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   2013| April-June  | Volume 10 | Issue 2  
    Online since July 15, 2013

 
 
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ORIGINAL ARTICLES
Do we need imaging to diagnose appendicitis in children?
Antonio Di Cesare, Filippo Parolini, Anna Morandi, Ernesto Leva, Maurizio Torricelli
April-June 2013, 10(2):68-73
DOI:10.4103/0189-6725.115024  
Background: To evaluate the role of clinical assessment with selective use of imaging studies in the management of suspected acute appendicitis in children. Patients and Methods: Medical records of children referred to Emergency Room in 2010 for suspected appendicitis were retrospectively reviewed. Diagnostic investigations divided by age and sex were related to pathological findings. Negative appendectomy and complication rates were calculated. Results: 923 children needed surgical assessment : i0 n 75.7% of them surgical indication was excluded and 24.3% were admitted to surgical ward for observation. Appendectomy was eventually performed in 137 patients (61.9%), 82.4% of them without any preoperative imaging while 17.6% underwent selective studies, mainly abdominal ultrasonography (14.6%). Imaging was requested twice as frequently in not operated admitted children (39.3%) than in the operated ones (17.5%, P < 0.001). Overall complicated appendicitis rate (peritonitis and abscess) resulted 26.4% and negative appendectomy rate 8.8%. Females older than 10 years presented histologically not-confirmed appendicitis in 22.2% of cases, while the younger ones presented more frequently complicated appendicitis (29.3%). Conclusions: Clinical assessment is the key to diagnose appendicitis. Nevertheless, in girls older than 10 years, selected use of imaging should be implemented to avoid unnecessary appendectomies. Imaging of choice in equivocal cases should be ultrasonography.
  6 4,046 583
Traumatic brain injuries in children: A hospital-based study in Nigeria
David O Udoh, Adebolajo A Adeyemo
April-June 2013, 10(2):154-159
DOI:10.4103/0189-6725.115043  
Background: Traumatic Brain Injury (TBI) is a significant cause of morbidity and mortality worldwide. Our previous studies showed a high frequency of motor vehicle accidents among neurosurgical patients. However, there is a dearth of data on head injuries in children in Nigeria. Aims: To determine the epidemiology of paediatric traumatic brain injuries. Setting and Design: This is a prospective analysis of paediatric head trauma at the University of Benin Teaching Hospital, a major referral centre for all traumatic brain injuries in Nigeria between October 2006 and September 2011. Materials and Methods: We studied the demographic, clinical and radiological data and treatment outcomes. Data was analysed using statistical package for the social sciences (SPSS) 16.0. Results: We managed 127 cases of paediatric head injuries, 65 boys and 62 girls representing 13% of all head injuries managed over the 5-year period. They were aged 3 months to 17 years. The mean age was 7.4 years (median 7 years) with peak incidence occurring at 6-8 years i.e. 31 (24.4%) cases. Motor vehicle accidents resulted in 67.7%, falls 14% and violence 7%. The most frequent computed tomography finding was intracerebral haemorrhage. Mean duration of hospitalization was 18 days (median 11 days). Eleven patients died, mortality correlating well with severity and the presence of intracerebral haematoma. Conclusion: Head injuries in children are due to motor vehicle and motor vehicle-related accidents. Hence, rational priorities for prevention of head injuries in children should include prevention of vehicular, especially pedestrian, accidents in developing countries.
  4 3,965 278
CASE REPORTS
Unusual case of congenital/infantile fibrosarcoma in a new born
Eddiba Tarik, Rouas lamiae, Amrani Abdelouahed, Madhi Tarik, Gourinda Hassan, Dendane Mohammed Anouar
April-June 2013, 10(2):185-187
DOI:10.4103/0189-6725.115052  
Congenital infantile fibrosarcoma (CIFS) is a rare mesenchymal tumor that is primarily developed in the soft tissue of distal extremities and occasionally in unusual locations such as the lung and retroperitoneum. It occurs mainly in children below the age of 5 years. About 200 cases have been reported in the literature so far, very few of them in new-borns. The prognosis of this tumor is relatively good compared to adult forms. We report an unusual case of CIFS occurring in new-born mimicking an hemangioma and causing hemorrhage in the neonatal period. The tumor is located in the left arm and axilla and associated with a hand malformation. A shoulder amputation is performed after chemotherapy failure. The infant is now two-years old with no recurrence.
  3 5,475 335
ORIGINAL ARTICLES
Intussusception in children: Comparison between ultrasound diagnosis and operation findings in a tropical developing country
Usang E Usang, Grace B Inah, Akan W Inyang, Alice T Ekabua
April-June 2013, 10(2):87-90
DOI:10.4103/0189-6725.115029  
Background: Intussusception is one of the more common causes of intestinal obstruction in children. The diagnosis may be based mainly on clinical features; however, there are no classic signs and symptoms that are common to all cases. This study reports our experience at US diagnosis and operation findings of children with intussusceptions in a tropical developing economy. Materials and Methods: This was an 8 years retrospective review of intussusceptions in children in a tertiary health facility in a tropical developing country from January 2004 to December 2011. Results: Twenty-five out of 41 children (M:F = 2.2:1) admitted with intussusceptions within the period were studied. The median age was 6.0 ± 5.57 months (range 3 months- 7 years). US positively diagnosed intussusceptions in 20 (80%) cases. Conclusion: US can increase diagnostic confidence in intussusceptions.
  3 4,158 335
Acute cholecystitis from typhic origin in children
Komla Gnassingbé, Guissaga Katakoa, Kokou K Kanassoua, Komla Adabra, Wakatou A Mama, Kpatekana Simlawo, Kossi Eteh, Hubert Tekou
April-June 2013, 10(2):108-111
DOI:10.4103/0189-6725.115033  
Background: To evaluate the particularities of typhoid cholecystitis in children. Materials and Methods: This was a 5-year prospective study of typhoid cholecystitis in children under 15 years old at Djougou and Sylvanus Olympio teaching hospital. The diagnosis of typhoid cholecystitis was based on clinical and investigation findings, confirmed by operative findings at cholecystectomy. Results: Six children with typhoid acalculous cholecystitis were treated over a five-year period (4 males and 2 females). Their ages ranged from five to 13 years (median 8.8 years). The mean duration of symptoms was six to 21 days. The clinical signs were fever, abdominal pain, which predominated at the right upper abdominal quadrant, and type II Hackett splenomegaly. The diagnosis was confirmed by a positive Widal's test and Salmonella typhi isolation from the culture in all patients; four patients had ultrasound evidence of acalculous cholecystitis. Open cholecystectomy was successful in the six cases. The operative findings were gangrene (3), perforation (2) and empyema (1). All the patients made an uneventful recovery, and have remained symptom free one and three months on follow-up. Conclusion: Typhoid acalculous cholecystitis is a frequent complication in children. Late presentation and diagnosis is associated with complications. Cholecystectomy in association with antibiotic is the treatment of choice.
  2 2,174 269
Spontaneous biliary peritonitis: Is bed side diagnosis possible?
Vijai Datta Upadhyaya, Basant Kumar, Mangal Singh, Rudramani , Sushila Jaiswal, Richa Lal, Sanjay Gambhir, M Rohan
April-June 2013, 10(2):112-116
DOI:10.4103/0189-6725.115034  
Background: Spontaneous biliary peritonitis is a rare cause of acute abdomen. In spontaneous biliary peritonitis there is perforation in the wall of the extra-hepatic or intra-hepatic duct occurs without any traumatic or iatrogenic injury and have been described more often in neonates. The symptoms may be acute or insidious delaying the diagnosis. Present manuscript deals with diagnosis and management of these cases. Materials and Methods: This is a prospective study and all patients of suspected biliary peritonitis presented during Dec 2010 to Feb 2012 were included in the study. After preliminary investigations in all patients abdominal paracentesis was done and in cases where intra-abdominal fluid bilirubin level was several fold higher than serum bilirubin level were subjected to exploratory laparotomy. Further investigation like T-tube cholangiogram and magnetic resonance cholangiopancreatography (MRCP) was done to rule out choledochal cyst before leveling these cases as SPBD. Results: A total of 6 patients were included in present series commonest presenting symptom was progressive abdominal distension without signs of overt peritonitis followed by progressive jaundice, fever and abdominal pain. On exploration site of perforation was observed in 50% of cases and in 50% of cases bile duct was not dilated. Second surgery was not required in 34% of cases. There was no mortality or significant morbidity in our series. Conclusion: Spontaneous perforation of bile duct is rare disease and high index of suspicion is required for diagnosis. Simple bed side test can help in diagnosis but T tube cholangiogram or MRCP are must to rule out choledochal cyst.
  2 4,155 251
Diagnostic value of high resolution ultrasound in localisation of the undescended testis in children
Opeoluwa A Adesanya, Adesoji O Ademuyiwa, Christopher O Bode, Adekunle A. O. Adeyomoye
April-June 2013, 10(2):127-130
DOI:10.4103/0189-6725.115037  
Background: The use of ultrasonography in the pre-operative localisation of undescended testes has become controversial due to fears about its accuracy. This study was designed to ascertain the accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of ultrasonography in the localisation of the undescended testes in children. Patients and Methods: A prospective evaluation of all boys undergoing operation for undescended testes at the Lagos University Teaching Hospital, Idi-Araba, Lagos, over a 12 month period was performed. The pre-operative clinical and ultrasound findings were compared with the findings on surgical exploration. Results: Forty boys with 52 undescended testes were studied. The mean age of the boys at the time of surgery was 4.0 ± 0 years (range 1-11 years). Forty-six (88.5%) testes were localised pre-operatively by ultrasound- 20 of 22 (90.9%) palpable testes and 26 of 30 (86.7%) non-palpable testes. Intra-operatively, 49 (94.2%) of the undescended testes were found while 3 (5.8%) were absent/vanishing testes. Ultrasound evaluation had an accuracy of 86.5%, sensitivity of 89.8%, and specificity of 33.3%, PPV of 95.7% and a NPV of 16.7%. Conclusion: Ultrasound assessment is beneficial in pre-operative evaluation of children with undescended testes.
  2 2,603 219
Hydatid cyst in children: A 10-year experience from Iran
Saeid Aslanabadi, Sina Zarrintan, Shahram Abdoli-Oskouei, Firooz Salehpour, Armin Zarrintan, Samad Beheshtirouy, Habib Abdollahi, Davoud Badebarin
April-June 2013, 10(2):140-144
DOI:10.4103/0189-6725.115040  
Background: Hydatid disease is one of the major world-wide health problems especially in endemic countries. Due to lack of statistics about this disease, various aspects of hydatidosis in children in North-West of Iran have been studied in this study. Materials and Methods: We studied 59 children with hydatidosis referring Tabriz Children Hospital, Tabriz, Iran from 2001 up to 2011. We surveyed chief complaint of patients, number, size and location of cysts in children and also we studied cysts as if they are infected or ruptured or not. Results: Average age of 59 patients (32 [54.2%] males and 27 [45.8%] females) was 7.93 ± 3.0. The most common chief complaints were cough and pain. Number of cysts was higher in females (2.00 ± 2.8 vs. 1.52 ± 1.0). The most common locations of cysts are lung and liver (52 patients); however, other organs had been also affected. Conclusions: Lung hydatidosis is more common than hepatic hydatidosis in children than adults and it is more frequent in males. Hydatid disease should be considered in differential diagnoses of liver and lung cystic lesions in children.
  2 3,723 336
Superior repair: A useful approach for some anatomic variants of total anomalous pulmonary venous connection
Kelechi E Okonta, Vijay Agarwal, Umar Abubakar
April-June 2013, 10(2):131-134
DOI:10.4103/0189-6725.115038  
Background: Total anomalous pulmonary venous connection (TAPVC) occurs when all the four pulmonary veins drain to the right atrium or to tributaries of the systemic veins. There have been various published techniques for the repair but none has been agreed on for the different anatomical variants that may be encountered during surgery. Patients and Methods: Between January 2005 and June 2010 the data of 6 of 18 patients who had surgical repair using the superior approach were retrospectively reviewed.Three patients had long narrow venous stalk connecting the coronary sinus to venous confluence; two had the right pulmonary veins draining to superior vena cava (SVC) and left pulmonary veins to left lateral wall of SVC and one had an obstruction at entrance of Pulmonary Vein into venous confluence. Results: Five patients initially had the superior approach while one had transatrial with unroofing of the coronary sinus. Two had a concomitant Wardens procedure. The mean aortic cross clamping was 87.5 (60-125) min, the mean cardiopulmonary bypass time should have min as unit of 127.8 (100-180), the mean Intensive Care Unit (ICU) stay of 2.5 (2-4) days and the mean hospital stay 8.2 (7-9) days. One patient died at early post-operation from low cardiac outputand five had an uneventful post-operative course and had remained stable until date. Conclusion: In our experience, the superior approach was an effective alternative approach for some anatomic variants of TAPVC that may be unexpectedly encountered during operation and also useful surgical approach for older children.
  1 2,345 204
Paediatric urologic pathologies at the national teaching hospital in Cotonou: A etiological and therapeutic aspects
Augustin Karl Agossou-Voyeme, Michel Armand Fiogbe, Judith Goundete, Gervais Martial Hounnou, René Hodonou
April-June 2013, 10(2):135-139
DOI:10.4103/0189-6725.115039  
Background: Urological pathologies of children are dominated by congenital malformations of the kidneys and urinary tract. Their management is often surgical. The objective of this survey was to study etiological and therapeutic aspects of urological presentations in children. Patients and Methods: Data for aetiology, treatment, and results in children hospitalized at the Paediatric Surgery service of National Teaching Hospital (CNHU) in Cotonou were retrospectively analyzed from January 1999 to December 2008. Results: A total of 214 patients with complete data were evaluated. Urological pathologies represented 4.8% of the hospitalizations in paediatric surgery, with an incidence of 21 cases per year. The mean age was 4.9 ± 3.2 years (age 1 week to 14 years). The male to female ratio was 14:14. Cryptorchidism, hydrocele, nephroblastoma, the posterior urethral valves, ureteropelvic junction obstructions, post-circumcision haemorrhage and hypospadias were the most frequent pathologies. Congenital urological malformations represented 81.3%, followed neoplastic pathologies (7.9%), traumatic pathologies (6.1%) and others (4.7%). The disorders of male genitalia were more frequent and constituted 68.2% of the cases. The anomalies of the urinary tract were 30.8% and intersex disorders were 0.9%. The average age of the children urological pathologies at the time of consultation was 8.85 ± 4.6 years. The treatment was often surgical with a mortality of 2.8%.
  1 2,229 207
Paediatric laparoscopic orchidopexy as a novel mentorship: Training model
Vipul Gupta, Sunil Kumar Yadav, Elterman Dean, Pradip Vincent, Farhat Walid, Abdulnaser Al Said
April-June 2013, 10(2):117-121
DOI:10.4103/0189-6725.115035  
Background: Although Laparoscopy is becoming a standard procedure in management of pediatric urology disorders, but its widespread use still limited. This can be attributed mainly to difficulty in acquiring such specialized technique, especially by post graduate practicing urologist. Thus, we herein evaluate the impact of condensed laparoscopic training programme in children hospital with the aim to analyze the feasibility and safety of laparoscopic orchidopexy in training basic laparoscopic skills. The aim of this study was to review experience as a mentor in training laparoscopic skills through condensed training programme based on high volume low risk procedure of pediatric laparoscopic orchidopexy. Materials and Methods: In order to implement a condensed laparoscopic curriculum in a short period of time while maintaining utmost patient safety, laparoscopic orchidopexy was used as the technique of choice. The course was conducted over a period of 5 days starting from 1 st November 2010 in a tertiary pediatric surgical center under guidance of an expert mentor. A total of 30 testicular units in 27 pediatric patients of different age group diagnosed with impalpable undescended testis underwent laparoscopic intervention. The course was conducted in three stages with the aim to deliver laparoscopic skills to trainee. In stage one out of eight cases operated by mentor with assistance of trainee six were operated on day 1 and two cases were operated on second day. The trainee performed 12 cases of laparoscopy independently with assistance of mentor in stage two which was carried out on day 2, 3 and 4. Finally all 7 cases including two second stage laparoscopic orchidopexy procedures were carried out independently by trainee under observer ship of mentor in stage three during day 4 and 5 of training programme. The feasibility and efficacy of laparoscopic orchidopexy in training laparoscopic skills through condensed training programme was assessed through analysis of mentorship experience.
  1 2,450 195
Clinico-pathological patterns of a rare presentation of abdominal neuroblastoma in children
Saleh M Aldaqal, Ali M Turki
April-June 2013, 10(2):100-107
DOI:10.4103/0189-6725.115032  
Background: To study the diagnosis, management, and outcome of abdominal neuroblastoma (NBL) in infants and children and also the behavior of some rare types. Patients and Methods: This is a retrospective review of 46 infants and children having abdominal NBL at King Abdulaziz University Hospital, Jeddah, Kingdom of Saudi Arabia and Tanta University Hospital, Tanta, Egypt (a joint study) between February 2008 and January 2012. The patients' medical records were reviewed for demographic details, clinical presentations, histopathology, radiological diagnosis, management, and outcome. Results: Of the 46 patients, 5 (10.7%), three males and two females, aged 1.5-6.5 years (mean: 4.5 years) had rare types of NBL (one bilateral NBL, one pelvic NBL, one pelvic-abdominal, and there were two cases of ganglioneuroblastoma). Three patients (two ganglioneuroblastoma and one pelvic) underwent complete surgical removal of the tumor with a good disease survival, whereas the other two patients (two bilateral and one pelviabdominal) had advanced disease and received palliative chemoradiotherapy. The remaining 41 patients, 23 males (56.1%) and 18 females (43.9%), with mean age 3.9 years (range: 1-7 years), had unilateral abdominal NBL. Twelve of them had resectable tumor and underwent primary surgical removal of the tumor, whereas the remaining 29 patients had unresectable tumor and received pre-operative chemotherapy with good response of the tumor in seven patients and no response in the remaining 22 patients. Conclusion: Primary complete surgical removal of tumor is advisable in localized NBL with a good outcome, whereas in advanced cases, it is better to start with pre-operative chemotherapy to downsize the tumour mass and safe delayed surgical excision. An increase in patient's age is associated with advanced stage of NBL and poor prognosis except in ganglioneuroblastoma cases due to maturation of tumor cells.
  1 3,465 299
Tonsillectomy: Vasoconstrictive hydrolytic cold dissection method
Titus S Ibekwe, Godwin Obasikene, Ekeng Offiong
April-June 2013, 10(2):150-153
DOI:10.4103/0189-6725.115042  
Background: Tonsillectomy, a common paediatric otolaryngology procedure, has undergone several evolutionary trends in the surgical techniques aimed at minimizing complications and improving patients' satisfaction. Despite the technological advancements in this respect, search for an ideal method is still ongoing, and some authorities are reverting back to the conventional methods. We wish to introduce the "Vasoconstrictive hydrolytic cold dissection" (VHCD) method. Patients and Methods: The VHCD method was described, and the outcome measures in one hundred and thirty-five patients who had the procedures were presented in . Data entrance was done with SPSS 14. Results: A total 135 patients comprising of 107 children aged 1-12 years and 28 adolescents/adults aged 14-52 years were operated upon using the VHCD between March 2009 and July 2012 by the same teams of Surgeons and Anaesthetists. The average surgical time and blood volume losses were 15 minutes and 5 mls for children and 12 mins and 10 mls for adults/adolescents, respectively. There was a single case (0.7%) of post-tonsillar bleed (reactionary haemorrhage). The rest (99.3%) recorded nil haemorrhage within and beyond first 2 weeks post-surgery. Conclusions: Surgeons used to other techniques of tonsillectomies may not revert to the cold steel; however, those practicing CSM will benefit from VHCD. We hereby recommend this simple, cost-effective modification of the cold steel tonsillectomy, which appears to have made dissection easier and also minimizes haemorrhage, a common complication of tonsillectomy surgery. It is timely in the advent of increased advocacy towards reversal to the conventional method of tonsillectomy. A randomized control trial is required for further evaluation of this method.
  1 3,325 181
Pattern of paediatric trauma in Sokoto, North West Nigeria
Muhammad Oboirien
April-June 2013, 10(2):172-175
DOI:10.4103/0189-6725.115047  
Background: Paediatric trauma has become a major cause of mortality, disability and socioeconomic burden in developing countries and the World Health Organization (WHO) projects that by 2020 it will be the leading disease globally. This study described the pattern of paediatric injuries seen at a regional trauma center in North West, Nigeria. Settings and Design: Trauma centre of a tertiary hospital in North-Western Nigeria. Materials and Methods: A retrospective look at the trauma register for records of paediatric trauma from January to December 2010 was performed. Information obtained include age and sex, causes and pattern of injury. The limit of 16 years was set for paediatric in our centre. Results: The numbers of paediatric trauma seen over the 12-month period were 567 out of a total of 3984 trauma cases representing 14.2%. The number of males was 407(71.8%) and females were 160(28.2%) with M: F ratio of 2.5:1. The mean age was 7.77 and standard deviation of 0.19. Road Traffic Accidents (RTA) and Domestic injuries representing 44.8 and 42.0%, respectively, were the commonest causes of injuries. Laceration and bruises, head injuries including extremities were the commonest types of injuries seen. Conclusion: Road traffic accidents and domestic injuries as common causes of paediatric trauma need to be 'addressed by the authorities' so as to reduce the burden of trauma on the vulnerable children in our society.
  1 2,737 204
Testicular tumours in prepubertal children: About eight cases
Rachid Khemakhem, Yosra Ben Ahmed, Said Jlidi, Faouzi Nouira, Faten Fdhila, Awatef Charieg, Sofiene Ghorbel, Sihem Barsaoui, Béji Chaouachi
April-June 2013, 10(2):176-179
DOI:10.4103/0189-6725.115048  
Background: To analyze the spectrum of testicular tumors in prepubertal children and the therapeutic resultants in an unselected population. Materials and Methods: Our hospital database was analyzed for testicular tumors from January 1995 to December 2010 concerning clinical presentation, treatment and therapeutic results. Results: Eight patients were operated on because of testicular tumors. In six cases (75%) the tumor was benign: benign teratoma (four cases), epidermoid cyst (one case) and immature teratoma (one case). Two patients (25%) had a malignant tumour: yolk-sac tumour (two cases). All this children underwent surgery. Radical inguinal orchidectomy was performed in six cases and conservative surgery was performed in two cases. One patient has received adjuvant chemotherapy. Follow-up was uneventfully three years after primary surgery. Conclusion: In prepubertal children, most testicular tumours are benign. If tumour markers were negative testis-preserving surgery can be proposed, complete excision of the tumour should be ascertained. In the case of testicular teratoma, the possibility of contralateral tumour should be considered in the follow-up.
  1 4,382 243
The comparison of the intestinal adaptation effects of subcutaneous and oral insulin in a rats with short bowel syndrome
Unal Bicakci, Ozgur K Tuncel, Birsen Bilgici, Burak Tander, Ender Ariturk, Riza Rizalar, Omer Alici, Ferit Bernay
April-June 2013, 10(2):91-94
DOI:10.4103/0189-6725.115030  
Aim: Insulin has been reported to have positive effects on intestinal adaptation after short bowel syndrome when applicated oral or subcutaneously. The purpose of this study is to compare the intestinal adaptation effects of subcutaneous and oral routes of insulin in rats with short bowel syndrome. Materials and Methods: The short bowel syndrome (SBS) was performed through 70-75% of small intestinal resection and an end-to-end anastomosis. The control group rats underwent SBS only. In the second group, oral insulin (1 U/ml) was administrated twice-daily. In the last group, the insulin was administrated subcutaneously (1 U/kg) as in the control group. All rats were killed on day 15. Outcome parameters were weight of small intestine, the crypt length, villous depth, the blood levels of vascular endothelial growth factor (VEGF), and granolocyt-monocyst colony-stimulating factor (GMCSF). Results: Intestinal weight was significantly more in oral insulin group and subcutaneous insulin group than in the control group (72.6 ± 4.3, 78.6 ± 4.8 and 59.7 ± 4.8) (P < 0.05). There was no difference between the groups according to villus length, crypt depth, and villous/crypt ratio both in proximal and distal parts of the resected bowel (P > 0.05). VEGF values were not statistically significant between the groups (200.3 ± 41.6, 178.9 ± 30.7 and 184.3 ± 52.2) (P > 0.05). GMCSF was statistically higher in the control group than in other groups (3.34 ± 1.34, 1.56 ± 0.44 and 1.56 ± 0.44) (P < 0.05). Conclusion: Insulin has positive effects on intestinal adaptation in short bowel syndrome. Subcutaneous administration is slightly more effective than the oral route.
  1 2,489 213
Paediatric laparoscopic hernia repair: Ex vivo skills in the reduced training era
Chris Parsons, Joanna Manson, Ramesh Nataraja, Niall Jones, Joe Curry, Niyi Ade-Ajayi
April-June 2013, 10(2):95-99
DOI:10.4103/0189-6725.115031  
Introduction: Changes to surgical working hours have resulted in shorter training times and fewer learning opportunities. Tools that develop surgical skills ex-vivo are of particular interest in this era. Laparoscopic skills are regarded as essential by many for modern paediatric surgery practice. Several generic skills models have been reported and validated. However, there is limited evidence regarding the role of procedure specific models. Here, a laparoscopic paediatric hernia repair model is trialled with surgical trainees and their competence compared with consultant colleagues. Patients and Methods: An ex-vivo paediatric inguinal hernia repair model was devised. Surgical trainees from 5 specialist centres were recruited and performed multiple standardised repairs. Results: 23 trainees performed 192 repairs. Experts performed 10 repairs for comparison. Trainees were timed performing the repair and their accuracy measured. With repeated attempts trainee's timings and accuracy improved until by the 10 th repair they were no different from benchmark consultant scores. Conclusion: A simple, procedure specific ex-vivo training model has been evaluated for laparoscopic hernia training in paediatric surgery. The results suggest improvements in competence with repetition. Trainee and benchmark consultant scores are no different by the 10 th trainee attempt. We conclude that this model may have a valuable role in the training and assessment of future paediatric surgeons.
  1 2,377 186
Anterior sagittal anorectoplasty: An alternative to posterior approach in management of congenital vestibular fistula
Man Mohan Harjai, Navdeep Sethi, Naveen Chandra
April-June 2013, 10(2):78-82
DOI:10.4103/0189-6725.115027  
Background: Better exposure, possibility of extension if needed and precise placement of the anal canal within the external sphincter complex have made the posterior and anterior sagittal approaches more popular and established for the correction of anovestibular fistula. The mini posterior sagittal anorectoplasty (PSARP) was the procedure of choice for female ARM at our center till date. As an alternative surgical option, we performed anterior sagittal anorectoplasty (ASARP) in 15 cases of anovestibular fistula and compared them with 12 cases of vestibular fistula operated by PSARP technique. Patients and Methods: Fifteen female infants with vestibular fistula who had anterior sagittal anorectoplasty (ASARP) procedure were reviewed. The procedure and its outcome were evaluated. Results : The manoeuvering during anesthesia and operative access were quite easier in ASARP compared to PSARP. Delineation of plane in ASARP between rectum and vagina was easier and clearer in comparison to PSARP. Rent occurred in the posterior vaginal wall in three cases of ASARP and two cases of PSARP. There were two cases of wound infection in each group. Three cases of PSARP group developed anal stenosis and constipation while one in the ASARP group developed constipation. Conclusion : Anesthesia and access in ASARP makes it an easier alternative option to PSARP in the management of anovestibular fistula in girls.
  1 13,506 443
Primary duodenal tuberculosis presenting as gastric-outlet obstruction: Its diagnosis
Vijai Datta Upadhyaya, Basant Kumar, Richa Lal, Moniak Sen Sharma, Mangal Singh, Rudramani
April-June 2013, 10(2):83-86
DOI:10.4103/0189-6725.115028  
Introduction: Gastrointestinal tuberculosis often involves the ileocecal region. Duodenal and gastric tuberculosis found in only 1% of patients suffering from pulmonary tuberculosis with associated HIV infection in non-endemic areas. Duodenal obstruction due to tuberculosis is very rare and needs high index of suspicions for diagnosis. Mostly this entity is suspected on intraoperative findings. In this manuscript we emphasized on ways and means for establishing histopathological diagnosis before starting anti-tubercular treatment in such cases. Method and Material: All patients of suspected gastroduodenal tuberculosis presented with feature of gastric-outlet obstruction managed during Jan 2009 to June 2011 were included in the study. After proper evaluation (routine hematological and biochemical examination, microbiological examination, serological and endoscopic evaluation) exploratory laparotomy was done and if there is no mesenteric lymphadenopathy or it is not safe to take biopsy form the diseased duodenum, multiple FNAC were taken from the diseased portion for histopathological and microbiological diagnosis. Result: A total of five patients were treated during this period. The most common presentation was vomiting followed by failure to thrive and weight loss; two patients had abdominal pain. Biopsy of mesenteric lymph node was possible in two cases. FNAC from diseases portion was taken in all cases. FNAC showed granulomas in four cases. Cases where even FNAC finding was non-conclusive on HPE/Microbiology was not subjected to antitubercular drug. Conclusion: Multiple intra-operative FNAC may be taken from the diseased portion of the duodenum to establish the histopathological diagnosis if diagnosis is not established by any other mean.
  1 3,509 281
CASE REPORTS
Early abdomino-perineal pull-through vaginoplasty
Ilhan Ciftci, Ayhan Tastekin, Ali Annagur, Mustafa Koplay
April-June 2013, 10(2):188-191
DOI:10.4103/0189-6725.115053  
Vaginal agenesis is known as one of the Mόllerian anomalies. Mόllerian anomalies occur during gonadal development and differentiation, and may lead to complex outcomes. McKusick-Kaufman syndrome (MKS) is an autosomal recessive multiple malformation syndrome characterized by Mόllerian anomalies with hydrometrocolpos (HMC) and postaxial polydactyly (PAP). We report a case of a female newborn that developed hydronephrosis and respiratory distress due to compression of the cystic mass and underwent surgery on postpartum day 3. Pull-through vaginoplasty was performed with an abdomino-perineal approach. We report the unique treatment approach in this case.
  - 7,617 196
Pyloric atresia: A report of ten patients
Amine Ksia, Hayett Zitouni, Ahmad Zrig, Rachida laamiri, Fatma Chioukh, Eya Ayari, Lassaad Sahnoun, Kais Maazoun, Imed Krichene, Mongi Mekki, Mohsen Belghith, Abdellatif Nouri
April-June 2013, 10(2):192-194
DOI:10.4103/0189-6725.115054  
Pyloric atresia (PA) is uncommon. It occurs in 1:100000 live births. Neonates usually present soon after birth with copious non-bilious vomiting. The treatment is surgical and its prognosis is poor, especially, when it is associated with epidermolysis bullosa (EB). The aim of this study was to evaluate the clinical presentation, diagnosis, operative management, post-operative courses, and outcome in infant with PA, based in our cases and literature review. Charts of 10 patients who underwent surgery for PA in the department of paediatric surgery in a Teaching Hospital in Tunisia (Monastir) between 1990 and 2012 were reviewed. Data were analysed for demographic, clinical, therapeutic, and prognostic characteristics. The average of age at presentation was 2 days and there were six males and four females. The main presenting symptoms were non-bilious vomiting in 90% of cases. Abdominal X-ray showed gastric dilatation with an absence of gas in the rest of the intestinal tract in 90%, and a pneumoperitoneum in one. The surgical approach was laparotomy in all cases. Gastric perforation was observed in one patient and was completely repaired. The distribution of the anatomic variations was type A in nine cases and type B in one. Five patients underwent excision of the diaphragm and Heineke-Mikulicz pyloroplasty and gastroduodenostomy in the other five cases. Identified associated anomalies were Down's syndrome in one and EB in 2 (20%), one family has three affected sibling. Post-operative mortality rate was 70%. No standard surgical approach can be adopted a better management of PA or the associated anomalies depends on an early diagnosis and the availability of neonatal intensive care unit.
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Uncorrectable coagulopathy due to intestinal obstruction: A clinical dilemma of competing priorities in a child
V Raveenthiran, S Balachandran
April-June 2013, 10(2):195-198
DOI:10.4103/0189-6725.115055  
Disseminated intravascular coagulation (DIC) is a contraindication for major surgical operations. However, if surgery is required to correct the underlying cause of DIC, a clinical conflict is created. In such complex scenario, standard resources such as textbooks and journals offer very little guidance. In this communication, we report a 22-month-old boy who developed sepsis-induced DIC following intestinal obstruction. Pre-operative attempts to normalize coagulation parameters failed. Damage control laparotomy was undertaken as it was considered essential to control the underlying cause of DIC. His abnormal coagulation status reverted quickly after surgical relief of intestinal obstruction. Paradoxically intraoperative blood loss was less than anticipated amount. There are a few case reports of adult patients who have successfully undergone major surgery despite the presence of abnormal coagulation. However, this appears to be the first paediatric report of successful surgery in DIC status. Lessons learnt from this case and hypothetical speculations of clinical paradoxes are discussed.
  - 2,188 141
Repair of isolated double-chambered right ventricle
M El Kouache, A Babakhoya, S Labib, A El Madi, S Atmani, M Harandou, Y Abouabdilah, M Hida
April-June 2013, 10(2):199-200
DOI:10.4103/0189-6725.115057  
The finding of a double-chambered right ventricle (DCRV) is exceptionally rare as an isolated anomaly. It is a congenital cardiac anomaly in which the right ventricle is separated into two chambers, a proximal high-pressure chamber and a distal low-pressure chamber, by anomalous muscles or fibrous tissues in the right ventricular cavity. We report the case of a 6-year-old infant who was admitted for growth retardation. The patient was diagnosed with an isolated DCRV without any other associated congenital anomalies. The patient underwent a successful cardiac surgical procedure of enlargement repair; he was discharged in good clinical condition with a normal cardiac function.
  - 2,773 174
Omental cyst presenting with profound anaemia
Boma T Adikibi, Richard Wood, Komala Pillay, Alastair J. W. Millar
April-June 2013, 10(2):180-184
DOI:10.4103/0189-6725.115050  
A male infant presented acutely with profound anaemia and abdominal distension. At laparotomy, a huge omental cyst was found. We reviewed our experience of this rare cause of abdominal pathology identifying five further cases since 2005, with a variety of presentations. The optimal treatment, complete resection, is associated with a low morbidity. The presentation with profound anaemia and shock due to haemorrhage into the cyst is unusual.
  - 2,827 174
LETTERS TO THE EDITOR
Looking beyond an abscess
Binit Sureka, Rohini Gupta, Aliza Mittal, Brij Bhushan Thukral
April-June 2013, 10(2):201-202
DOI:10.4103/0189-6725.115059  
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The disorders of sex development and the problems of their management in Togo
Komla Gnassingbé, Sylvia Da Silva-Anoma, Komlan Mihleudo-Agbolan, Tsipa Anoukoum, Kondo Bignandi, Komlatse G Akakpo-Numado, Hubert A Tekou
April-June 2013, 10(2):202-203
DOI:10.4103/0189-6725.115061  
  - 992 99
ORIGINAL ARTICLES
Histopathological review of breast tumours in children and adolescents in Delta State Nigeria
Francis Nwachokor, Alex Payim Igbe, Gerald Dafe Forae
April-June 2013, 10(2):65-67
DOI:10.4103/0189-6725.115022  
Background: Breast swellings in children and adolescents may be overlooked on assumption that they are physiological enlargement. Pathologic swellings including cancers have however been encountered in this age group. This study highlighted the spectrum of tumours in childhood and adolescents. Materials and Methods: This was a 7 year retrospective analysis of all histologically diagnosed breast tumours in people aged 0 - 19 years. Results: There were 134 breast tumour diagnoses occurring in 133 females and 1 male (gynaecomastia). One hundred and nineteen cases (88.8%) were recorded in the 10 - 14 year age group and 15 cases (11.2%) in the 15 - 19 year age group. No case was found in children aged less than 10 years. The most common tumour was fibroadenoma accounting for 75.4% (n = 101) of all tumours followed by tubular adenoma (n = 11; 8.2%) and adenosis (n = 10; 7.4%). No case of malignancy was recorded in this study. Conclusion: Fibroadenoma is the most common breast tumour in children and adolescents in our environment.
  - 2,489 296
The comparative study of the outcomes of early and late oral feeding in intestinal anastomosis surgeries in children
Omid Amanollahi, Bahram Azizi
April-June 2013, 10(2):74-77
DOI:10.4103/0189-6725.115025  
Background: A leakage of intestinal anastomosis is typically regarded as a devastating post-operative complication. Traditionally its believed that long fasting after intestinal surgery protect anastomosis site and most surgeons applied this method. Post-operative long fasting has many physical and mental adverse effects, especially in children, but its benefit has not proven yet. This study aimed to compare the outcomes of early and late oral feeding in intestinal resection and anastomosis surgery in children. Patients and Methods: This randomized, double-blind controlled trial evaluated the outcome of early-feeding following in children aged 1 month to 12 years who underwent intestinal resection and anastomosis and compared the results with those who had late-feeding. The results were anlysed for fever, nausea and vomiting, abdominal distension, first passage of gas and stool were also evaluated hospital stay time, major post-operative complications such as anastomosis leakage, wound infection or dehiscence, intra-abdominal abscess between the two groups. Results: The mean time of first oral feeding in the early feeding group (study group) was 2.5 ± 0.7 days but it was 5.3 ± 0.6 days in the late feeding group (control group). There was no mortality in both groups. There was no difference in major complications in both groups (anastomosis leakage). In the study group, first defecation time was shorter than the control group (3.7 days v. 4.4 days) and they had less hospital stay also (5.2 days vs. 8.3 days) and lower cost of hospitalization. Conclusion: Early oral feeding after intestinal resection and anastomosis in children is a safe method, it has many benefits and does not increase the major or minor post-operative complications (anastomosis leakage) long time fasting is not necessary and has not any beneficial effect and early feeding increases satisfaction of the parents and children, and reduce hospital stay and costs.
  - 5,009 582
Management of congenital bladder diverticulum in children: A report of seven cases
Rachid Khemakhem, Sofiane Ghorbel, Said Jlidi, Faouzi Nouira, Héla Louati, Wiem Douira, Faouzia Chennoufi, Ibtisem Bellagha, Béji Chaouachi
April-June 2013, 10(2):160-163
DOI:10.4103/0189-6725.115044  
Background: The purpose of the study is to present the author's experience with congenital bladder diverticula in seven pediatric patients at a developing world tertiary care center. Materials and Methods: Records of seven patients diagnosed and treated as congenital bladder diverticulum, from January 1998 to December 2009 were retrospectively reviewed for age, sex, clinical symptoms, investigative work-up, operative notes, and postoperative follow-up. Results: All patients were males. Age at presentation ranged from six months to six years (mean three years and six months). All were manifested postnatally by urinary tract infection in four cases, bladder retention in three cases and abdominal pain in two cases. Diagnosis was suggested by ultrasound and confirmed by voiding cystourethrography (VCUG) in all cases and urethrocystoscopy in three cases. Open surgical excision of diverticulum was done in all the patients associated with ureteral reimplantation in four patients with VCUG-documented high-grade vesicoureteral reflux (VUR). Average follow-up was four years; there is a resolution of symptoms and no diverticulum recurrence at the defined mean follow-up. Conclusion: Recurrent urinary tract infections and voiding dysfunction in pediatric population should always be evaluated for congenital bladder diverticulum. Investigations such as abdominal ultrasound, VCUG and nuclear renal scanning, form an important part of preoperative diagnostic work-up and postoperative follow up. Diverticulectomy with ureteral reimplantation in case of high-grade reflux, provides good results without recurrence.
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Histopathological examination of the prepuce after circumcision: Is it a waste of resources?
Hussein Naji, Esraa Jawad, Husam A Ahmed, Rajaa Mustafa
April-June 2013, 10(2):164-166
DOI:10.4103/0189-6725.115045  
Background: The aim of this article is to evaluate the histopathological findings of foreskin after circumcision for medical indications and to find out if analyzing the biopsy is a waste of resources. Material and Methods: This retrospective analysis was carried out of the medical records and histopathological findings of 112 boys who underwent circumcision from June 2002 to June 2005. The study group consisted of 52 boys that were circumcised for medical indications, while the control group consisted of 60 boys who underwent circumcision for religious belief. Results: The mean (range) age of children in the study group was six (2-12) years. 36 boys had phimosis, 15 had recurrent balanoposthitis and one had paraphimosis as an indication for circumcision. Balanitis xerotica obliterans (BXO) was diagnosed in eight out of 52 biopsies (15%). In five of the eight BXO, the histopathological examination revealed focal lichenoid infiltrate which was considered as early form of BXO. There was no suspicion of BXO in the physical examination of those five patients. Chronic inflammation was reported in seven patients, while minor changes in the form of minimal inflammation and oedema were found in another 15 patients. The rest of the biopsies (22 patients) showed normal preputial pathology. The histopathological examinations of the control group revealed chronic inflammation in three patients and acute inflammation with cellular oedema in another three patients. Conclusions: There is a place for routine biopsy after circumcision for medical indications. The clinical examination failed to suspect 5 of the 8 cases of BXO that were diagnosed by histopathology.
  - 7,817 249
Single-layer closure of typhoid enteric perforation: Our experience
Musa Ibrahim, KI Getso, AH Yashuwa, AM Mohammad, L. J. C. Anyanwu
April-June 2013, 10(2):167-171
DOI:10.4103/0189-6725.115046  
Background: Typhoid enteritis is rare in developed countries. The increasing prevalence of typhoid fever with enteric perforation in our environment is alarming. Peritonitis follows enteric perforation due to typhoid enteritis. Surgical treatments and repair of the perforated areas due to typhoid enteritis varies between institutions with high mortality and morbidity. Materials and Methods: We retrospectively studied the effects of single versus double layer intestinal closure after typhoid enteric perforation with peritonitis in 902 pediatric patients from September 2007 to April 2012. All the patients underwent laparotomy after resuscitation and antibiotic cover. The patients were divided into two groups: group A (n = 454) double layer closure and group B (n = 448) single layer closure. Results: There were 554 males and 348 females with male to female ratio 1.6:1. Ages of the patients were three years to 14 years with mean age at eight years and mode at nine years. The following clinical outcomes were recorded: burst abdomen 38 (8.3%) vs 3 (0.6%), enterocutaneous fistula formation 52 (11.4%) vs 8 (1.7%), superficial wound infection 215 (47.3%) vs 91 (20.3%), ligature fistula 13 (2.8%) vs 7 (1.5%), mean length of 29.4 ± 7.8 vs 45.3 ± 11.6. Conclusion: Our results showed that single layer closure of the perforated ileum due to typhoid enteric perforation with peritonitis in children was effective by reducing complication rates.
  - 3,480 246
Outcome of tube thoracostomy in paediatric non-traumatic pleural fluid collections
Eyo E Ekpe, MU Akpan
April-June 2013, 10(2):122-126
DOI:10.4103/0189-6725.115036  
Objective: Management of pleural fluid collection not due to trauma increases workload of the paediatric thoracic surgeons, while delay or inappropriate treatment worsens the prognosis of the disease. This study aimed at assessing the outcome of therapeutic tube thoracostomy in non-traumatic paediatric pleural fluid collections and identifying factors responsible for treatment failure with tube thoracostomy. Design: Prospective analysis of socio-demographic characteristics, clinical features, clinical diagnosis, radiological diagnosis, and bacteriological diagnosis including bacteria cultured with sensitivity pattern, also treatment offered including tube thoracostomy with duration of tube thoracostomy and length of hospitalisation, indication for additional surgical procedure with type, and outcome of treatment of 30 paediatric patients with non-traumatic pleural fluid collection. Results: Thirty paediatric patients with various causes of non-traumatic pleural fluid collection in 34 pleural spaces were analysed. Their ages ranged between six months and 16 years (mean = 6.5 years) and M:F ratio of 2:1. Pleural effusion and empyema thoracis accounted for 46% and 40% with staphylococcus aureus and streptococcus pneumoniae cultured in 10% each and a high negative culture rate of 46%, which was higher with age. The parents of 40% of the patients belonged to social class 3. Success rate of tube thoracostomy was 86% in unilateral cases, 50% in bilateral cases and 81% in all cases. Alternative treatment with thoracotomy and decortications gave a success rate of 100%. Conclusion: Thoracotomy with decortication is superior to tube thoracostomy in paediatric non-traumatic pleural fluid collection and should be chosen as the primary treatment option when there is bilateral disease, chronicity, loculated effusion, thickened pleural membranes or trapped lung.
  - 2,864 216
Utilization of banked blood in pediatric surgical procedures in Calabar, Nigeria
Usang E Usang, Akan W Inyang, Ini-Abasi U Ilori, Marcus Inyama-Asuquo
April-June 2013, 10(2):145-149
DOI:10.4103/0189-6725.115041  
Background: Performing major surgery in a child demands that blood is cross-matched and saved to be transfused as indicated. Because the cost of cross-matching and donation of blood can be enormous and may equal or surpass the cost of surgery in our setting, it is pertinent to evaluate its utilization. The aim of this study was to determine how banked blood meant for pediatric surgical procedures was utilized with the hope of streamlining our blood requisition policy. This may be useful to pediatric and other surgeons involved in the operative care of children in similar settings. Materials and Methods: This was a prospective study of all children who had ELECTIVE or EMERGENCY surgical procedures between January 2009 and June 2010. The age, sex, nature of surgery, blood loss, banked units of blood and amount transfused were collected and analyzed. Results: Eighty two patients had 81 units of blood banked for them. Forty - eight and half units (59.9%) of the banked blood were for the emergency group but only 18 units (22.2%) were actually transfused at the end (P = 0.044) leading to inadequate use of the product. Conclusion: Banking large quantities of blood but utilizing only little is tantamount to inadequate use and delays surgical intervention. Indirectly, it increases cost of surgery. There is need to rationalize our blood ordering habits without causing harm to patients.
  - 2,196 141
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