Journal of Pediatric and Adolescent Surgery

The safety of laparoscopic appendectomy in complicated appendicitis in children

2022-05-10T04:24:45-04:00

BACKGROUND: Laparoscopic Appendectomy (LA) is no longer a new procedure in pediatric surgery. In many pediatric surgery centers, laparoscopic management of acute appendicitis is practiced but we have observed that most of them performed laparoscopic appendectomy for simple straight forward appendicitis. It is generally considered that complicated appendicitis is better managed by an open procedure. The objective of this study was to establish safety of laparoscopic appendectomy in complicated appendicitis in children.

METHODS: Research was conducted at the Department of Pediatric Surgery, Shifa International Hospital Islamabad. Duration of study was 3 years after due approval from the ethical and research review board. Medical records of 42 patients who were operated on for complicated appendicitis laparoscopically at Shifa International Hospital, Islamabad from January 2018 to December 2020 was reviewed. All patients were enrolled from the emergency department. Clinical assessment of the patients was done in a routine way by history and physical examination. Investigations included complete blood count, C reactive protein and ultrasound abdomen and pelvis. Patients who had simple uncomplicated appendicitis, who had open appendectomy, and those who had laparotomy for other reasons were excluded from the study. All those patients who had complicated appendicitis like perforation, abscess, mass, or gangrene were included in the study. Variables observed in this study were age, gender, operative findings, operative time, hospital stay and postoperative complications.

RESULTS: The mean age of the patients was 9.95 ±3.22 years. Of 42 patients, 32 (76%) patients were male and 10 (24%) were female. Mean operative time was 42.5 ±20.03 minutes. Mean hospital stay was 2.23 ±1.55 days. Out of 42 patients, 20 (48%) had perforated appendicitis, 9 (21%) patients had appendicular mass, 12 (29%) patients had appendicular abscess, and 1 (2%) patient had gangrenous appendicitis. Postoperatively, one patient of perforated appendicitis had trocar site infection. One patient who had appendicular mass developed urinary retention with periorbital puffiness postoperatively. Two patients of appendicular mass had transaction of appendicular base due to perforated and sloughed appendicular base. One patient with an appendicular abscess had a large collection in the right paracolic gutter. One patient of appendicular abscess developed peritonitis with abscess formation secondary to cecal perforation.

CONCLUSION: Laparoscopy for complicated appendicitis is safe in children with only fewer complications. Despite our limited experience of laparoscopic appendectomy, we believe that laparoscopy may safely be done as a first choice in all patients with appendicitis, whether simple or complicated.

Efficacy of fluoroscopy-guided hydrostatic reduction of acute ileocolic intussusception in children-one center experience

2023-09-15T07:26:58-04:00

Abstract

Background: Intussusception is one of the common causes of acute abdomen in children with male preponderance. Most of the cases are idiopathic in origin. Abdominal ultrasound is the modality of choice to diagnose this condition. Reduction either by hydrostatic or pneumatic technique, is the first modality of the therapeutic approach, while failed cases necessitate surgical intervention.

Methods: In this retrospective study, 31 patients underwent fluoroscopy-guided hydrostatic reduction of ileocolic intussusception, between May 2017 to January 2023. The data of all patients, consisting of age, sex, and presenting complaint, were retrieved from the hospital's electronic database record. At presentation, all patients were adequately resuscitated, and all basic investigations were achieved. The preliminary diagnosis of intussusception, based on history and examination, was confirmed by abdominal ultrasound, in all patients. The hydrostatic reduction was attempted in all cases lacking signs and symptoms of peritonitis and shock, irrespective of the duration of symptoms. Patients with successful reduction were observed overnight and discharged the next day. Surgical intervention was performed in failed/incomplete reduction cases.

Results: Among 31 children (up to 5 years of age), 23 (74.20%) were male and 8 (25.80%) were female (male to female ratio: 2.8:1). In our study 58.06% cases presented within the first 24 hours of onset of symptoms, followed by 32.25% and 9.68% between 24-48 hours and 48-96 hours respectively. A high success rate (83.33%) was observed in patients who presented within 24 hours, followed by patients who presented between 24-48 hours (50%) and 48-96 hours (33.33%). Overall, hydrostatic reduction was successful in 67.74% of cases. Ten patients (32.26%) needed surgical intervention.

Conclusion: Fluoroscopy-guided hydrostatic reduction of intussusception is an effective therapeutic modality that avoids surgery and anesthesia-related risks. Early presenting patients showed a high success rate which signifies the importance of quick diagnosis. We suggest that if there is no contraindication, all cases, regardless of duration, should be attempted for hydrostatic reduction as late-presenting patients can also benefit from this modality

Infantile hypertrophic pyloric stenosis: Perspective from a developing country

2022-09-21T04:30:34-04:00

Background: Infantile hypertrophic pyloric stenosis (IHPS) is pyloric muscle hypertrophy that causes gastric outlet obstruction. This study explores the prevalence of IHPS and the challenges in its diagnosis and treatment in a developing country. The study aimed to identify factors contributing to delays in the diagnosis and treatment of IHPS and compare the management practices for IHPS at the study hospital with international surgical guidelines.

Methods: A retrospective cross-sectional study was conducted at The Aga Khan University Hospital. Data were collected from records of 126 pediatric patients diagnosed with IHPS between January 2015 and 2019. Quality parameters, including delay in presentation, diagnosis, referral, surgery, diagnostic modalities, surgical practice, post-operative feeding, and hospital stay, were assessed. Statistical analysis was performed using SPSS version 22.

Results: Of the 44 included patients, the majority (84%) were male. The mean age at presentation was 5.2 weeks. Ultrasound was the primary diagnostic modality (81.8%), with upper GI studies used in 11.3% of cases. Delays in presentation and diagnosis were observed, with parents' delay being a major factor. The mean lag time between symptoms and surgical consult was 11.2 days, contributing to delays. Complications correlated with increased lag times.

Conclusion: This study reveals variations in IHPS management compared to international guidelines. The hospital predominantly uses an open Ramsted's pyloromyotomy, while laparoscopic surgery is recommended. Postoperative feeding initiation and discharge practices differ from international standards. Delays in diagnosis result from the disease's rarity and a lack of trained surgeons. The study underscores the need to educate primary care physicians and parents for early IHPS referral. IHPS management can be optimized by addressing delays, improving surgical practices, and ensuring early referral and intervention.

Microbiology of pediatric soft tissue abscesses presenting to a Low-Middle Income Country

2022-12-13T05:24:49-05:00

Background: Skin and Soft Tissue Infections (SSTIs) are a prevalent and diverse group of clinical conditions, ranging from simple abscesses to severe cellulitis, often involving microbial invasion of skin and underlying soft tissues. Understanding the microbiology and antibiotic sensitivities of these infections is essential for effective management.

Methods: A retrospective cross-sectional study was conducted at The Aga Khan University Hospital in Pakistan. Data from 154 pediatric patients aged up to 17 years diagnosed with soft tissue abscesses were reviewed between January 2015 and June 2019. Exclusion criteria were applied to ensure the study's accuracy.

Results: Among the 121 included patients, the majority were male (57.9%), and children less than one year of age accounted for the highest percentage (43%). The most frequently affected anatomical sites were the legs and thighs (17.3%), followed by the buttocks (15.7%) and arms/forearms (13.2%). Staphylococcus Aureus was the most common pathogen (64.5%), with 89.7% being Methicillin-Sensitive Staphylococcus Aureus (MSSA) and 11.3% MRSA. Other pathogens included Streptococci, Escherichia coli, and anaerobic Bacteroides species.

Conclusion: MRSA remains a concern in pediatric SSTIs, necessitating targeted antibiotic therapy. However, MSSA was the primary pathogen and empirical antibiotic therapy remains crucial, guided by culture results. Improving injection safety practices is essential for reducing SSTI incidence. This study contributes valuable insights for optimizing SSTI management and underscores the need for evidence-based decisions in resource-constrained settings.

Complications of the traditional treatment of closed trauma of the limbs in children

2023-01-12T03:57:11-05:00

Background: This study aims to describe the complications arising from traditional medicine following blunt trauma to the limbs in the Pediatric Surgery Department of the Academic Hospital Gabriel Touré (Mali).

Methods: This prospective and descriptive study spanned 25 months, conducted from January 1, 2020, through February 28, 2022. It included all children aged 0-15 years treated for complications of traditional blunt limb trauma in the service.

Results: During the study period, 82 complicated cases resulting from the traditional treatment of blunt limb trauma were recorded. The average patient age was 7.01 years (4 months - 15 years) with a sex ratio of 2.03. Parents of patients were uneducated in 43.9% of cases. Domestic accidents caused 69.5% of trauma cases, with the forearm being the most affected segment in 28.0% of cases. Parents' beliefs motivated the choice of traditional treatment in 54.9% of patients. Localized massaging of traumatized limbs was performed on 97.6% of patients, and 15.0% were treated by their parents. The average time for hospital visits was 111 days (3 days to 2 years). The most common complications were osteitis (25.6%), subcutaneous abscess (23.2%), and skin necrosis (13.4%). Management primarily involved abscess drainage. Morbidity was 28%, with a mortality of 6.1%. Long-term complications included limb deformity.

Conclusion: Despite the legalization of traditional medicine, implementing strategies for information, awareness, and education of the population through media and places of worship should minimize complications resulting from the traditional treatment of blunt limb trauma.

Functional retrocaval paraganglioma: A case report

2022-06-26T10:15:50-04:00

Background: Functional paragangliomas are one of the rare and curable causes of secondary hypertension. Its usual location is in the region of the head and neck but is rarely seen in the retrocaval region.

Case Presentation: We present a rare case of an 18-year-old young boy who presented with functional retrocaval paraganglioma. The Imaging workup revealed a 6cm mass abutting the inferior vena cava (IVC). The mass was successfully excised. Histopathology showed it was a paraganglioma.

Conclusion: Retroperitoneal retrocaval paragangliomas are rarely seen tumors with very few cases reported so far. The location of paragangliomas in this region is usually uncommon and its surgical resection is itself a challenge for the surgeon. Complete surgical resection with prior adequate hypertension control is the only curative treatment of paragangliomas. Lifelong follow-up is necessary to detect early recurrence

Posterior urethral valve and ureterocele in a neonate: A rare association

2022-08-16T08:03:24-04:00

Posterior urethral valve and ureterocele usually presents as two separate entities in neonates. Their coexistence appears to be extremely rare owing to different embryonic developmental defect. We here in present this rare association in 3 weeks old male with antenatal right hydroureteronephrosis. Patient underwent cystoscopy with fulguration of posterior urethral valve along with endoscopic drainage of ureterocele and was doing well on follow up for last 5 years. Authors discuss management of this rare association with the aim to highlight the need for systematic management approach.

Side-to-side refluxing ureteroneocystotomy for an infant with refluxing and obstructed ectopic ureter associated with duplex system

2023-04-07T00:32:36-04:00

Background: Surgical management of the obstructed ectopic ureter is one of the most difficult problems, particular in neonates and infants. The bladder-level definitive repair has technical limitations during infancy because of the size discrepancy between the ureter and the bladder.

Case Presentation: We report our experience of side-to-side refluxing ureteroneocystotomy (SSRUC) as a temporary procedure for an infant with refluxing and obstructed ectopic ureter associated with a duplex system.

Conclusion: SSRUC relieved obstruction and controlled febrile UTI successfully while waiting for maturation of the bladder required for the bladder-level definitive repair.

Pediatrics vascular injury management with total replacement of blood volume- Anesthesia challenges: A case report

2022-06-26T10:20:31-04:00

Background: Vascular injuries with significant blood loss causing ischemia and revascularization for limb salvage are rarely done in developing countries. Hence, most hospitals and surgeons lack the experience to deal with vascular injuries.

Case Presentation: A 9-year-old child presented with left subclavian artery transection and massive hemorrhage. The patient required massive transfusions during the repair of the injured vessel. Herein, we describe the challenges faced during the management of this patient.

Conclusion: In an emergency setting, full optimization is not always possible. Every effort should be made to manage the patient by utilizing the available resources without undue delays.

Rare presentation of nephrogenic adenoma at the meatus of penoscrotal hypospadias: A case report

2022-06-20T08:57:18-04:00

Introduction: Nephrogenic adenoma is a rare benign condition that arises in the urothelium however can occur anywhere along the urinary tract. Mostly it occurs in Caucasian males with a ratio of 2:1 (male/female) . The condition mostly occurs in adults however 10% children are also affected. The lesion may occur as a metaplastic response to urothelium, or it may occur congenitally due to proliferation of meta nephrogenic rest. In this report , we emphasize on its congenital origin without any pre-existing cause in a patient of penoscrotal hypospadias.

Spontaneous gallbladder perforation in a full-term neonate: A case report

2022-03-15T06:05:25-04:00

Background: Spontaneous gall bladder perforation is an uncommon event among neonates. The etiology of perforated gall bladder in this pediatric age group is idiopathic. Only 9 cases are available in literature up till 2019.

Case Presentation: We are reporting a case of spontaneous gall bladder perforation in a 15-day-old neonate who presented with vomiting, abdominal distension, and jaundice. The gall bladder was perforated near the fundus. Per-operative cholangiogram showed the normal passage of contrast. Open cholecystectomy was performed. No postoperative biliary complications were observed.

Conclusion: Though Gall bladder perforation of spontaneous nature is rare but should be kept in the differential diagnosis in neonates who present with jaundice, abdominal distension, and acute abdomen.

Congenital anterior urethral diverticulum: A case report

2023-01-31T06:16:52-05:00

Background: Anterior urethral diverticulum and valve are rare causes of lower urinary tract obstruction in children and cause recurrent urinary tract infections (UTIs).

Case Presentation: A 7-year-old male child presented with dribbling of urine and pain during micturition. RGU and MCUG showed a narrowed mouth diverticulum in the anterior urethral wall. He underwent laser fulguration of the posterior obstructing lip of the diverticulum which resulted in excellent urinary flow postoperatively.

Conclusion: Anterior urethral diverticulum and valve can be easily treated by valve fulguration using Laser of Bugbee with an excellent prognosis. It can avoid further deterioration of the upper tract with simple treatment.

Candida intermedia induced central line infection in an infant: A case report

2023-08-30T04:49:21-04:00

Background: Central venous catheter (CVC) carries a risk of infection, particularly with prolonged use of antibiotics and parenteral nutrition (PN). The most common causative agent is Staphylococcus aureus but other bacteria and fungi can cause infection as well.

Case Presentation: This is a case of an 11-month-old male PN-dependent infant with a complex medical history who developed a fungal infection of the central line due to Candida intermedia. Despite displaying in-vitro sensitivity to Fluconazole, the infection ultimately required treatment with Caspofungin and the removal of the venous catheter for successful clearance and full recovery.

Conclusion: This case underscores the importance of tailoring treatment based on both anti-fungal sensitivity and clinical response, emphasizing the importance of CVC removal in achieving infection clearance

Testicular sparing surgery for a rare case of multiple bilateral testicular dermoid cysts in a 7 years old boy

2023-01-28T15:10:30-05:00

Neonatal pyloric stenosis in the early neonatal period

2023-02-14T05:22:14-05:00

Background : Neonatal hypertrophic pyloric stenosis is a rare pathological entity in pediatrics. The incidence of hypertrophic pyloric stenosis is 1-3 per 1000 live births in the neonatal period.

Case Presentation: We have presented a 4-day-old male who has non-projectile, non-bilious vomiting and has not passed stool for the last two days. Necessary investigations have been carried out, and the final diagnosis was made by an ultrasound of the abdomen, which revealed hypertrophic pyloric stenosis. Ramstedt's Pyloromyotomy was performed to correct pyloric stenosis alongside intraoperative findings of malrotation of the gut with normal mesentery and small gut.

Conclusion:

In this report, we have discussed the presentation of, hypertrophic pyloric stenosis in the early neonatal period with no electrolyte imbalance, no metabolic alkalosis ( varies from usual presentation ) and associated malrotation of the gut. In Pakistan, hypertrophic pyloric stenosis in the early neonatal period has not been documented before.

Inverted Meckel’s diverticulum: A rare lead point for intussusception

2022-09-21T04:49:19-04:00

Laparoscopy in disorders of sex development: Diagnostic and therapeutic implications

2023-04-09T00:04:25-04:00

Disorders of Sex Development (DSD) comprise a broad spectrum of hormonal, chromosomal, and metabolic abnormalities that result in abnormal genital development. Every aspect of DSD, starting from diagnosis to treatment, is a challenge to the clinician. Standard evaluation with karyotyping, hormonal assays, and imaging may not be sufficient to categorize the type of DSD, due to overlapping clinical presentation across the spectrum. Laparoscopic visualization provides an accurate picture of the gross morphology of the gonads and the mullerian structures. Laparoscopy also serves as a tool for therapeutic intervention, while ensuring maximal cosmesis. Herein we aim to discuss the role of laparoscopy as a preferred diagnostic and therapeutic modality in DSD patients.

Biliary atresia splenic malformation syndrome: A case series

2023-08-15T06:32:55-04:00

Background: Biliary atresia with splenic malformation (BASM) syndrome carries an unfavourable outcome related to complex surgical anatomy that poses technical difficulties during surgery.

Case Presentation: Herein we report two cases of biliary atresia with polysplenia syndrome. Other associated anomalies were complex cardiac anomalies (in both), preduodenal portal vein (in one), midgut malrotation (in one), and right hepatic artery originating from the superior mesenteric artery (SMA) (in one). In one patient Ladd’s procedure along with porto-duodenostomy was done while in the other, Kasai porto-enterostomy was performed. One patient is alive, with normal liver function tests, on a 3 year follow-up.

Conclusion: Patients with biliary atresia and splenic malformation syndrome have complex associated anomalies. Additional procedures or modification of surgical procedures are often required that may affect the already guarded prognosis.