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April-June 2018
Volume 15 | Issue 2
Page Nos. 63-120

Online since Thursday, June 27, 2019

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SYSTEMATIC REVIEW  

Congenital anterior urethrocutaneous fistula: A systematic review p. 63
Yang Lin, Changkai Deng, Qiang Peng
DOI:10.4103/ajps.AJPS_97_17  PMID:31290465
Congenital anterior urethrocutaneous fistula (CAUF) is a rare anomaly characterized by fistulization of penile urethra to skin. It's usually seen as an isolated deformity or may accompany genitourinary or anorectal malformations. We aim to define the common properties of patients mentioned in literatures by systematic review. A comprehensive search of PubMed, Embase, Web of Science, and Cochrane Library was performed including cross-referencing independently by two assessors. Selections were restricted to human studies in English. Based on the systematic review, 63 patients in 34 articles were included in the study. Most common fistula site was subcoronal in 29 (46.0%) patients. Chordee was in 8 (14.5%) and associated genitourinary anomaly was detected in 19 (30.2%) of patients. Fistula recurrence ratio was 6/59 (11.3%) using different surgical techniques and 3/6 was closed spontaneously. CAUF is frequently located in subcoronal level and usually an intact urethra distal to it. Success rates are high with the principles of hypospadias surgery.
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ORIGINAL ARTICLES Top

Incidence of hyponatraemia following the use of three different intravenous fluids in paediatric surgery p. 69
Casmir Edobor Omoifo, Nosa Philomena Edomwonyi, Sylvester Eshiotseme Idogun
DOI:10.4103/ajps.AJPS_40_16  PMID:31290466
Background: It is a common practice to administer 4.3% dextrose in 0.18% saline peri-operatively and for routine fluid maintenance in the paediatric age group. Concerns have been expressed about the risk of hyponatraemia associated with the administration of hypotonic intravenous fluids, hence the need to re-evaluate our practice. This study aims to evaluate the relative incidence of intra-operative hyponatraemia following the use of isotonic and hyopotonic intravenous fluids. Patients and Methods: This randomised double-blind clinical trial recruited consecutive American Society of Anaesthesiologists physical status Class I and II children aged between 6 months and 17 years scheduled for various minor elective surgical procedures. The patients received one of 3 intravenous infusions for intra-operative fluid management. Group I received 4.3% dextrose in 0.18 saline (n = 25), Group II received normal saline (n = 20) and Group III received Ringer's lactate (n = 20). Blood samples were collected before the surgery and at the end of surgery for serum electrolytes. Results: One patient in each group developed moderate hyponatraemia intraoperatively. This constituted a 4% (1/25) incidence of intra-operative hyponatraemia among patients who had hypotonic maintenance fluid and a 5% (2/40) incidence in the isotonic maintenance groups. The incidence of hyponatraemia was therefore comparable between patients who had hypotonic and isotonic intra-operative maintenance fluids (P = 1.000). Conclusion: We conclude that healthy children who have intraoperative hypotonic maintenance fluids during minor elective surgeries are not exposed to the additional risk of hyponatraemia compared to those who have isotonic fluids. The study of a larger sample size is recommended to further validate our findings.
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Effect of corrective or palliative procedures on arterial to end-tidal carbon dioxide pressure difference in pediatric cardiac surgery p. 73
Eissa Bilehjani, Solmaz Fakhari, Alireza Yaghoubi, Yashar Eslampoor, Simin Atashkhoei, Mousa Mirinajad
DOI:10.4103/ajps.AJPS_97_16  PMID:31290467
Background: The normal small difference (3–5 mmHg) between arterial (partial pressure of carbon dioxide [PaCO2]) and end-tidal carbon dioxide pressure (ETPCO2) increases in children with congenital heart disease. The present study was conducted to evaluate the effect of corrective or palliative cardiac surgery on this difference (known as DPCO2). Patients and Methods: In a prospective study, 200 children (aged <12 years old) candidate for corrective or palliative cardiac surgery were studied. Using arterial blood gas measurement and simultaneous capnography, DPCO2 was calculated at various intra- and postoperative periods. DPCO2 values were compared within and between corrective or palliative procedures. Results: Corrective and palliative procedures were carried out on 154 and 46 patients, respectively. Initial DPCO2 was higher than normal values in corrective or palliative procedures (15.50 ± 13.1 and 10.75 ± 9.1 mmHg, respectively). DPCO2 was higher in patients who underwent palliative procedure, except early after procedure. The procedure did not have any effect on the final DPCO2 in palliative group. Although DPCO2 decrease was significant in the corrective group, it did not return to normal values. Operation time was longer, and the need to inotropic support was higher in corrective procedures; however, longer periods of ventilatory support were needed in the palliative group. Complication rate and Intensive Care Unit stay time were the same in two operation types. Conclusions: DPCO2 did not change after palliative cardiac procedures. DPCO2 decreased after corrective procedures; however, it did not return to normal values at early postoperative period. Thus, DPCO2 may not have any clinical value in monitoring the quality of corrective or palliative procedures.
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Paediatric surgical outreach in central region of Ghana p. 80
Gladys Amponsah, Victor Kobby Etwire
DOI:10.4103/ajps.AJPS_114_16  PMID:31290468
Background: Conditions that are amenable to surgery are found globally. However, surgery is not easily accessible for most people in low- and middle-income countries due to physical and financial barriers, among others. One-way of mitigating against this situation is through surgical outreach programmes. Patients and Methods: A paediatric surgical outreach in a teaching hospital in the Central Region of Ghana was carried out by a paediatric surgeon from Korle Bu Teaching Hospital. Data on the cases done from June 2011 to June 2014 were analysed. Results: A total of 185 patients had surgery during the study. There were 153 males with the mean age of 4.53 ± 3.67 years. Patients aged 1–5 years represented 51.9% of the patients. Twenty-four (13%) had major surgery and 161 (87%) had minor operations. The most common minor operation performed was inguinal herniotomy representing 47.2% of the cases. None of the patients had any complications. Conclusion: The need for paediatric surgical outreach programme has been shown in this paper as well as its cost-effectiveness. With the current rate of graduation of paediatric surgeons in Ghana, paediatric outreach programmes will be needed in Ghana in the foreseeable future. This outreach should be extended to other regions of the country to cover a larger percentage of children in Ghana.
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Presentation and outcome of treatment of jejunoileal atresia in Nigeria p. 84
Tunde Talib Sholadoye, Philip Mari Mshelbwala, Emmanuel Adoyi Ameh
DOI:10.4103/ajps.AJPS_120_16  PMID:31290469
Background: Intestinal atresia is a common cause of neonatal intestinal obstruction. Previous reports from Nigeria have indicated a high mortality rate. This is a report of current outcome review from one tertiary center. Patients and Methods: A retrospective analysis of infants managed for jejunoileal atresia in 10 years (2005–2014). The information retrieved from patients' records was analyzed using SPSS 17. Results: There were 38 patients (19 boys and 19 girls) aged 1–28 days (median 4 days). Twenty-four patients (63.2%) presented after 48 h of life. Twenty-five (65.8%) had jejunal atresia and 13 (34.2%) had ileal atresia. Six patients had associated anomalies. The most common atresia was type III (39.5%, 15 patients). Twenty-eight (73.7%) patients had a resection of the atresia and anastomosis and others had enterostomies. Total parenteral nutrition and neonatal intensive care support were not available during the period of the study. Bowel function was established within 1 week and 27 (71.1%) patients commenced oral feeding. Twenty-six (68.4%) patients had postoperative complications resulting in prolonged hospital stay of 2–44 days (median = 13). Mortality was 34.2% (13 patients). Factors that significantly affected mortality were intestinal necrosis at presentation, postoperative complications, and severe malnutrition. Conclusion: Intestinal atresia is still associated with unacceptably high morbidity and mortality, due to late presentation, and lack neonatal intensive care services and parenteral nutritional support. Efforts need to be intensified to address these factors to improve outcome.
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Tongue flap as salvage procedure for recurrent and large palatal fistula after cleft palate repair p. 88
Advait Prakash, Sangram Singh, Shailesh Solanki, Bhavesh Doshi, Venkatesh Kolla, Tanmay Vyas, Anvesh Jain
DOI:10.4103/ajps.AJPS_131_16  PMID:31290470
Background: Recurrent palatal fistula is a common complication of cleft palate repair. The main causes are poor surgical technique or vascular accidents and infection. Local flaps are not adequate for larger and recurrent fistula. The aim of this study is to analyze the utility of tongue flap in recurrent and large palatal fistula repair. Materials and Methods: From January 2008 to July 2016, 18 patients with recurrent palatal fistula were included in the study. All the patients had undergone repair of cleft palate and fistula previously. Tongue flap repair of the recurrent palatal fistula was performed in all 18 patients. The flaps were divided after 3 weeks and final inset was done. Flap viability, fistula closure, residual tongue function, esthetics, and speech impediment were assessed. Results: In all the patients, fistula could be closed primarily by tongue flap. None of the patients developed flap necrosis while flap dehiscence and bleeding were observed in one patient each. No functional deformity of the tongue and donor-site morbidity was seen. Speech was improved in 80% cases. Conclusion: The central position, mobility, excellent vascularity, and versatility of tongue flap make particularly suitable choice for the repair of large fistula in palates scarred by previous surgery. It is very well tolerated by children. We, therefore, recommend tongue flap for large and recurrent palatal fistula in children.
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Comparison between testicular volumes as measured with prader orchidometer and ultrasonography in Healthy Nigerian Newborns p. 93
Olakayode Olaolu Ogundoyin, Omolola Mojisola Atalabi
DOI:10.4103/ajps.AJPS_32_17  PMID:31290471
Background: We compared the testicular volume (TV) measured with Prader orchidometer (PO) to the volume measured with ultrasonography in male neonates and their relationships with some selected neonatal characteristics. Subjects and Methods: A cross-sectional study of all term male neonates who had clinical examination of their external genitalia performed and TV was measured using PO and ultrasonography. Information about the gestational age, birth weight, and birth length was also recorded to determine their relationships with TV measured. Results: The mean TV measured with PO was 1.06 (standard deviation [SD] ± 0.24) ml for both sides. With ultrasonography, the mean left TV was 0.273 (SD ± 0.081) ml and the mean right TV was 0.272 (SD ± 0.079) ml. There were significant correlations between TV using both methods with the birth weight and length. Conclusion: TV measured with the two methods was comparable and correlates well with their birth weight and birth length.
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Paediatric day-case surgery in a new paediatric surgical unit in Northwestern Nigeria p. 97
Stephen Akau Kache, Danjuma Sale, Jonathan Luka Ajah, Jerry Godfrey Makama
DOI:10.4103/ajps.AJPS_50_17  PMID:31290472
Background: Day-case surgery is defined as when the surgical day-case patient is admitted for investigation or operation on a planned non-resident basis and who nonetheless requires facilities for recovery. A significant number of our patients were treated as day cases. This study was conducted to audit paediatric day-case surgery practice at our centre, to determine the indications as well as morbidity and mortality from day-case surgeries. Patients and Methods: This is a prospective study over a period of 14 months. The patients scheduled for surgeries were assessed in the paediatric surgical outpatient clinic and information obtained for each of the patients included age, sex, diagnosis, type of operation, type of anaesthesia and post-operative complications. The data were analysed using SPSS version 15.0 for windows. Results: A total of 182 patients were operated during the study period. The age range of patients was 0.5–156 months and the mean age was 46.6 months. There were 152 male patients (83.5%) and 30 female patients (16.5%). Most of the patients had intact prepuce for circumcision (34.1%). Two patients who had herniotomy developed superficial surgical site infections which were managed as outpatients. There were no readmissions or mortality. Conclusion: Intact prepuce for circumcision as well as hernias and hydroceles is the most common day cases in our centre and is associated with low morbidity and no mortality.
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Is transcatheter closure superior to surgical ligation of patent ductus arteriosus among Nigerian Children? p. 100
Barakat Adeola Animasahun, Motunrayo O Adekunle, Olabode Falase, Mohammed Tunde Gidado, Olusola Y Kusimo, Michael O Sanusi, Adeyemi Johnson
DOI:10.4103/ajps.AJPS_53_17  PMID:31290473
Background: Patent ductus arteriosus (PDA) is common among Nigerian children. It is the second only to ventricular septal defect among congenital heart diseases in Nigeria children. The study centers are the only centers in Nigeria which are able to offer both transcatheter closure of PDA and surgical ligation. The study aims to compare both methods in terms of the demographics of the individuals, cost and outcome. Patients and Methods: Prospective, cross-sectional involving consecutive individuals who had either transcatheter closure or surgical ligation of PDA from June 2010 to January 2014. Individuals were grouped according to the method of closure of their defect. Data on their demographics, size of the defects, cost of treatment and outcome were compared for the two groups. The analysis was done using Microsoft Excel statistical software supplemented by Statistical Package for Social Sciences version 20.0. P < 0.05 was considered statistically significant. Results: A total number of 28 individuals had either surgical ligation or device closure of PDA done at the studied period. The mean age of all the individuals was 4.58 ± 4.20 years with a median age of 3 years. The mean age of individuals that had surgical ligation was 3.40 ± 0.92 years and mean age of those who had transcatheter device closure was 6.69 ± 1.05 years (P = 0.677). Male to female ratio in both groups were 0.4:1. No mortality was recorded in both groups. However, 6 (21.4%) of the surgical patients and 1 (3.57%) of the patient with device closure had complications. The direct cost of the procedure for each of the patient who had device closure of PDA was about $3000 whereas the cost of surgical closure was about $1000. The indirect cost for device closure was about $100 while that of surgical closure was about $5000. Conclusion: Device closure of PDA has lesser risk of complications compared to surgical ligation. Its indirect cost is also cheaper. There is a need for availability and accessibility to device closure of PDA in our environment.
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Horseshoe kidney and associated anomalies: Single institutional review of 20 cases p. 104
Kailas P Bhandarkar, Dinesh H Kittur, Santosh V Patil, Sudhakar S Jadhav
DOI:10.4103/ajps.AJPS_55_17  PMID:31290474
Background: Horseshoe kidney (HSK) is a common renal fusion anomaly. We undertook this study to discuss various anomalies associated with HSKs. The objective of the study is to study various anomalies associated with HSKs and to assess the need for surgical intervention in patients with these anomalies. Patients and Methods: This is a retrospective cohort study of twenty patients who presented to our institute with the diagnosis of HSKs. The data were analysed with regard to age at presentation, symptoms, associated anomalies, investigations and surgical intervention. Results: Twenty patients were included in this study. They were referred either with a diagnosis of HSK or were diagnosed during investigations for symptoms and during workup for associated anomalies. Eleven patients were incidentally diagnosed and were asymptomatic, and there were no associated anomalies diagnosed in these patients. Nine patients were symptomatic and were diagnosed with various associated anomalies. Our results concur with recent literature review which suggests that nearly half of the patients with HSKs have associated anomalies. In the present series, all symptomatic patients with associated anomalies required surgical intervention. Conclusion: HSKs being a common fusion anomaly, necessitates a prompt and thorough search of the search for any associated anomalies. Many of these anomalies may require surgical intervention.
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Risk factors and short outcome of bowel atresia in neonates at Tertiary Hospital p. 108
Fares Al-Jahdali, Maan A Alsania, Asem A Almagushi, Mohammed T Alsaqqat, Mohammed K Alnamshan
DOI:10.4103/ajps.AJPS_65_17  PMID:31290475
Background: Bowel atresia is a rare congenital anomaly that could affect any part of the bowel. It is categorized based on the type and location of the affected bowel with jejunoileal being the most common type worldwide. Risk factors for developing intestinal atresia are not well established, but we know that genetics, poor prenatal care, and low birth weight are considered risk factors. Patients and Methods: This is a case–control study conducted in King Abdulaziz Medical City tertiary hospital in Nursery Intensive Care Unit from 2004 to 2015 with a total number of 50 cases. Each case was matched with two control groups: a female and a male; the matching was based on the date of birth. Results: Our study showed an interesting results with esophageal atresia being the most common type (n = 16, 32%) after that jejunoileal (n = 11, 22%). Both genders were affected almost equally with no gender predominance. Twenty-six (51%) of the cases were having below normal birth weight (odds ratio [OR] =0.07; 95% confidence interval [CI] =0.03–0.2). One mother of the control groups had cesarean section in comparison to 15 mothers from the cases (OR 42.4; 95% CI 5.4–333.09). The study also showed that there is no correlation between the number of pregnancies and the risk of atresia (P = 0.798) (OR 0.9; 95% CI 0.72–1.3). Conclusion: Unlike western countries, esophageal atresia was the most common type with no gender differences. Interestingly, both groups had high rates of low birth weight.
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A 6-year retrospective review of histopathological pattern of surgical biopsies in children with refractory constipation in a Tertiary Hospital in Ghana p. 111
Abiboye C Yifieyeh, Babatunde M Duduyemi, Anthony Enimil
DOI:10.4103/ajps.AJPS_70_17  PMID:31290476
Background: Children with chronic constipation dating to infancy frequently undergo rectal biopsy in order to rule out Hirschsprung's disease (HD) which is a common cause of this sort of presentation. Few publications have however focused on the documentation of the proportion of such patients who truly had histopathological findings confirming the disease. In this preliminary work, we aim to present the histopathological findings of children who had rectal biopsies in our centre from 2009 to 2014. Patients and Methods: A retrospective study was undertaken to review the histopathology reports of all rectal biopsies submitted to the Department of Pathology of the Komfo Anokye Teaching Hospital, Kumasi, from 2009 to 2014 on account of refractory constipation and suspected HD. Patient's biodata, clinical signs and symptoms were extracted from the request form. Results: Eighty-eight cases were seen during the study period with male to female ratio 2.8:1 and age range 6 months to 10 years. The modal age range is 24–36 months. Seventy-six of the specimens were adequate for histopathological assessment with 64 cases confirmed as HD while 12 cases were normal. Out of the confirmed cases, 3 cases showed absence of ganglion cells but no hypertrophy of nerve fibres. Conclusion: This preliminary work reveals that HD is rarely confirmed by biopsy in early infancy in our setting due to late presentation although the epidemiology of the disease is similar to that reported elsewhere.
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Management of femoral neck fractures in children: Experience of a short series in a developing country p. 114
Jean Baptiste Yaokreh, Thierry-Herve Odehouri-Koudou, Gaudens Atafy Dieth, Samba Tembely, Yapo Guy-Serge Kouame, Bertin Dibi Kouame, Ossenou Ouattara
DOI:10.4103/ajps.AJPS_93_17  PMID:31290477
Background: Fractures of the femoral neck are rare injuries in children but can have many devastating complications. Their treatment is not standardized, but the objectives are early anatomic reduction to minimize the risk for complications. The aim of this study was to assess outcomes of a short series of femoral neck fractures managed in a resource-limited setting. Materials and Methods: The medical charts of 11 children who were managed in our institution for femoral neck fractures between January 2000 and December 2015 were assessed retrospectively. There were two cases (n = 2) of Delbet type I, 5 (n = 5) type II, and 4 (n = 4) type III fractures. Patients were treated either surgically by open reduction and internal fixation (n = 4) or conservatively by traction followed by spica cast (n = 7). Outcomes were assessed using Ratliff system. Results: Femoral neck fracture incidence was one case per year. Of the 11 patients, there were 7 boys and 4 girls, with a mean age 9.4 ± 3.28 years. At the mean follow-up of 3.64 ± 1.97 years (range, 2–8.8 years), outcome was fair to good in 8 (72.7%) and poor in 3 (27.3%) cases. Average union time was 13.5 ± 1.77 weeks. Complication rate was 72.7%. Avascular necrosis occurred in three cases (27.3%). Six patients (54.5%) developed coxa vara, with a mean neck-shaft angle of 102.16° ±12.07° (range, 90°–118°). Five patients (45.5%) had leg length discrepancy with a mean 18 mm (range, 7–35 mm). Discussion: local conditions negatively influenced the management of femoral neck fractures. Conservative treatment led to many complications which increase the cost of management.
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Malformations: A 5-year review of the presentation and management in a Teaching Hospital in Ghana p. 118
Abiboye C Yifieyeh, Babatunde M Duduyemi, Anthony Enimil, Michael Amoah, Boateng Nimako
DOI:10.4103/ajps.AJPS_10_18  PMID:31290478
Background: Anorectal malformations (ARMs) are congenital defects affecting the distal gastrointestinal tract and anus with frequent fistulous connections to the genitourinary system. The spectrum of the disease is considerably wide, and thus, an individualised approach to its management is required. There are few recent publications about the burden of this malformation in Africa and the outcome of surgical intervention. We present our experiences with the management of ARM, peculiar challenges and the outcome at a tertiary hospital catering for the Northern and Central parts of Ghana. Materials and Methods: This was a retrospective folder review of children with ARM at the Paediatric Surgical Unit of Komfo Anokye Teaching Hospital, Kumasi, Ghana, from 2011 to 2015. The data extracted included diagnosis, associated features, initial and definitive surgical treatment and post-operative complications. Results: Of the 53 records that were conclusively retrieved, the sex ratio was 1:1. The median age of presentation was 4.5 days (neonates), 4.5 months (infants) and 1.6 years (older children). There were 12 (44%) rectoperineal and 18 (69%) rectovestibular fistulas, representing the most common types of ARM in boys and girls, respectively. Posterior sagittal anorectoplasty and abdominoperineal pull-through were the corrective procedures performed. The overall complication rate was <10%. Conclusion: Our patients generally presented later than their Western counterparts, making a single-stage correction rare. The types of ARM documented in our study suggest the existence of a geographical variation.
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