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   Table of Contents - Current issue
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July-September 2021
Volume 18 | Issue 3
Page Nos. 127-178

Online since Tuesday, July 20, 2021

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REVIEW ARTICLE  

Current issues of gastro-oesophageal reflux disease surgical treatment in children p. 127
Nurlan Nurkinovich Akhparov, Riza Boranbayeva, Saule Bakhtyarovna Suleimanova, Madina Temirkhanova
DOI:10.4103/ajps.AJPS_104_20  
Gastro-oesophageal reflux (GER) disease is one of the most common diseases amongst a wide range of chronic inflammatory diseases of the gastrointestinal tract in children of all ages, significantly impairing the quality of life of the child and posing a serious threat to the health of the patient. From 2008 to 2019, 134 patients aging from 6 months to 12 years were hospitalised at the Scientific Center for Pediatrics and Pediatric Surgery including 69 (51%) infants. Of them, 51 (38%) were the patients with persistent manifestations of regurgitation, despite an outpatient course of conservative therapy; 29 (22%) patients with recurrent reflux-associated pneumonia; also, 35 (26%) children with GER in the structure of the main pathology of the central nervous system, as well as 19 (14%) patients after surgery of the anastomosis of the oesophagus with its atresia. One hundred and seven (79.8%) patients underwent surgery. Nissen oesophagofundoplication was traditionally performed in 41 (38%) patients, in combination with Stamm gastrostomy in 14 (34%), with Mikulich pyloroplasty in 9 (22%) and in combination with gastrostomy and pyloroplasty in 12 (29%) children. Laparoscopic Nissen oesophagofundoplication was used in 16 (15%) cases. Thall oesophagofundoplication was performed in 48 (45%) patients, while in two (2%) cases, Boerema gastropexy was conducted. The immediate results were studied in all 107 patients. Complications in the form of gastric distress syndrome were revealed in four (3.7%) patients who did not undergo pyloroplasty, which in two (1.9%) cases required additional surgery of the stomach draining, whereas in the other two (1.9%) patients, the distress syndrome was stopped conservatively. A dumping syndrome was identified in two (1.9%) patients. Timely recognition of the pathological process, its nature and prevalence determines the indications for the use of various methods of operation, which are based on an individual approach to each patient.
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ORIGINAL ARTICLES Top

Congenital right diaphragmatic defects: Our institutional experience p. 133
Jayalaxmi Shripati Aihole
DOI:10.4103/ajps.AJPS_29_20  
Background: The descriptive clinical study was conducted to analyse the clinical profile as well as the outcome of congenital right diaphragmatic defects among children including neonates in a tertiary care referral neonatal and paediatric centre in southern Karnataka, India. Materials and Methods: This retrospective and prospective observational clinical study was conducted from January 2005 to August 2019, over a period of 14.7 years in a tertiary care referral neonatal and paediatric centre. Clinical characteristics and risk factors of 33 children including neonates admitted and diagnosed with congenital right diaphragmatic defects were assessed both pre- and postoperatively. Neonates and children with acquired right diaphragmatic hernia defects and the left-sided diaphragmatic defects were not included in this clinical study. Results: For statistical as well as clinical analysis, 33 study subjects were grouped into four groups, depending on the pre-operative and intraoperative findings as well as on their final diagnosis. Group I comprised right congenital diaphragmatic hernia (RCDH) (n = 18), Group II comprised RCDH with sac (n = 6), the babies with diagnosis of right diaphragmatic eventration were included in Group III (n = 7), whereas babies with other right-sided diaphragmatic hernia defects diagnosis were included in Group IV (n = 2). Conclusion: Right-sided congenital diaphragmatic defects, though rare, do carry excellent survival if referred early and managed in a tertiary care neonatal and paediatric centre as that of left diaphragmatic defects.
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Manual separation of labial synechiae: A cost-effective method in prepubertal girls p. 139
Manal Abdul Rahman Dhaiban, Muhammad Amjad Chaudhary
DOI:10.4103/ajps.AJPS_34_20  
Background: Labial synechiae is a fairly common gynaecological problem that occurs as a result of inflammation leading to fusion between the labia minora. Being in a developing country with limited resources and poor compliance of patients to prolonged treatments, we are faced with immense challenges in the management of these girls. Aims: We wanted to evaluate the efficacy and the cost-effectiveness of manual separation and topical antibiotics with perineal hygiene in the management of pre-pubertal girls with labial synechiae. Materials and Methods: Design: Prospective, non-randomised interventional study. Participant: Pre-pubertal girls presenting with the diagnosis of labial synechiae in the period from September 2015 to January 2018. Interventions: Manual separation followed by topical antibiotic ointment application for 1 week with local hygiene. Outcomes measure: Complete release of the synechiae and no recurrence up to 6 months. Results: Out of the total 55 patients, only 48 patients were included, their age ranged from 3 months to 7 years (mean 2.8 years). Almost half of our patients were asymptomatic, and other half had symptoms (urinary tract infection, dripping of urine and itching). Majority of our patients belong to low middle class status. We had 100% complete release of synechiae and no recurrence on 6 months follow-up. Conclusion: Manual separation followed by topical antibiotics is a cost-effective method of the treatment of labial synechiae with immediate response and low recurrence rate.
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Changing trend in the management of omphalocoele in a tertiary hospital of a middle-income country p. 143
Olakayode Olaolu Ogundoyin, Akinlabi Emmanuel Ajao
DOI:10.4103/ajps.AJPS_7_21  
Background: The peri-operative management of omphalocoele in low- and middle-income countries is challenging owing to non-availability of neonatal intensive care units and equipment needed for the care of this anomaly. Aim: This study examined our experience in the management of omphalocoele and compared the pattern and outcome with a similar study from the same centre conducted four decades ago. Methods: A retrospective study of neonates managed for omphalocoele from 2003 to 2017 (Group A) was performed. Their demographic characteristics, clinical presentation, management modality and outcome were obtained and statistical analysis was performed to determine the predictors of mortality. The findings were also compared with the findings of a similar study (Group B) published from this centre four decades ago from 1973 to 1978. Results: A total of 95 patients were managed in Group A and 33 in Group B. Their ages ranged from 1 to 15 days with a median age of 1 day and a median gestational age at birth of 37 weeks (range – 36–43 weeks) in Group A and 5–72 h in Group B. There were 54 (56.8%) boys and 41 (43.2%) girls in Group A and 17 (51.5%) boys and 16 (48.5%) girls in Group B. Rupture of the sac was observed in 18 (18.9%) patients in Group A and 13 (39.4%) in Group B. Operative management was adopted for 55 (57.9%) patients in Group A compared to 14 (42.4%) in Group B. Mortality was recorded in 16 (16.8%) patients in Group A and 16 (48.5%) in Group B. Following further analysis in Group A, management outcome was noted to be significantly associated with the state of the sac (P = 0.011), presence of associated sepsis (P = 0.002) at presentation and management modality (P = 0.048) with only associated sepsis independently predicting mortality. Conclusion: Although epidemiological trend and clinical presentation are still similar, management outcome has improved over the years.
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Posterior urethral polyp in children p. 148
Najoua Aballa, Mohamed Oulad Saiad
DOI:10.4103/ajps.AJPS_88_20  
Background: Polyps of the urethra is a rare cause of obstruction of the lower urinary tract. The clinical presentation is not specific; the symptoms vary and may be isolated or associated, including acute retention of urine, dysuria, and hematuria. Ultrasound and voiding urethrocystography guide the diagnosis. Urethrocystoscopy confirms the diagnosis and allow the treatment. Our aim is to bring to light this rare condition and report our experience in the management of posterior urethral polyps. Subject and Methods: A retrospective study of posterior urethral polyp presented from 2008 to 2019 was performed. Charts were evaluated for clinical presentation, management, pathology findings, and long term follow-up. Results: Six patients were recorded. Dysuria and hematuria are the most reported features. Ultrasonography and voiding cystourethrogram made the diagnosis in 4 patients out of 6. Urethrocystoscopy made the diagnosis and transurethral resection in all our patients. Conclusions: Posterior urethral polyp is a rare benign tumor in children. Urethrocystscopy allow both diagnostic and therapeutic.
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Applicability of the revised trauma score in paediatric patients admitted to a South African intensive care unit: A retrospective cohort study p. 150
Cameron Kuronen-Stewart, Nirav Patel, Tarryn Gabler, Isabel Khofi-Phiri, Gladness Dakalo Nethathe, Jerome Loveland
DOI:10.4103/ajps.AJPS_33_20  
Context: Revised Trauma Score (RTS) is a validated tool in assessing patients in a pre-hospital setting. There are limited data describing its potential use in guiding referral to intensive care. Aims: Trauma scoring systems require appropriate validation in a local setting before effective application. This work examines the applicability of RTS to a paediatric intensive care trauma population. Settings and Design: A retrospective record review of trauma patients admitted to the paediatric intensive care unit at Chris Hani Baragwanath Academic Hospital between 2011 and 2013 was performed. Subjects and Methods: The cohort was arbitrarily split into three subgroups based on RTS using the 33rd and 66th percentile values and groups compared. Outcome measures examined included mortality, age, gender, length of stay (LoS), duration of ventilation (DoV) and change in Glasgow Coma Scale (GCS) from admission to discharge. Statistical Analysis Used: Categorical values examined with Fisher's exact test. Non-categorical values examined with the Kruskal–Wallis and Dunn's multiple comparisons tests. Results: Of 919 children admitted, 165 admissions were secondary to trauma. Data necessary for calculation of RTS were available in 91 patients. The mean RTS was 5.3, 33rd percentile was 4.7 and 66th was 5.9. DoV (P = 0.0104) and LoS (P = 0.0395) were significantly different between intermediate- and low-risk groups as was change in GCS between low-risk and both other groups (P < 0.0001). Conclusions: RTS is not predictive of mortality between high-risk (RTS < 4.09) and low-risk patients (RTS > 5.67) in this population. It may be useful in predicting other outcomes such as DoV and LoS.
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Diagnosis and surgical management of children with oesophageal achalasia: A 10-year single-centre experience in Morocco p. 155
Salahoudine Idrissa, A Oumarou, Abdelhalim Mahmoudi, Aziz Elmadi, Khalid Khattala, Youssef Bouabdallah
DOI:10.4103/ajps.AJPS_46_20  
Introduction: Achalasia is a primary oesophageal motility disorder with unknown aetiology. The aim of this study was to evaluate our 10-year experience in the diagnostic process and surgical management of oesophageal achalasia (OA) in children. Methods: A retrospective review of all children (age: 0–15 years) treated for achalasia at the department of paediatric surgery from 2007 to 2016 was conducted. The demographics, presenting symptoms, associated diseases, diagnostic process, outcomes and complications were analysed. Results: Fourteen patients were identified, with a mean age of 5.2 years. There were eight female and six male patients. The most common symptom was chronic vomiting, in all patients (100%), followed by weight loss in 10 (71.4%), cough in 6 (42.9%), dysphagia in 5 (35.7%) and chest pain in 3 (21.4%). The mean duration of symptoms until diagnosis was 36.3 ± 29.1 months. Three patients underwent an open Heller myotomy (HM) and 11 laparoscopic HM (LHM) including three conversions. The reasons for conversion were mucosal perforation in two cases and liver bleeding in one patient. The mean operating time and the average length of postoperative stay in the patients of LHM group were, respectively, 2.0 ± 0.7 h and 4 ± 1.5 days. The mean follow-up was 43.2 months. Conclusion: The diagnosis of OA in children is based on clinical arguments and especially on the barium oesophagram findings. Laparoscopic myotomy is the most effective surgical approach in children.
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Is application of salt for 3 days locally is sufficient to treat umbilical granuloma? p. 160
Anita Singh, Kirti Naranje, Aakash Pandita, Vijai D Upadhyaya, Basant Kumar, Ashish Datta Upadhyaya
DOI:10.4103/ajps.AJPS_50_20  
Background: The falling of Umbilical stump occurs by 7-15 days of age. The healing of umbilical stump may be complicated by Umbilical Granuloma. It is often treated by chemical cauterisation which require repeated applications and may lead to local or systemic complications. Common salt by way of its dessicative property may help in treatment of Umbilical Granuloma. Objective: The objective of the study is to assess the role of common salt application in umbilical granuloma. Materials and Methods: This is retrospective study over 3 years from a pediatric surgery unit in Northern India. The study subjects were infants less than 10 weeks of age who presented with umbilical granuloma. The method of salt application was 1 pinch of common salt for 1 hour twice a day for 3 consecutive days. The babies were assessed at day 5th for resolution. The success was defined as thrice resolution after 3 cycles. The baseline demographic details were taken and the association of success of treatment was analyzed. Results: A total of 36 infants were given treatment in form of common salt application for treatment of umbilical granuloma. The success of around 96% and the cases which presented early responded well. Most of the cases resolved after 3 cycles of treatment. Conclusion: The common salt application is effective in treatment of granuloma without any side effects.
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Femoral hernia in children: How to avoid misdiagnosis? p. 164
Basma Haggui, Saida Hidouri, Amine Ksia, Sana Mosbahi, Marwa Messaoud, Lassaad Sahnoun, Mongi Mekki, Mohsen Belghith, Abdellatif Nouri
DOI:10.4103/ajps.AJPS_74_20  
Background: Femoral hernias are an uncommon groin pathology among pediatric patients. Therefore, they are frequently misdiagnosed. In the present study, we review our experience with this rare surgical entity during the past 25 years. Methods: The medical records of 19 patients who underwent 22 femoral hernia repairs between January 1994 and December 2019 were retrospectively analysed. Results: Patients' age ranged from 2 to 12 years (mean age was 5. 5 years) with an approximately equal sex ratio (10 girls/9 boys). There were three bilateral cases identified separately. They were discovered and managed at different times. All the children were referred with a groin lump, but the correct pre-operative diagnosis was made in only 13 cases (59%). In the remaining cases, four were identified intraoperatively following negative exploration for a supposed inguinal hernia. The other five were found to have a femoral hernia 1 month to 12 months after ipsilateral inguinal hernia repair. All patients underwent elective surgery. The femoral canal was closed using either Lytle or McVay procedure. Recurrence occurred in only one patient 2 months after initial repair. Conclusion: Femoral hernias are often misdiagnosed. Pre-operative diagnosis can be obtained through careful clinical assessment. In equivocal cases, ultrasonography and laparoscopy could be useful. A correct pre-operative diagnosis will lead to suitable treatment, thus avoiding unnecessary reoperations and their related complications.
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Choledochal cyst in children in dakar: Diagnostic and therapeutic aspects p. 168
Ndeye Aby Ndoye, Ibrahima Bocar Wellé, Lissoune Cissé, Doudou Guèye, Cheikh Diouf, Pape Alassane Mbaye, Faty Balla Lo, Ndèye Fatou Seck, Aloïse Sagna, Oumar Ndour, Gabriel Ngom
DOI:10.4103/ajps.AJPS_4_20  
Context: Choledochal cyst is a rare malformation that mainly affects girls. Aims: The aim of this work is to report the diagnostic, therapeutic and evolutionary aspects of bile duct cyst in children in Dakar. Subjects and Methods: we conducted a prospective monocentre descriptive study from 1 July, 2016, to 30 June, 2019, in the Pediatric Surgery Department of Albert Royer Children's Hospital in Dakar. The studied parameters featured clinical, biological, radiological, therapeutic and evolutionary data. Overall, ten patients, including eight girls and two boys, were selected. Results: Two patients presented the classic triple-syndrome complex featuring an abdominal pain, an abdominal mass and jaundice. Most of the patients presented a symptomatology associating abdominal pain and vomiting. Biological cholestasis syndrome was present in six cases and biological cytolysis syndrome in five cases. The abdominal ultrasound-computed tomography (CT) scan confirmed the diagnosis and helped to set the Todani classification with a predominance of Types 1 and 4. Surgical treatment by laparotomy consisted of total excision of the cyst followed by a Y-en-Roux hepatico-jejunal anastomosis in nine cases, whereas we performed a drainage of the cyst in one case. Two patients presented a morbidity of anastomotic suture release and evisceration and had a good outcome after surgical repair. There was no mortality. Conclusions: The diagnosis of choledochal cyst dilatation (CCD) can be suspected in the postnatal period on the basis of a gastro-intestinal symptomatology with or without associated to jaundice. The combination ultrasound-abdominal CT-scan helps set the diagnosis. The laparatomic approach always has its place for the management of CCD, especially in our context.
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CASE REPORTS Top

Neutropaenic enterocolitis: A medical/surgical oncological dilemma p. 171
Yetunde Tinuola Israel Aina, Victor Chekwube Emordi, Osasumwen Theophilus Osagie
DOI:10.4103/ajps.AJPS_70_20  
Neutropaenic enterocolitis (NE) is a life-threatening condition characterised by an inflammation of the colon and/or the small bowel in the background of chemotherapy-induced neutropaenia. A 16-year-old girl with acute myeloblastic leukaemia (AML) developed fever, right-sided abdominal pain and tenderness with severe neutropaenia. Initial ultrasound findings suggested acute appendicitis for which she had surgery. She developed recurrent symptoms 3 weeks later. Abdominal computed tomography (CT) scan showed features of NE, but she succumbed to the illness. Another 17-year-old boy with AML developed fever and severe right-sided lower abdominal pain and tenderness, following completion of induction chemotherapy. He was neutropaenic and abdominal CT was typical of NE. He was managed nonoperatively and symptoms resolved. The diagnosis of NE can be a dilemma. A high index of suspicion is needed to avoid a misdiagnosis of acute appendicitis.
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Cecal volvulus in children p. 174
Mohamed Oulad Saiad, Najoua Aballa
DOI:10.4103/ajps.AJPS_43_20  
Cecal volvulus is a rare complication of malfixation anomalies and intestinal malrotation in children. Only few cases have been reported. The rarity of the condition, frequently leads to diagnostic delay and complications. The best option for cecal volvulus repair remains unclear. Our aim is to increase the awareness of surgeons about cecal volvulus and to discuss its management.
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BOOK REVIEW Top

Clinical pediatric surgery: A case-based interactive approach p. 177
Emmanuel A Ameh
DOI:10.4103/ajps.AJPS_150_20  
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