Iranian Journal of Pediatric Surgery

Introduction: Adequate pain control is essential in immediate postoperative
period. Different methods are being used to provide pain management but none of these is completely effective. Regional blocks are becoming more popular then systemic opioids in all age groups due to efficacy and safety of agents used. The objective of this study was to establish the effectiveness of tramadol and bupivacaine for pain control after inguinal herniotomy in children.
Materials and Methods: This randomized controlled trial was conducted at pediatric surgery department, services hospital Lahore over 2 years. Two hundred and eighty four cases randomly divided into two groups B (Bupivacaine) & T (Tramadol). Bupivacaine (dose of 2 mg/kg) in group B or Tramadol (2mg/kg) in group T was infiltrated in the wound. Postoperatively pain score was measured using Wong-Baker Faces pain scale (WBFPS) at 0,1,2,4 and 8 hours. Both groups experienced side effects.
Results: Age and gender distribution in both groups were comparable. Pain score in both Groups was equal at 0- hours. However at 1-hour, 2-hour and 4-hour, pain score was slightly more in Group-B, But at 8-hours mean pain score was markedly raised in Group-B as compared to Group-T (3.32 ± 1.42 vs 2.45 ± 1.35). Only complication noted in patients was vomiting which was higher in Group T.
Conclusion: Locally infiltrated Tramadol is a better choice than bupivacaine as a local anesthetic for pain management in children after inguinal herniotomy. Further research is needed to elucidate any benefits it may have in other surgeries.

Introduction: Ketamine is a medication that suppresses the central nervous system and can be used as an analgesic. The aim of this study is to compare the post-operative pain reduction of rectal ketamine and caudal bupivacaine in pediatric lower abdominal surgery.
Materials and Methods: This double-blind clinical trial was performed on 68 children aged 1-7 years whom were allocated into two groups of 34 patients. The first Group received rectal ketamine (2mg/kg), and the second received 0.75mg/kg caudal bupivacaine (0.125%). Mean pain intensity and hemodynamic variables were recorded 2,6,12 and 24 hours following lower abdominal surgery in children. Pain was assessed using FLACC (Face, Legs, Activity, Cry, Consolability) Scale.
Results: There were no significant difference in terms of pain intensity between admission and discharge from recovery (p>0.05). Patients who received ketamine endured less pain than bupivacaine 2, 6, and 12 hours following surgery (p<0.05). Mean extubation time and duration of recovery stay was significantly shorter in the ketamine group.
Conclusion: Rectal ketamine was associated with more effective pain control and shorter recovery stay, when compared to caudal bupivacaine in lower abdominal pediatric surgery.

Introduction: The purpose of this study, is evaluation of the average of cumulative radiation exposure in admitted neonates in neonatal surgery ward.
Materials and methods: Participants were all neonates consecutively admitted to the neonatal surgery unit of the study hospital for surgery and need one type of radiological study during hospitalization. Thermo luminescent dosimeters (TLD GR200) were used for evaluating absorbed dose of radiation on the body. For controlling of confounding variables, 130 admitted neonates who need no radiation were selected as control group.
Results: In this study, we evaluated 169 neonates.The most x -ray examination was on ribcage (338 cases). Total amount of bowel and backbone x-ray examinations were 117 and 11 respectively. Total amount of contrast enema, meal and swallow was 8, 9 and 5 respectively. The cumulative absorbed dose in 19 patients was more than 10 mSv. There was a significant differences between control group with other x ray examination groups (p=0.001). The mean of accumulated received dose for patients during admission period was 3.13±5.12 mSv.
Conclusion: The average of accumulated received dose for neonates was about 3.13 mSv. Although this dose is less than annual limit dose, but it is inacceptable in comparison with other medical centers.

Introduction: The management of long-gap esophageal atresia (LGEA) remains challenging and esophageal replacement is inevitable in some patients. The current study aimed at assessing the outcomes of gastric pull-up surgery for esophageal reconstruction in neonates with LGEA, and investigating the postoperative results, complications, and mortality.
Materials and Methods: In a prospective study 16 patients with LGEA were studied at Tabriz Children’s Hospital, Tabriz, Iran. Gastric pull-up technique was used for esophageal replacement in all the patients. The study duration was 23 months from April 2014 to March 2016.
Results: The mean age of the neonates was 7.31 ± 3.91 days. Eleven patients (68.75%) were male and five (31.25%) female. Seven neonates (44%) had esophageal atresia type A and nine patients (56%) had type C. All of them (100%) were in need for postoperative mechanical ventilation. Mean period of postoperative mechanical ventilation was 0.87±5.69 days. Postoperative mortality was observed in three patients (18.75%). Patients were followed up for six months after the operation; poor feeding was observed in four patients (30.77%), mild respiratory distress in three patients (23.08%), and choking and aspiration in three patients (23.08%).
Conclusion: It was observed that gastric pull-up technique is a feasible and safe surgical method for neonates with long-gap esophageal atresia when primary anastomosis is not possible. Quality of life, feeding, and growth pattern were also acceptable. However, long-term outcomes were not assessed in the current study.

Introduction: Totally implantable port insertion is a common procedure in pediatrics surgery and the main concern is the position of catheter tip, which is directly related to its complications, failure and durability. The best position is in superior vena cava (SVC)/ right atrium (RA) junction which is compatible with carina or T5-T6 vertebral level in chest x-ray. In our center we routinely use surface anatomy to estimate the adequate length for the tip to reach SVC/RA junction. In this study we compared the precision and accuracy of this method by post-operative chest x-ray study.

Materials and Methods: as a retrospective study we evaluated the accuracy of surface anatomical land marks to estimate the catheter tip position, considering the carina or vertebra in chest x-ray which represents the SVC/RA junction. Fourty eight patients were included and their records were reviewed in Dr. Sheikh Children’s hospital in Mashhad.

Results: Considering the carina as the best radiographic land mark, we had accurate tip position only in 29.2%, over insertion in 45.8% and under inserted catheter tip in 10.4%. Considering the vertebral bodies as radiographic land mark, 50% were over inserted, 35.4% accurate and 14.6% under inserted.

Conclusion: Regarding our high rate of catheter tip mal-position arising from considering surface anatomy alone, we suggest not only to rely on surface anatomy but use imaging modalities such as portable X-ray, fluoroscopy or ultra-sonography within the operation room while inserting implantable port devices.

Introduction: Our aim was to evaluate clinical manifestation, and outcome of biliary tract disease in patients referred for treatment to two referral centers of pediatric surgery of Ahvaz.
Materials and Methods: In this retrospective study, patients with biliary tract disease admitted in Imam Khomeini and Abuzar hospitals (two referral centers for pediatric surgery in Ahvaz) during a 10-year period starting from March 2000 were evaluated. Age, sex, clinical manifestation, type of surgery, imaging finding, laboratory finding, duration of hospital stay, blood product infusion, and mortality rates were recorded. Data was analyzed with SPSS Ver 13.0(Chicago, IL, USA). We used Chi-square and t-test for comparison.
Results: Twenty cases (m=13, f=7) of biliary atresia were included in this study. Mean age at the time of diagnosis and operation was 82.11 days (30 days- 6.5 months). Jaundice (100%), acholic stool (55%), and dark brown urine (55%) were the most frequent clinical manifestation in patients with biliary atresia. Of all cases, 17 patients underwent surgery. Eighteen cases (m=11, f=7) of cholecystitis were included in this study. Abdominal pain (72%) was the most frequent sign. Eleven cases underwent surgery. Five cases of choledochal cyst (m=0, f=5) were included in this study. Abdominal pain and vomiting was the most common clinical manifestation in cases with choledocal cyst.
Conclusion: Jaundice, acholic stool, and dark brown urine were the most frequent clinical manifestation in cases with biliary atresia. Mean age at the time of diagnosis and operation for biliary atresia was 82.11 days (30 days- 6.5 months). Abdominal pain was the most frequent sign of cholecystitis. Early referral and more experience are needed in order to increase survival of biliary atresia cases in our hospital.

Rectal adenocarcinoma is rare in children. The patient described here is a 9-year-old girl who presented with rectorrhagia. Her problem started 3 months ago and she had been treated for infectious diarrhea. A colonoscopy was performed 3 months after the onset of symptoms and a non-pedunculated polyp in the rectum was noted and resected. After the colonoscopy signs and symptoms of peritonitis developed and in laparotomy a rectal perforation was noted and a biopsy from rectal mucosa was taken. The result of biopsy was adenocarcinoma. Then a low anterior resection of rectum with protective ileostomy followed by adjuvant chemotherapy was performed. During a 15 month follow-up the patient had no problems and no clinical, radiological or laboratory signs or symptoms of recurrence was found. However rectal adenocarcinoma is rare but it should be considered in the differential
diagnosis of intestinal problems.

Disorders related to Bartholin’s duct and glands affect approximately 2% of young women, and are very rare in premenarchal girls. Bartholin’s gland cysts are usualy small, do not cause any symptoms and resolve spontaneously. However, symptomatic larger cysts require medical treatment. Although many treatment modalities have been applyed, the best approach has not yet been found. Treatment modalities of Bartholin’s cyst include application of silver nitrate to the abscess cavity, incision and drainage of the cyst, curettage of the abscess cavity, placement of “Word catheter”, marsupialization, needle aspiration and alcohol sclerotheraphy, carbon dioxide laser excision and surgical gland excision. Here, we report a case of a large, soft, regular contoured painless Bartholin’s cyst located in the left labia minora with a diameter of 8 x 5 cm in an 11-year-old premenarchal girl, treated by surgical gland excision after previous unsuccessful incision and aspiration of the cyst.