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   Table of Contents - Current issue
Coverpage
Oct-Dec 2016
Volume 13 | Issue 4
Page Nos. 161-222

Online since Thursday, November 24, 2016

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ORIGINAL ARTICLES  

Experience with neonatal hydrometrocolpos in the Niger Delta area of Nigeria: Upsurge or increased recognition? p. 161
Philemon Ekemenye Okoro, C Obiorah, CE Enyindah
DOI:10.4103/0189-6725.194666  PMID:28051043
Background: Hydrometrocolpos (HMC) is a clinical condition in which there is a cystic distension of the vagina (hydrocolpos), uterus and sometimes, fallopian tubes (hydrosalpinx) with fluid. This study described our experience with cases of HMC seen in our practice, and highlighted the flare in our practice. Patients and Methods: A retrospective study of cases of HMC managed at the University of Port Harcourt Teaching Hospital between September 2010 and August 2012. Results: There were seven cases; their ages ranged from 2 to 27 days (median 13 days). All the patients had abdominal distension but abdominal mass was obvious only in four. Other features varied depending on the presence of sepsis or other associated anomalies. The diagnosis of HMC was missed in all cases by the referring clinicians. One patient was referred with the diagnosis of tracheoesophageal fistula and esophageal atresia, 2 with bladder outlet obstruction, 1 with intestinal obstruction, 2 with anorectal malformation, and 1 with neonatal sepsis. Ultrasound identified bulky uterus in two cases and upper urinary tract dilatation in 3 patients. Six patients had laparotomy, 1 had hymenotomy only. Postoperative complications were basically wound sepsis and rectovaginal fistula resulted. Conclusion: Diagnosis of HMC should be considered as a differential in newborn girls presenting with lower abdominal mass. Attention to clinical detail is necessary to avoid a misdiagnosis.
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Childhood intussusception: Impact of delay in presentation in a developing country p. 166
Olakayode Olaolu Ogundoyin, Dare Isaac Olulana, Taiwo Akeem Lawal
DOI:10.4103/0189-6725.194665  PMID:28051044
Background: The classical cases of intussusception are readily diagnosed clinically, and despite recent improvements in radiological techniques, the diagnosis of intussusception and success in its nonoperative reduction has been suboptimal, thus making operative management a veritable backup. This study examined the impact of delays in presentation on the rate of bowel resection, length of hospital stay, and appraised the outcome of operative treatment. Patients and Methods: This was a retrospective study of consecutive children admitted and treated surgically for intussusception between January 2002 and December 2011 at the University College Hospital, Ibadan, Nigeria. Results: The mean age at presentation was 13.4 months with a male: female ratio of 1.8:1. Fourteen patients (25.5%) presented within the first 24 h of onset of symptoms with majority (36.4%) presenting between 2 and 3 days of onset of symptoms. The primary surgical intervention was performed on 47 patients (85.5%), and the secondary operative intervention was performed on eight patients (14.5%) who had failed initial nonoperative management of intussusception. Manual reduction of intussusception was performed on 27 patients (49.1%), 26 patients had resection of gangrenous bowel with end-to-end anastomosis while two patients (3.6%) had spontaneous reduction of intussusception which was discovered at laparotomy. The mean duration of hospital stay was 12.1 days (range 3–60 days). The overall mortality was 5.5% (three patients), and three patients (5.5%) had recurrence of intussusception. Conclusion: Although mortality is reducing, a high rate of bowel resection is a consequence of delayed presentation and effort should be made to make an early diagnosis of intussusception and make prompt referral to improve outcome.
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Meckel's diverticulum in children: Our 12-year experience p. 170
Kamal Nain Rattan, Jasbir Singh, Poonam Dalal, Ananta Rattan
DOI:10.4103/0189-6725.194671  PMID:28051045
Background: Meckel's diverticulum (MD) is the one of the most common congenital malformation of gastrointestinal tract and has varied clinical presentations. We are presenting here our 12-year experiences with MD in children at tertiary care hospital in North India. It highlights the fact that isolated gangrene of MD can occur, and it is associated with increased morbidity. Materials and Methods: This retrospective study is conducted by analysing the medical records of the patients who were operated for MD in the last 12 years in paediatric surgery department at our hospital. Results: Sixty-five patients were operated for MD in study period; in this 52 were males and 13 were females with mean age of presentation 3.2 years. The most common presentation was intestinal obstruction seen in 86.1% (56 cases). Intestinal haemorrhage was seen in 4.6% (3 cases) and diverticulitis in 3% (2 cases). Perforation of the gut with peritonitis was present in 6.1% (four cases). Cause of obstruction was intussusception in 21.4% (12 cases), fibrous band connected to umbilicus in 17.8% (10 cases), volvulus in 17.8% (10 cases), kinking in 16.0% (9 cases), knotting in 14.2% (8 cases) and herniation of gut below in 12.5% (7 cases). Isolated gangrene of MD was present in ten cases with intestinal obstruction. The ectopic gastric mucosa was seen in three and pancreatic mucosa in two cases. Mortality and morbidity during the study were one and three cases, respectively. Conclusion: MD may remain clinically silent for lifetime, or it may have life-threatening complications. In our series, intestinal obstruction and not the haemorrhage was the most common presentation. Isolated gangrene of MD with obstruction was present in significant numbers, which we failed to find in literature.
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Typhoid perforation: Post-operative Intensive Care Unit care and outcome p. 175
Mukaila Oyegbade Akinwale, Arinola A Sanusi, Oluwaseun K Adebayo
DOI:10.4103/0189-6725.194664  PMID:28051046
Background: Typhoid perforation ileitis is a serious complication of typhoid fever, a common and unfortunate health problem in a resource-poor country like Nigeria. Following bowel perforation, treatment is usually by simple closure or bowel resection and anastomosis after adequate aggressive fluid resuscitation and electrolyte correction. Postoperatively, some of these patients do require management in Intensive Care Unit (ICU) on account of sepsis or septic shock and to improve survival. Patients and Methods: This is a prospective observational study in which 67 consecutive patients who had exploratory laparotomy for typhoid perforation between August 2009 and October 2012 in the main operating theatre of the University College Hospital, Ibadan, were studied. The attending anaesthetists had the freedom of choosing the appropriate anaesthetic drugs depending on the patients' clinical condition. The reason for admission into the ICU, the types of organ support required and outcomes were recorded. Results: Twenty-five patients (37.3%) out of 67 required critical care. Reasons for admission among others included poor respiratory effort, hypotension, septic shock and delayed recovery from anaesthesia. Twenty-one patients (84%) required mechanical ventilation with a mean duration of 2.14 days (range 1–5 days). Fourteen patients required ionotropic support and the length of ICU stay ranged from 1 to 15 days (mean 4.32 days). Nineteen patients (76%) were successfully managed and discharged to the ward while 24% (6 patients) mortality rate was recorded. Conclusion: This study showed high rate of post-operative ICU admission in patients with typhoid perforation with a high demand for critical care involving mechanical ventilation and ionotropic support. In centres that manage patients presenting with typhoid ileitis and perforation, post-operative critical care should be available.
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Evaluation of the use of laparoscopic-guided cholecystocholangiography and liver biopsy in definitive diagnosis of neonatal cholestatic jaundice p. 181
Khalid Shreef, Abdullah Alhelal
DOI:10.4103/0189-6725.194667  PMID:28051047
Background: Once it is established that a jaundiced infant has direct hyperbilirubinemia, the principal diagnostic concern is to differentiate hepatocellular from obstructive cholestasis. Traditional tests such as ultrasonography, percutaneous liver biopsy and technetium 99 m hepatobiliary iminodiacetic acid (HIDA) scan are often not sufficiently discriminating. Definitive exclusion of biliary atresia (BA) in the infant with cholestatic jaundice usually requires mini-laparotomy and intra-operative cholangiography. This approach has many drawbacks because those sick infants are subjected to a time-consuming procedure with the probability of negative surgical exploration. Aim of the Study: The aim of this study was to determine the feasibility of laparoscopic-guided cholecystocholangiography (LGCC) and its accuracy and safety in the diagnosis of BA and thus preventing unnecessary laparotomy in infants whose cholestasis is caused by diseases other than BA. Patients and Methods: Twelve cholestatic infants with direct hyperbilirubinemia subjected to LGCC (age, 7–98 days; mean, 56 days) after ultrasound scan and (99 mTc) HIDA scan and percutaneous liver biopsy failed to provide the definitive diagnosis. Results: One patient had completely absent gall bladder (GB) so the laparoscopic procedure was terminated and laparotomy was done (Kasai operation). Four patients had small size GB; they underwent LGCC that showed patent common bile duct with atresia of common hepatic duct, so laparotomy and Kasai operation was performed. Seven patients had well-developed GB, LGCC revealed patent biliary tree, so laparoscopic liver biopsies were taken for histopathology. Five of those patients had neonatal hepatitis, and two had cholestasis as a complication of prolonged TPN. No perioperative complications or mortalities were recorded. Conclusion: When the diagnosis neonatal cholestasis remains elusive after traditional investigations, LGCC is an accurate and simple method for differentiating BA from hepatocellular causes.
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Outcome of primary closure of abdominal wounds following laparotomy for peritonitis in children p. 185
Stephen Akau Kache, Philip M Mshelbwala, Emmanuel A Ameh
DOI:10.4103/0189-6725.194669  PMID:28051048
Background: Primary wound closure following laparotomy for peritonitis is generally believed to be associated with wound complications and long hospital stay. Open wound management has long been the most common practice after laparotomy for peritonitis. Primary closure (PC), however, has recently been advocated to reduce cost and morbidity. This study determined the incidence and severity of wound complications and their impact on hospital stay and overall outcome when PC of abdominal wounds is done following laparotomy for peritonitis. Patients and Methods: A prospective review of patients who had PC of abdominal wounds following laparotomy for peritonitis over a 6-year period. Results: Fifty-six children were analysed (35 boys and 21 girls), aged 11 months to 13 years (median: 8 years). The indication for laparotomy was typhoid intestinal perforation 47 (83.9%), perforated appendicitis 4 (7.1%), complicated cholecystitis 3 (5.3%) and penetrating abdominal injury with bowel perforation and intestinal obstruction with bowel perforation, 1 (1.8%) each, respectively. Postoperatively, 34 patients had wound complications. Nine patients (16.1%) had superficial wound infection alone, 12 (21.4%) had superficial wound infection with partial wound dehiscence, 6 (10.7%) had deep wound infection, 7 (12.5%) had deep wound infection with complete wound dehiscence, whereas 22 (39.3%) had no wound complication. Overall, wound complications in 13 (23.2%) patients were considered to be severe, but none resulted in mortality. Hospital stay in patients who developed wound complications was 8–37 days (median: 25 days) and 6–22 days (median: 10 days) in patients who had no wound complications (P = 0.02). Conclusion: The rate of wound complications following PC of dirty abdominal wounds remain but PC is safe and gives good healing outcomes.
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Non-laparoscopic minimal surgical approach to pyloromyotomy: An experience from a challenged resource setting p. 189
Ossama M Zakaria
DOI:10.4103/0189-6725.194672  PMID:28051049
Background: The aim of the study is to review the experience with the classic Ramstedt's pyloromyotomy through the RUQ approach and the circumlinear supraumbilical fold approach (circumumbilical [CU]) pyloromyotomy (an approach that combines the ease and safety of the open pyloromyotomy with the advantages of minimal invasiveness). Patients and Methods: A single centre review in a period of 12 years from January 2001 to December 2013 with the institutional ethical committee's approval, evaluating 316 pyloromyotomies based on surgical approach: RUQ (171); and CU (145). Patients' demographics, acid-base/electrolyte status on presentation, mean operative time (MOT), postoperative length of stay (LOS) at hospital, and complications were recorded. Results: Patients demographics, acid − base/electrolyte status on presentation; and MOT were not significantly different. The median LOS was 33 and 30 minutes for CU and RUQ, respectively, with no statistical significant difference between the two groups. One patient in the CU group had a late adhesive bowel obstruction requiring laparotomy and bowel resection. Moreover, wound infection rates did not differ significantly between the two groups (CU 3; and RUQ; 3; P = 0.15). Conclusions: Pyloromyotomy is associated with a low complication rate. Cosmetically, CU is superior to the RUQ approach. Its short learning curve and the feasibility to examine the integrity of the duodenal mucosa intraoperatively may make CU a safer alternative in case of surgeons who are still practicing the RUQ approach in countries with a challenged resource settings.
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Our experience of proximal hypospadias repair using the Cloutier–Bracka technique at the Gynaeco-Obstetric and Paediatric Hospital, Yaounde-Cameroon p. 193
Mouafo Tambo Faustin Felicien, AS Nwaha Makon, C Kamadjou, G Fossi, C Le Coultre, OG Andze, MA Sosso, PY Mure
DOI:10.4103/0189-6725.194673  PMID:28051050
Background: In parts of Africa, routine circumcision is practised and sometimes even on children with hypospadias. The lack of preputial foreskin renders urethroplasty more difficult and often requires to use of a mucosal graft as described by Bracka. Objective: The authors describe their experience of hypospadias repair using Bracka's technique. Materials and Methods: Over a period of 5 years, 100 cases of proximal hypospadias were operated in our institution. All patients aged 0–18 years who had already been circumcised were included in this study. Results: The outcome of the 12 cases operated according to Bracka's technique was analysed. The mean age was 11.5 years. The ectopic meatus was penoscrotal in three cases, scrotal in one case and perineal in eight cases. After reconstruction, the new meatus was sutured at the top of the glans in one case, at the prepuce in seven cases and at the penile midshaft in one case. The main complications noted were surgical site infection, wound dehiscence, residual chordee and urethrocutaneous fistula. No neourethral stenosis nor uretrocele was recorded. Discussion: The buccal mucosal graft urethroplasty as described by Bracka is associated with a lower risk of meatal strictures compared to other free mucosal grafts. The buccal mucosa is easier to harvest and causes less scarring than bladder mucosa. Conclusion: Repair of severe hypospadias remains a challenge for paediatric surgeons. The functional and cosmetic outcomes depend on the choice of the donor site for the graft and objective assessment of successful reconstruction criteria during follow-up.
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CASE REPORTS Top

Impact of umbilical polyp resection: A report and literature review p. 196
Hisayuki Miyagi, Shohei Honda, Masashi Minato, Tadao Okada, Kanako C Hatanaka, Akinobu Taketomi
DOI:10.4103/0189-6725.194677  PMID:28051051
The preferred treatment for this lesion should be the total resection of the umbilical polyp with a mini-laparotomy because residual intestinal mucosa at the umbilicus can be confirmed to eliminate the risk of recurrence.
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Acute neonatal parotid abscess: A rare case report p. 199
Shreesh Kolekar, Tejas S Chincholi, Ashok Kshirsagar, Narendra Porwal
DOI:10.4103/0189-6725.194675  PMID:28051052
Acute suppurative parotitis is uncommon in children and is very rare in neonates. Most common organism isolated is Staphylococcus aureus. We present a 15-day-old full-term breast-fed female neonate with left-sided acute parotid abscess. The baby presented with a left preauricular swelling, pain and redness. Pus was exuded from left Stensen's duct on compression of the gland externally. Early diagnosis and proper intravenous antibiotics are the keys to the treatment.
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Simultaneous occurrence of intussusception and duodenal haematoma in a patient with Glanzmann's thrombasthenia p. 202
Iftikhar Ahmad Jan, Saif Khalfan AlKaabi, Awadh AlMughadam, D Sreenivas Murthy, Basmah AlHamoudi
DOI:10.4103/0189-6725.194676  PMID:28051053
Glanzmann's thrombasthenia (GT) is a rare autosomal recessive disorder in which the platelets have anomalies of fibrinogen receptors causing bleeding tendencies. The disease usually presents with mucosal bleeding, petechial haemorrhages or gastrointestinal (GI) bleeding. Only sporadic cases of intussusception or duodenal haematoma have been reported with GT. We present a case of 5-year-old girl admitted with non-bilious vomiting, watery diarrhoea and abdominal pain. She is a known patient of Glanzmann's thrombasthenia.
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Appendicular bilharzioma: An unusual cause of acute intestinal obstruction in childhood (a case report at Charles de Gaulle Paediatric Teaching Hospital of Ouagadougou) p. 206
Albert Wandaogo, Isso Ouédraogo, Toussaint Wendlamita Tapsoba, Emile Bandré, Francis Somkieta Ouédraogo, Bernadette Béré, Balima Elie
DOI:10.4103/0189-6725.194668  PMID:28051054
The authors report the case of a 12-year-old boy admitted to the surgical emergency department of Charles de Gaulle Paediatric Teaching Hospital of Ouagadougou for acute abdominal pain. A strangulation of the terminal ileum by a tumour-like appendix wound around the bowel loop was seen during operation. The histological examination of the removed appendix disclosed eggs of Schistosoma haematobium and concluded to bilharzian appendicitis. A course of praziquantel treatment was instituted, and the patient underwent an event-free recovery. Such cases report are infrequent, even in areas where bilharzia-related diseases are endemic. It is important to recognise them and to treat them in an aetiological manner so as to prevent any potential complications. The diagnosis is always an operatory and histological curiosity. Appendectomy and treatment with a course of praziquantel seem quite suitable for this situation.
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Thoracic heteropagus conjoined twins associated to an omphalocele: Report of a case and complete review of the literature p. 209
Kotti Ahmed, Ben Dhaou Mahdi, Zitouni Hayet, Louati Hamdi, Jallouli Mohamed, Mhiri Riadh
DOI:10.4103/0189-6725.194670  PMID:28051055
Heteropagus twins are an extremely rare event with an incidence of 1–2 million live births that represents, sometimes, a real challenge for paediatric surgeons. The majority of cases have complete or partial duplication of the pelvis and/or lower extremities. Thoracic heteropagus conjoined twins is a rare condition in which a grossly defective foetus (the parasite) is attached to the thorax of the main foetus (the autosite). We describe a case of a parasitic heteropagus attached at the chest wall with a rare presentation of giant exomphalos on the autosite. In this situation, the separation procedure was simple after a well-done anatomic study using X-ray, ultrasonography, magnetic resonance and echocardiogram are performed.
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Unusual presentations of child abuse: A report of two cases and the role of imaging p. 213
Olubukola Titilayo Abeni Omidiji, Omolola Mojisola Atalabi, Ogbeide Ejeordamen Evbuomwan, Francis Ikechukwu Okwuegbuna, Olugbenga Oluseyi
DOI:10.4103/0189-6725.194678  PMID:28051056
Insufficient attention has been paid to child abuse in Nigeria, where corporal punishment is still acceptable both at home and in the wider public including schools. This is notlimited to the parents; these punitive measures can also be undertaken by the extended family, caregivers, and neighbors. Mild to extreme force is allowed particularly when the crime involves tarnishing the family image. We hereby report two cases of extreme discipline that can be termed as a form of child abuse to draw the attention of clinicians and radiologists to other possible findings aside from those already reported in literature.
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Neonatal neuroblastoma with adrenal primary and metastasis to the liver: A case report and a review of literature p. 217
Oladipo Omoseebi, Mosebolatan Olatokunboh Odubanjo, Olakanmi Ralph Akinde, Nzechukwu Z Ikeri, Adesoji O Ademuyiwa, Adekunle A.O. Adeyomoye
DOI:10.4103/0189-6725.194674  PMID:28051057
We report the case of a 23-day-old neonate with neuroblastoma (NBL) in the right adrenal gland and widespread metastases to the liver. This raises the possibility of foetal NBL, which was missed during periodic ultrasonography done during the mother's pregnancy. We hope that this report would increase the awareness of physicians about foetal, congenital and neonatal NBL; and of sonographers about space-occupying lesions in the foetus. The clinicopathologic features and the management of neonatal NBL are discussed.
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