, Abantanga FA

Komfo Anokye Teaching Hospital, Kumasi, Ghana

Background : Sacrococcygeal teratoma is the most common solid neoplasm in neonates with an estimated prevalence of 1 in 40000 live births. The clinical characteristics were reviewed.

Methods : A retrospective review of all patients treated for treated for SCT at the pediatric surgery unit between January 2006 and February 2010 was conducted and the results analysed.

Results : In all, 18 children were treated over the study period with a female preponderance of 3.5:1 and 61.1% of patients presented within the 2 nd week of life with a median age of 5 days. The oldest child was 2.5yrs. Eighty-three percent of tumors were Altman grade I whiles 88.9% and 94.4% were cystic and benign respectively. Ultrasonography was the imaging investigative tool used. The largest tumor was 35 by 26cm but there was no correlation between age and size of tumor. Excision of tumor was by sacral approach via a chevron incision mostly as an elective procedure. Six (33.3%) were done as emergency procedures for various reasons. There was 89.9% surgical site infection with varying degrees of wound dehiscence. One child had a sigmoid colostomy on account of repeated wound breakdown from fecal contamination. Most patients do not honor follow-up appointments once tumor has been excised.

Conclusion : Sacrococcygeal teratoma is mostly benign and prompt and complete surgical excision will provide good prognosis. Complex investigative tools may not be necessary. A prospective study will help bring on board other clinical characteristics. Patients need to be educated on the necessity of follow-up in order to capture long term sequelae.


Cleft lip and palate: Experience of pediatric service at the teaching hospital of Treichville

Bankole SR, Guemaleu P, Nandiolo A, Yebouet E, Coulibaly D, Mobiot L

University Hospital of Treichville, Abidjan, Cote d'Ivoire

Introduction : Cleft lip and palate are relatively frequent in Cote d'Ivoire. The frequence in the literature ranged from 1, 5/1000 birth to 1/7000 in some population.

The aim of this study was to report our results in the treatment of this malformation.

Materials and Methods : Data of the patients operated was retrospectively collected over 15 years (January 1995 to December 2009).

Results : 506 children aged from 3 months to 15 years (median age was 16, 4 months), 274 male (54, 15%) and 231 female (45, 85%). Consanguinity was present in 16, 86% of the cases, familial cases in 1, 18%. The clefs lip without clefs palate represented 51, 18%. The clefts lip with clefts palates; 40, 31%. Isolated clefts palate was found in 43 cases (8, 48%). The clefs lip were unilateral in 397 cases (78, 45%), bilateral in 66 cases (13, 04%)]. Associated malformations were found in 44 cases (8, 7%). We perfomed Millard Cheiloplasty in 68, 39% and Tennisson cheiloplasty in 28, 27%, for the unilateral clefs. For bilateral clefs, we have used Veau technic. Staphylorraphy was done by Veau Wardill technic. According euro cleft criteria for cheiloplasty, the results were good in 98, 16%.We observed 9, 4% of complications after staphylorraphy,

Conclusion : The initial aesthetic results are good, but the orthophonic and orthodontic management of these children must be improved. The definitive result of these patients should be evaluated at the end of the growth.


Neonatal burns in Kano, Nigeria

Anyanwu LJC, Mohammad AM, Farouk Z, Ibrahim M

Paediatric Surgery Unit, Department of Surgery & Department of Paediatrics, Aminu Kano Teaching Hospital & Bayero University & Paediatric Surgery Unit, Department of Surgery, Murtala Mohammed Specialist Hospital, Kano, Nigeria

Introduction : Although burn injury in neonates is rare, it nevertheless occurs. The thinness of the skin in this age group predisposes them to a higher injury severity when compared to the older child and adult for any given thermal exposure, thus making their management challenging.

Methods : This is a prospective study of all burns patients admitted into the Paediatric surgery unit of the Aminu Kano Teaching Hospital Kano, Nigeria. Records of all neonates recruited into the study between November 2009 and May 2010 were reviewed. Demographic data, clinical presentations, management and outcome were retrieved for analysis.

Results : There were seven patients managed during the study period. There were 4 females and 3 males (M:F = 1:1.3). Their ages ranged between 2 days and 25 days (Median 4 days). Five injuries occurred in November (71.4%), 1 occurred in January (14.3%) and 1 occurred in May (14.3%). The median length of time before presentation to the hospital was 4 days (Range <1 day to 8 days). The median duration of admission was 11.5 days (Range 1-39 days). The mean percentage burns surface area was 14.4% (Range 1%-30%). The cause of the injury was scalding by hot water in 5 patients (71.4%), flame burns in 1 patient (14.3%) and one patient sustained an iatrogenic burn from a faulty radiant warmer. Five of the injuries occurred in the bathroom (71.4%), 1 in the bedroom (14.3%) and 1 in the hospital (14.3%). Two patients (28.6%) died of burns wound sepsis while on admission, 1 patient with a full thickness burnt left foot had an amputation (14.3%), four of the patients were managed conservatively and discharged following wound epithelialisation (57.1%).

Discussion : Due to the limited physiological reserves of the neonate, an early resuscitation and prompt institution of treatment is critical for the survival of the burnt newborn.


Advances in our fast recovering concept

Kljenak A, Karaman IM, Visnjic S

Children's Hospital Zagreb, Zagreb University Medical School, Zagreb, Croatia

Background : With advances in the management of acute paediatric burns survival rates have not only increased, but mortality in our Paediatric Burn Center in the last 12 years was pushed to zero.

Purpose : As all our burned patients survive the acute phase, surgical reconstruction becomes complex and challenging. Does the impact of all new techniques, surgical materials and new scientific discoveries change our old paradigma of paediatric burn treatment?

Methods : We analyzed the characteristics and clinical course of burned patients admitted to our PBC over a past 12-year-period. As a National Referral Centre for Paediatric Injuries, in our Department for Burns we treated 4117 children with burns from 1997-2008.

Results : It was observed that during the last 12 years different new techniques were introduced in our practice. Advanced intensive care treatment with balanced needs of burned child with adequate fluid resuscitation associated with adequate feeding formulas, new anticatabolic drugs, recombinat-FVIIa as effective-hemostatic-agent etc. is essential in the optimal resuscitation of burned patients. Our DGC technique of skin grafting as a technique of fragile equilibrium in the deep dermis, were used alone or in conjunction with other techniques: i.e. in vitro cultivated keratinocyte autografts, vacuum assisted closure systems etc. Today, as the result of good practice, we developed FRC (Fast Recovering Concept) based on expert's long-term team experience.

Conclusion : The goal of treatment is no longer mere survival but a meaningful and worthwhile life. A new age of treatment of paediatric burns can decrease the painful procedures, and shorten the list of long-term consequences.


A dancing graft concept: Advantages of our new original surgical technique in pediatric burns

Kljenak A, Samprec K, Vrtar Z, Barcot Z

Children's Hospital Zagreb, Zagreb University Medical School, Zagreb, Croatia

Introduction : Special problems have to be considered in operative treatment of third-degree burns in children. In cases of extensive burns, the donor areas are usually limited and the burned skin is very often susceptible to some of the most serious complications. As a part of National Referral Centre for Pediatric Injuries, in our Department for Burns we treated more than 5000 children with burns during the last 10 years. While the technique of early total excision and grafting has many advantages in the treatment of deep thermal injuries, it is not without significant complications. Hemorrhage accompanying burn wound excision can be extensive, as can the metabolic stress of large surgical procedures performed in the postburn period. In an effort to minimize these complications, in 2004, we have developed a new surgical technique for deeply burned skin area called "A Dancing Graft Concept (DGC)".

Our original technique : Correct estimation of the depth of burn is crucial for effective local surgical therapy, which is guided mainly by the visual criteria. A subtotal, "skin friendly " excisions of necrotic skin are made until a punctate bleeding surface in the deep dermis is reached. We make an effort not to take out the burned deep layer in toto. We rather tend to save the survived cells of the skin, than to cut until a completely healthy base of the deep dermis is reached. Following this procedure, STSG grafting of prepared burn wounds are performed. During the first couple of days, grafts covering the burned area are very often not entirely fixed to the base - they are "dancing". In the same time an internal process of wound healing is given a chance, and this process is strongly enforced by the healthy potential of transplanted FTSG. Protected in this way, with the absence of dangerous involvement of external infection pathogens, the wound tends to heal without scar formation.

Discussion : Starting 2004 year the "Dancing Graft Concept" (DGC) was performed in 17 patients with burns greater than 30% TBSA. DCG technique, as a technique of "fragile equilibrium " in the deep dermis, may be used alone or in conjunction with other techniques: i.e. in vitro cultivated keratinocyte autografts etc. DGC technique has become an important part of every successful therapy in large burn management of third-degree burns in our group of patients. It is of special value in selected burns of the deep partial skin loss variety, especially scalds, which are predominant in children. Decreasing stress, hypermetabolism, and decreasing the overall bacterial load in such patients enables them to resist other complications better. Using this technique the final results are remarkably better, with the less probability of scar formation and a resultant graft with improved texture. Primary closure of an open wound circumvents the possibility of infection from outside. On the other hand, using this technique we skip the problems of total necrectomy as hemorrhage and heat loss, and so the final result is decreasing the possibilities of scar and keloid formations.

Conclusion : It is important to work out a strategy for each individual case. Our concept, with the consequent use of appropriate Split Thickness Skin Grafting (STSG) after early, "skin friendly" necrectomy of burns, lead to an increase in survival rate and the quality of life. The dynamics of burn wound healing was studied in patients treated by DGC method. The current state of the art, combined with our initial experience and the first results in treating deep pediatric burns, obtained by pediatric plastic surgeons, undoubtfully speak in favor of DGC application.


Sexual abuse in children: Problems and management in north central Nigeria

Osagie OO, Osagie EO, Soo CT, Uba AF, Chirdan LB

Paediatric Surgery Unit & Department of Obstetrics and Gynaecology, Jos University Teaching Hospital, Plateau State, Nigeria

Introduction : The sexual abuse of children is a tragic problem that has been in existence from time immemorial cutting across tribe, religion, race and social status. It is an underreported crime in Nigeria. The aim of this study is to present our experience with the problems and management of sexual abuse in children at our centre.

Methods : The folders of all victims of alleged sexual abuse aged 0-16years presenting in Jos University Teaching Hospital between January 2007 and December 2009 were reviewed for sex, age, socio-economic status, location of the crime, previous sexual activity, relationship of victim with the assailant[s], number of assailants involved, method of overcoming victim's resistance, interval before presenting in the hospital, form of presentation and management.

Results : During the study period, a total of 117 cases of alleged rape was seen in Jos University Teaching Hospital. All of them were female. 73 (63.8%) cases involved girls less than 17 years of age.

28(38.35) were aged 1-6years, 19[26.0%] were aged 7-11years and 26[35.65%] were 12-16years.

86.5% of victims came from poor socio-economic backgrounds with illiterate parents.

91.7% of victims were abused by a known assailant the commonest being a neighbor [47.9%].

23.2% were abused by more than one assailant and 54.7% of assailants used threat and/or physical force to overcome the victim's resistance. 49.3% of victims were abused in their own homes, 35.6% in the assailant's home. 50.6% of victims presented 48 hours after the assault.

62 [84.9%] cases had positive physical findings of body bruising and abrasions, vaginal bruising and/or bleeding, perineal tears, perianal bruising, torn hymen and vaginal discharge. 11 [15.1%] victims did not have any physical evidence of abuse.

Management involved the treatment of wounds, prevention of sexually transmitted disease and pregnancy and counseling.

Discussion : The incidence of sexual violence is on the increase with the girls aged 1-6 years being especially vulnerable. Most assailants are known to the victim who is abused in a familiar environment. Poverty appears to increase the risk of child sexual abuse. Victims and their families are reluctant to present at medical centres for care.


Outcome of vascular trauma in children

Tshifularo N, Moore SW

Vascular trauma is uncommon in children but may be complex. Children have major advantages in the rich collateral circulation and one major disadvantage in that they are still growing and developing. Many can be trated expectantly. Arterial injury in children presents a challenge to the surgeon and may have long term implications.

Methods : Patients (<13 yrs) with vascular injury requiring surgical intervention were retrospectively reviewed from a trauma database of 446 trauma patients admitted to the Tygerberg childrens Hospital. Demographic data, and factors influencing outcome were studied, as well as different modalities of management.

Results : We review a total of 20 patients where surgical intervention was required. 6 resulted from penetrating injuries (2 gunshot), 10 followed blunt trauma (2 popliteal extension injuries, 1 degloving injury, 2 presented later with arterio-venous fistulae. Haemorrhage from the wound in 1 Haemphiliac patient made urgent surgery mandatory. Outcome was variable and long term limb maldevelopment occurred in 1 patient

Conclusion : Vascular injuries may be complex in childhood due to the complexity of these injuries. Growth and developmental considerations must be borne in mind in treatment.


A potentially fatal penetrating injury but a fortunate child

Khaled Ashour *† , Kokila Lakhoo

* Alexandria University, Alexandria Egypt, Children's Hospital Oxford, U.K.

Introduction : Although children are more prone to all sorts of trauma, sharp penetrating injuries are less common than blunt trauma, being mainly recorded in child abuse. This may be due to lack of access to sharp objects among children, as well as the high prevalence recorded road traffic accidents, which raises the proportion of blunt injuries. Nevertheless, penetrating injuries in children are potentially fatal especially in the neck and chest.

Methods : A five-year old male child presented to the Paediatric Emergency Centre, with a sickle (a large sharp, curved, and serrated knife used by farmers). The sickle was transfixing the right side of his neck, with the site of entrance anterior, and that of exit posterior. The child was conscious with stable vital signs. Plain X-ray showed the sickle shadow lateral to and separate from the trachea. Immediate surgical exploration was performed to determine the relation of the sickle to the vital neck structures, and the possibility of removing the sickle without further injury to surrounding tissues. The incision was transverse from the inlet of the sickle to ~2 cm short of the exit.

Results : Surprisingly, the sickle took a very strange course in the child's neck, being lateral to the trachea, and medial to the carotid sheath. Moreover, the thyroid gland and the right recurrent laryngeal nerve were preserved. The sickle was gently pulled under vision, preventing pressure from the serrated edge on surrounding tissues. The child made an uneventful recovery and was dismissed on postoperative day three.

Conclusion : In this fortunate child, retained consciousness and spontaneous breathing were signs that a sharp transfixing neck injury had taken a safe course. However the chances of a similar injury taking a similar course are nil.


Parents' satisfaction and assessment of quality of paediatric surgical care in A tertiary health facility

Nasir AA, Abdur-Rahman LO, Adeniran JO

Division of Paediatric Surgery, Department of Surgery, University of Ilorin Teaching Hospital, Ilorin, Nigeria.

Introduction : The aim of this study is to evaluate parental satisfaction and assess the quality of care provided by our paediatric surgical unit.

Methods : This is a descriptive cross-sectional study conducted at the paediatric surgery clinic in a tertiary health facility in Nigeria to determine parents' satisfaction and perception of quality of care received in the facility. A semi structured questionnaire was used through interview, including parents' socio-demographic data, nature of surgery (elective or emergency), waiting time for consultation and surgery, opinion regarding reception by care providers, quality of care, charges, supportive services such as ease of movement from one service point to the other and explanation of ailment.

Results : There were 90 respondents, 80 of whom were mothers. Their mean age was 34.2 years. Fifty-one percent had tertiary education. More than 90% of the respondents were satisfied with the reception by the health care provider. The mean waiting time for consultation was 118 and 120 minutes for elective and emergency cases respectively. Twenty five percent of the parents had their child's surgery postponed. The mean waiting time for surgery was 3 months and 56 hours for elective and emergency cases respectively. Majority (72.2%) expressed dissatisfaction with movement from one service point to the other. Thirty-four percent reported pharmacy as the most difficult service point. Eighty percent of respondents reported our charges as being moderate. Most parents(81.1%) reported having received adequate explanation on the ailment from the care givers. However, twenty-seven percent of parents perceived the explanation of the surgical procedure as not adequate. Most of the parents (94.4%) expressed satisfaction with the quality of care received. Majority(98.9%) will recommend our services to another person.

Conclusion : Most parents perceived the quality of surgical care for their ward(s) as satisfactory. This study emphasizes the importance of periodic assessment of patient/care-giver satisfaction to aid improvement in surgical practice.


Laparoscopic training programme: Proof of efficacy

Ashour K, Kubiak R, Evans C, Zilvetti M, Mchoney M, Grant HW

Department of Paediatric Surgery, John Radcliffe Hospital, Oxford, UK.

Introduction : Laparoscopic surgery is now widespread. There is a clear need for a structured training programme as it involves new skills and techniques compared with open surgery. Trainees were assessed by standard box training exercises before and after entering a basic laparoscopic skills training programme. The data show that box training exercises can help improve performance and monitor the acquisition of the Laparoscopic skills.

Methods : Eight candidates were recruited for this study (senior house officers, registrars, and consultants). They underwent initial assessment, consisting of the six basic Laparoscopic tasks (peg transfer, pattern cutting, application of endoloops, application of clips, intra-corporeal and extra-corporeal knot tying). All tasks were performed using a box trainer with a 10mm 30 degree scope and 5 mm instruments. Scoring was based on the time (seconds) to perform the task, combined with penalties for inaccuracies for each task. Maximum time limits were set for each task, when exceeded, more penalty points were applied. All candidates had a minimum of 5 hours on a Laparoscopic box trainer over 4-week period, together with time in theatre performing laparoscopic procedures. They were subsequently reassessed using the same 6 tasks. Results were compared using paired-sampled T test to test for significant improvement.

Results : There was significant improvement following the training programme regarding the total score and total accuracy (P<0.05). This improvement was strongly significant with some tasks, e.g. pattern dissection, and intra-corporeal suturing. In some tests e.g. loop application there was no overall improvement. There was no significant improvement (P>0.05) in overall time although there was improvement with some specific tests.

Conclusion : Laparoscopic box training is a useful tool in improving laparoscopic skills. It is also a useful tool to evaluate the trainees' progress, [Additional file 2]


Two-port versus three-port laparoscopic appendectomy in children

*Ahmed Khairi a,d , Magdi Lolah b , Ahmed A. Khalaf c,d , Mostafa Tolba d

Pediatric Surgery Units, Departments of Surgery, a Alexandria Faculty of Medicine, Alexandria and b Monofya Faculty of Medicine, Monofya, c Department of Surgery, Ein-Shams Faculty of Medicine, Cairo, Egypt, d Department of Surgery, Dallah hospital, Riyadh KSA

Background : Laparoscopic appendectomy is the routine technique to manage acute appendicitis in children in many centers. The classic three-port technique is compared to the two-port technique in the non-complicated non-difficult acute appendicitis.

Methods : This is a retrospective study of the cases of non-complicated acute appendicitis treated laparoscopically between June 2003 and June 2009. Cases treated by the two-and three -port techniques were compared regarding the operative duration, operative and postoperative complications and the length of hospital stay.

Results : During the study period, 85 children (45 males and 40 females) had laparoscopic appendectomy for acute non-complicated appendicitis; 48 children by the Three-port technique (group I) and 37 by the Two-port technique (group II).The age ranged from 4 to 13 years (mean 9.7). The mean operative duration was 40 minutes (range 30-70) in group I and 25 minutes in group II (range 17-35). Operative bleeding occurred in 9 cases (19%) (group I) and 8 cases (22%) group II, operative rupture of the appendix in 1(2%) , Port site infection (redness or discharge) in 3 (6%) in group I and none in group II, Postoperative ileus (> 48 hours) 3 (6%) in group I and 1(2.7%) in group II. The length of hospital stay was 2.3 days group I and 2 days group II. Three cases in group II were converted to total laparoscopic appendectomy because of residual long stump (conversion rate 8%).

Conclusions : The Two-port laparoscopic appendectomy had less operative duration and length of hospital stay than the three-port technique in non-complicated non-difficult acute appendicitis in children. However, the operative and post operative complications were almost the same.


Anterior abdominal wall ulcer in a 10 day old female, congenital or acquire?

Taiwo JO

Federal Medical Centre Lokoja, Nigeria

Introduction : Anterior abdominal wall defect is a common anomaly seen in paediatric surgical practice, anterior abdominal wall ulcer at birth is however rare, only a case report was found in the English literature.

Method : A 10 day old female with a mature anterior abdominal wall C- shaped ulcer said to have been present at birth was managed by the author and is presented.

Result : Patient was admitted and managed with daily honey dressing and antibiotics; wound and vaginal (mother's) swab yielded the same organism outcome was satisfactory with complete wound healing within two (2) weeks.

Conclusion : Anterior abdominal wall ulcer though rare may be another members of the anterior abdominal wall defect group.


Intussusception in children in Sokoto, North-western Nigeria

Lukong CS, Jabo BA

Paediatric Surgery Unit, Department of Surgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria.

Background : Intussusception is a common cause of morbidity and mortality in children. We present our experience with the management of this condition.

Methods : A prospective study of children managed with intussusceptions in our centre over a 2 year period. Data recorded on a structured proforma was extracted and analysed.

Results : There were 17 children, 11 boys and 6 girls. The median age was 8 months (range 3 - 20 months). The median duration of presentation was 4 days (range 2-6 days). Symptoms were; paroxysm of screaming attacks 13, passage of red currant jelly 17, abdominal mass 13. Signs were; abdominal mass 13, rectal mass 3, prolapsing mass per anus 1. 13 had ultrasonic scan and 10 demonstrated classical features. The commonest type of intussusceptions was ileo-caeco-colic 14, then ileocaecal 1, ileo-ileal 1, colo-colic 1. 3 had associated malrotation. 5 had gangrene of bowel with 2 having associated bowel perforations. 12 had open manual reduction, 4 had resection and anastomosis while 1 had resection and ileostomy. 5 developed surgical site infection (4 superficial, 1 deep). There were 2 mortalities from overwhelming sepsis.

Conclusion : Intussusception is common. Late presentation and overwhelming sepsis are poor prognostic factors


Appendicitis in children in Sokoto, North-western Nigeria

Lukong CS, Jabo BA

Paediatric Surgery Unit, Department of Surgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria, West Africa.

Background : Appendicitis is a common cause of acute abdomen in children. Initially thought to be rare in children. This article highlights the presentation and outcome of appendicitis in our centre.

Methods : A prospective study of all the children with appendicitis, managed in our centre from January 2008 to May 2010.

Data extracted from a structured proforma was analysed and the results presented as below.

Results : There were 25 children managed for appendicitis within the study period. 22 boys and 3 girls. The median age 12 years (range 7- 15 years). The duration of symptoms at presentation was 3-14 days( median 4 days). All presented with abdominal pain, while 10 had associated abdominal distension, 10 had peritonitis.

Intraoperative diagnosis was; acute appendicitis 8, recurrent acute appendicitis 5, perforated appendicitis 7, acute appendicitis and peritonitis 3, appendiceal knotting 1. Caecal perforation 1.

13 had appendectomy, 10 appendectomy and drainage, release and appendectomy 1. The complications were; surgical site infection 1, postoperative pelvic abcess 1. The mortality was 1, due to anaesthetic problems.

Conclusion : Appendicitis is common in our environment. The outcome is good with early presentation and prompt treatment.


Gastro-intestinal ulceration following NSAID ingestion in children

Anyanwu LJC 1 , Aohammad AM 1 , Ibrahim M 2

1 Paediatric Surgery Unit, Department of Surgery Aminu Kano Teaching Hospital Kano, Nigeria, 2 Paediatric Surgery Unit, Department of Surgery Murtala Mohammed Specialist Hospital Kano, Nigeria.

Background : Gastro-intestinal (GI) bleeding could result from various conditions in a child, and could be life threatening. Severe GI bleeds are however rare, and their incidence is relatively unknown.

Cases : We herein report 2 cases of GI bleeding in children secondary to NSAID ingestion. Both patients were females, one aged 6years, the other 2years. Both presented with a one week history of fever and passage of bloody stools about 48 hours before presentation. There was a positive history of Non steroidal anti-inflammatory drug (NSAID) ingestion in both patients which was prescribed in peripheral hospitals. The older child had a PCV of 19% on presentation, and digital rectal examination revealed melaena. There was no history of vomiting. She had one unit of blood transfused and was managed non-operatively with antacids, and the fever was treated with anti-malarial drugs. Her recovery was uneventful. The younger patient presented with an abdominal distension and peritonitis, PCV was 17% on presentation, and patient was malnourished. on exploratory laparatomy, 2 kissing perforations were seen. One measuring about 2cm in the 2 nd part of the duodenum, and the other measuring 1cm in the gallbladder. There were no demonstrable gallstones. She had a cholecystectomy and closure of the duodenal perforation. The patient however developed a superficial surgical site infection which responded to local wound care. She received nutritional support . Recovery was otherwise uneventful.

Conclusion : NSAID syrups are readily available OTC drugs in our environment. A thorough drug history should be taken to rule out their ingestion in the child with a GI bleed.


Diagnostic and treatment algorithm for chronic constipation in children

Ibrahim Musa

Murtala Mohammed Specialist Hospital Kano, Nigeria

Introduction : Gastro-intestinal disease is among the most frequent pathologies in children and adolescents. One of the common pathologies of the gastro-intestinal track in childhood is the pathology of evacuative dysfunction of the colon leading to chronic constipation. Apart from colonic aganglionosis that had wide acceptance, up till now there is no uniform classification leading to definite prime time for treating chronic colostasis in children.

Aim : The aim of our study is to define the effective methods of evaluating chronic constipation in children with suggestive diagnostic and treatment algorithm which could lead to various ways of treating chronic constipation in childhood period.

Material and Methods : To suggest solutions to the above problem, we evaluated 104 children with history of chronic constipation. The children were divided into two groups. In the first group there were 43 children with chronic constipation due to various forms of congenital anomaly. The second group consists of 61 children with functional chronic constipation.

Patients in the two groups had complaints of constipation of different duration. Days of constipation ranges from 2 to 10 days. The faeces in most cases were had and dry. Other symptoms were that of abdominal pains of different intensity, nausea, vomiting and encopresis.

For patient's evaluations, the following investigative methods were used- routine FBC; blood biochemistry; stool microscopy; stool bacteriological evaluations; general abdominal ultra-sound scanning; Ba-enema; fibro-gastro-duodenoscopy; recto-sigmoidoscopy; colonos-ileoscopy and upon indication, general abdominal CT-scan was carried out.

The effect of conservative treatment in the first group was insignificant, while short term relief with remission was seen in 29.4% of the total number of patients. In contrast with the second group were 94.5% relief was achieved after conservative management.

Conclusion : Criteria for differential diagnosis of chronic constipation in children are detailed history, clinical and instrumental investigations. Diagnostic algorithm provides us with suggestive diagnosis and clues to different forms of chronic constipation and their modes of treatments.


Posterior urethral valve resection is not the end of the story

Safwat S. Andrawes

Nairobi Hospital

Case Report : This is a 4 year old male child who came with an end stage renal failure. At the age of 4 months he had Urinary Tract Infection (UTI) and it was diagnosed as Phimosis and was circumcised. About 6 months later it was then diagnosed as Posterior Urethral Valve (PUV) and Trans-Urethral Resection of Valve (TUR-V) was done. Then a third surgery of TUR-V was done in a third hospital. The child still deteriorated until both kidneys failed and while waiting for a kidney transplant a Cystoscopy was done and division of a Stricture Urethra and Suprapupic Cystostomy for Valve Bladder.

Conclusion : PUV is usually under diagnosed, antenatal ultrasound is useful for diagnosis, and screening of UTI patients by ultrasound is non invasive. Voiding Cysto Urethrogram (VCUG/MCU) is the diagnostic method of choice. PUV patients should be monitored for life.


The value and limitations of repeated reconstructive hand surgery for Epidermolysis Bullosa patients

A. Kljenak, Karaman Ilic M., Visnjic S.

Children's Hospital Zagreb, Zagreb University Medical School, Klaiζeva 16, 10 000 Zagreb, Croatia

Background : Children with hereditary blistering skin disorder Epidermolysis Bullosa (EB) as a result of daily trauma of the extremely fragile skin, are always at risk of acute loss of the entire skin cover of one or more fingers or of an entire hand, an injury known as "degloving". The cumulative risk of pseudosyndactyly stratified across all major EB subtypes are high. Hand movements during the newborn period and early infancy become limited , and progress of disorder cause significant functional impairment. In severe cases the hand becomes mitten like, encased in an epidermal cocoon.

Methods : In our 15-years experienced European Regional Debra Centre for EB, we provided 825 procedures for various surgical indications. Surgical intervention is relatively often recommended and performed to correct EB hand deformities, but recurrence and the need for repeated surgery are due to nature of EB common.

From 1994-2009 we provided 84 reconstructive hand surgical procedures for 23 EB patients (range 6 -27 years old), involving extensive release of contractures and pseudosyndactyly, with split skin grafting of secondary defects. All hand surgery was performed under general anaesthesia using a well padded arm tourniquet. We prefere an "aggresive" surgical approach aiming for complete correction of their hand deformity at the time of surgery. From the year 2002 we practice our new split thickness skin grafting technique "PRST" originally designed by dr. Kljenak (Pick up, Roll, Shape, Transfer technique). Dressing changes were performed in operative theatre every 7-10 days thereafter under general anaesthesia or sedation. At a mean of 30 days postoperatively when the hand was well healed, a mould was taken using special compund, from which body-shaped acrylic glove was made. A special postoperative programmme of long term night splintage was employed with meticulous skin care to delay recurrence.

Results : With appropriate plastic surgical technique surprisingly good hand function may be establish. After reconstruction of the hand with our ZSRP technique all our patients showed significant improvement postoperatively. Finger extension and functional assessment was significantly improved for up to 7 years postoperatively. Surgery and the postoperative regimen of rigid night splints has allowed arrest or minimal progression of contractures in short-term follow-up study of an average of 36 months (range, 25-84 months).

Conclusions : Progressive deformities of the EB hands lead to a marked reduction in function including reduced fine manipulative skill. Surgical interventions definitely result in increased functionality of the hands, as characterized by improvement in grasp and gross pinch Our ZSRP (Zagreb Surgical Reconstructive Procedure) technique can provide favorable results and can be carried out repeatedly for up to 5 times. Our data would argue that every one of these patients should be evaluated by a multidisciplinary team, which includes an experienced hand surgeon, within the first 1 or 2 years of life, so as to identify early disease activity and to institute physical measures (digital dressings; splinting; other) that might prevent or delay web formation and the need for more extensive surgical interventions. Efficient repeated reconstruction of EB hand significantly change a life of young EB patients providing them hand skills needed for better school based education continuity.

P 13

Challenges in the management of childhood solid tumours in Kano-Nigeria: A preliminary report

Anyanwu LJC 1 , Mohammad AM 1 , Ibrahim M 2 ,

Chiroma MM 1 , Musa BB 1

1 Paediatric Surgery Unit, Department of Surgery Aminu Kano Teaching Hospital Kano, Nigeria, 2 Paediatric Surgery Unit, Department of Surgery Murtala Mohammed Specialist Hospital Kano, Nigeria

Background : Cancer is a major cause of morbidity and mortality, and is estimated to affect 1 in 600 children before their 15 th birthday.

Objective : This study's objective is to outline the challenges we have faced in the management of Paediatric solid tumours in our practice.

Methodology : Clinical records of all children less than 13 years of age who were managed for solid tumours in our ward between October 2008 and December 2009 were retrospectively reviewed. Demographic data, clinical presentations, management schedule and outcome were recorded for analysis.

Results : Ten patients were managed during the study period. There were 5 males and 5 females. Their ages ranged between 8 months and 11 years (Median 3.5 years). Six of the patients (60%) had a Nephroblastoma, and 4 had Infantile fibrosarcoma (40%). All of the patients presented with an advanced tumour. One patient who had a metastatic disease died during the course of treatment. All the patients had surgery and adjuvant chemotherapy. Majority of the patients received financial aid for the procurement of their drugs, with most being compliant to their treatment protocol.

Conclusion : Financial constraints and late presentation, pose a serious challenge to the management of childhood tumours in our practice.

P 14

Tumour of the floor of the mouth with glossoschisis and cleft palate: A new association

Heuric Rakotomalala, Dan Poenaru

Bethany Kids at Kijabe Hospital - Kenya

Aim : Neonatal tumours of the floor of the mouth and congenital glossoschisis (forked tongue) are both very rare occurrences, seldom reported. We describe an unusual combination of the two in association with cleft palate, hitherto not described. The literature review aims at clarifying the pathophysiology of this rare association.

Methods : A healthy term newborn female presented with a 3cm complex mass of the midline floor of the mouth. The tongue was widely divided in the midline, and there was a complete bilateral cleft palate as well as a prominent medial mandibular ridge.

Results : Following appropriate evaluation, the tumor was resected completely, the glossoschisis repaired, and the mandibular ridge leveled. The cleft palate closure will be undertaken at a later stage. Histopathology reported a salivary gland adenoma. The postoperative course

was complicated by a small pneumothorax and distal dehiscence of the glossoplasty. Breastfeeding resumed normally on post-operative day 5, and the patient was discharged home.

Conclusion : The association described has never been reported to date. Embryologically the glossoschisis likely resulted from the congenital midline soft tissue tumour, which together with the cleft palate probably represent a midline fusion defect.

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Source of Support: None, Conflict of Interest: None

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