Iranian Journal of Pediatric Surgery

Introduction: Several studies have addressed the unique management challenges in poorly functioning kidneys of patients with ureteropelvic junction obstruction. Trial with percutaneous drainage of such kidneys as a guide to choose the type of surgical management would be a solution to this dilemma. We aimed to evaluate the role of percutaneous nephrostomy in treatment of poorly functioning kidneys in pediatric patients with UPJO.

Materials and Methods: A prospective study was performed on patients with poorly functioning kidneys (split renal function<10% on renal dynamic scan) and unilateral ureteropelvic junction obstruction from August 2016 to January 2018. Ultrasound-guided nephrostomy was inserted for these patients. Data regarding the differential renal function and glomerular function rate (GFR) was collected before and after nephrostomy insertion. Decision regarding pyeloplasty or nephrectomy of the involved kidney was made based on changes seen in differential function and Glomerular filtration rate following the drainage.

Results: Thirty three patients with unilateral UPJO with poorly functioning kidneys were treated during this period. Thirty patients had significant increase in differential function and glomerular filtration rate. These patients underwent pyeloplasty. In 2 patients, these parameters did not increase much and they underwent nephrectomy. One patient had an infected kidney which did not improve significantly on drainage and had to be removed. Of the 30 patients who had pyeloplasty, two developed obstruction after 3 months of removal of double-J stent and needed reoperation.

Conclusion: Percutaneous nephrostomy in poorly functioning kidneys with ureteropelvic junction obstruction helps to identify potentially salvageable kidneys which merit pyeloplasty. Kidneys which do not improve with nephrostomy are unlikely to improve with pyeloplasty and therefore nephrectomy is done in such cases.

Introduction: Hypospadias is a common pediatric surgical procedure. Early postoperative pain management is essential to inhibit pain impulses and endocrine responses; leading to decreased mortality and morbidity and lower rate of agitation and faster return to normal functional status. This study evaluates the analgesic efficacy of bupivacaine alone versus bupivacaine plus dexmedetomidine in penile block for hypospadias surgery.

Materials and Methods: In this randomized clinical trial, 64 children undergoing hypospadias surgery in a referral center in Tehran, Iran during 2018 were enrolled and randomly assigned to receive either bupivacaine 0.25% alone 0.2 ml/kg or bupivacaine 0.25% 0.2 ml/kg plus dexmedetomidine 0.3 μg/kg. After performing penile block, reversion of anesthesia was carried out and patients were extubated after regaining complete consciousness. Patients were monitored for 24 hours for pain according to FLACC scale and also the analgesia and block duration was determined.

Results: Mean analgesia duration was 2.63±0.9 and 2.03±0.5 hours in the combination group and alone group respectively which was significant (P=0.003). The mean duration of block was significantly longer in the combination group (P=0.001).

Conclusions: According to the results it may be concluded that addition of dexmedetomidine to bupivacaine in hypospadias surgeries would result in longer analgesia and block duration; without addition of adverse effects.

Introduction: Different countries have their own residency programs in order to train new residents in the field of medicine. Some of these programs are very efficient while some have room to improve, especially in developing countries. These residency programs can play an important role in producing great consultants in the future. So it is very important to evaluate the residency program of a country so as to make sure their residents receive quality training.

Materials and Methods: A cross-sectional survey was conducted in Pakistan using PHEEM questionnaire; for assessment of educational environment of pediatric surgery post graduate residents (PGR’s) of Pakistan. A questionnaire was sent to all 95 pediatric surgery residents via E-mail in February 2017 and SPSS 20 was used to analyze data.

Results: The response rate from pediatric surgery PGR’s was 48.4% (n= 45).

The mean age of participants was 29.69 ± 2.71 years. Most of the participants were male (76%) and in 5th year of residency (39.13%). The high scored items (mean >2.5) were only 3: question 9, 17 and 26. The mean PHEEM total score was found to be 63.06 ± 16.77. When categorized into global scales, most of the residents (84.4%) labeled educational environment into level 2. Mean PHEEM score was found significantly higher among female and those residing in province ‘Sindh’.

Conclusion: We conclude that although educational environment depends upon and varies with many factors; overall it is not reported to be satisfactory by pediatric surgery PGR’s across our country. Authorities urgently need to look into the matter and take serious actions in order to improve the quality of our future consultants.

Introduction: To identify complications requiring early reoperation and to determine associated risk factors in the pediatric surgery of the teaching hospital Gabriel Toure.

Materials and Methods: A retrospective study of children 0-15 years old during 4 years (January 2014 to December 2017) presenting with a postoperative complication requiring a reoperation and taken care of during the period of study. Observation of bowels or the liquid stools through the opened wound, the presence of air-fluid levels on an abdominal plain X-ray and the absence of resumption of intestinal transit allowed us to make a decision to re-operate.

Results: We have re-intervened on 103 patients because of early postoperative complication out of 4730 cases of pediatric surgery carried out in this hospital during these 4 years. This represented 1.54 % of our total surgical activities. The average age of our patients was a 5.2±2.3 year ranging from 2 months to 15 years. The sex ratio was 0.94. Eighty four (81.55 %) of our patients were admitted and operated on emergently. Peritonitis due to digestive system perforation represented 45.28 % of the indications for reoperation followed by the acute intestinal intussusceptions (10.7 %) and traumatic eviscerations (9.7 %). The average duration before the first intervention was 80±13.6mn. The postoperative evisceration was the 1st cause of reoperation followed by the post-operative peritonitis and then post-operative intestinal obstruction. The average time to reoperation was 6.9 ± 4.2 days.

Conclusion: In our hospital risk of reoperation has an association with: indication of first surgery, operating technique, experience of the surgeon, malnutrition and anemia (p<0.05). On the other hand sex, age and the duration of surgery have no effect on early reoperation (p > 0.05).

Introduction:The most common congenital abnormality of the penis is hypospadias. Although the main treatment is surgical; hormone therapy with dihydrotestosterone is also used.

Materials and Methods: This randomized clinical trial was carried out between January 2012 and December 2017 on 79 children with hypospadias (in the Clinic of Pediatric Surgery, Clinical Centre University of Sarajevo). Their mean age was 38.2±2.8 months. GroupI included 36 children whom were treated with 2.5% dihydrotestosterone gel which was applied twice a day to the penile shaft and glans for one month prior to surgery. GroupII included 43 children whom did not receive any treatment preoperatively.

Results: Mean age of patients in group I was 37.3±6.3 months and in group

II it was 39.1±5.9 months which were comparable. Complications occurring postoperatively were: urethrocutaneous fistula in 6 patients (13.9%) in group II, versus 1 patient (2.7%) in group I. There were 2 patients with meatalstenosis in group II (4.7%), and 3 (8.3%) in group I. Finally, there was a significant difference (p<0.05) between the overall reoperation rates between groups (p<0.05).

Conclusion: Pretreatment with 2.5% dihydrotestosterone transdermal gel before hypospadias repair is beneficial in decreasing complication rates.

Introduction: Hydroceles is accumulation of fluid in the processus vaginalis

(PV) resulting in swelling of the inguinal region or scrotum. Its treatment depends on age, symptoms and conection with abdomen. Preferred method of treatment is subject of debate. In this study we assessed two different method of hydrocele repair in children's hydrocelotomy and hydrocelectomy and compared their complications and recurrences rate.

Materials and Methods: 70 children with noncomunicating hydrocele included in study, allocating every other subject to each treatment group (alternating allocation) for the hydrocelotomy group(incision and evacuation of hydrocele sac)and hydrocelectomygroup(excision and removing of heydrocele sac. The complications and recurrence rate were recorded in both groups and compared together.

Results: From 70 children 25 patient had right side hydrocele(%35/7) and in 45 children hydrocele found in left side.(%64/3). No statistical difference was found for complications like bleeding, wound infection, spermatic cord damage, and recurrent hydrocele between two groups in post operation Period.

Conclusion: although there not found very different result in rate of complications and recurrency between two groups but it seems that hydrocelotomy is enough treatment with less probability of spermatic cord damage and other complication.

Congenital diaphragmatic hernia (CDH) is usually accompanied by pulmonary hypoplasia, pulmonary hypertension, and other associated anomalies which result in high mortality rates in these cases. This condition occurs when there is a defect in the diaphragm (mostly to the left and posterolateral) from which herniation of the abdominal contents into the thorax can take place. Morgagni hernia is a less common CDH (only 5-10% of CDH cases), in which congenital herniation of the abdominal content through the triangular parasternal gaps of the anterior diaphragm happen. Morgagni hernia usually affects the right side, and the patients are usually asymptomatic. Herein, we present the case of a 15-month-old male infant with large Morgagni hernia resulting in poor weight gain. The presentation was unique due to its huge orifice, its gastrointestinal obstruction presentation and also its unremarkable radiologic findings. The patient was monitored by the follow up team for 12 months. The follow-up revealed no recurrence, and the patient had favorable weight gain without any gastrointestinal symptoms.

Xeroderma pigmentosum (XP) is an autosomal recessive genetic disorder with the following conditions: neurologic disorders that gradually progress and skin hypersensitivity to ultraviolet (UV). Inhalational anesthetic drugs should be avoided in these patients since they may induce DNA damage, also use of muscle relaxants should be kept to a minimum. Thus for XP patients, total intravenous anesthesia (TIVA) is more appropriate for inducing general anesthesia and airway manipulation must be kept to a minimum. We report a 6 year old boy with XP and its airway management and anesthesia during surgery