Iranian Journal of Pediatric Surgery

Introduction: Providing the material for penile reconstruction after release of chordee associated with hypospadias is challenging. We have used the preputial vascularized island flap for this purpose. We report the results of this prospective study.

Materials and Methods: One hundred and twelve boys ranging from 13 months to 12 years of age were enrolled in this study. The location of meatus ranged from midshaft to glanular and all of them had associated penile curvature from 10 to 40 degrees. The preputial skin vascularized flap was created and used for covering the defect in all cases. The underlying dartus tissue of the flap also lied on the uretheral suture line to prevent the formation of fistula. The follow up period ranged from 2 months to 72 months. All patients received caudal anesthesia for postoperative pain management.

Results: All patients had skin defects on the ventral surface of their penile shaft after correction of penile curvature. The ischemia and necrosis of the flap developed in 5 cases however these were in initial phases of the study. In 20 cases the appearance of the flap seemed liked a hyperthrophied loose patch on the ventral aspect of penis. These cases went on to have a good appearance over time. Only in two of these cases a second operation to refashion the flap was needed.

Conclusion: Thepreputial island flap is a safe method for covering the new urethra and penile skin defects, with good cosmetic results.

Introduction: Jejunoileal atresia (JIA) is a common cause of neonatal intestinal obstruction and is a common surgical emergency. The aim of this study was to compare primary anastomosis without resection of the dilated segment with transanastomotic T tube jejunostomy (TATTO) versus resection of the dilated segment without T tube as the control group for treatment of patients with JIA.

Material and Methods: During 2008 to 2013, 105 patients were diagnosed with JIA at the time of surgery and were recruited for this study. Data relating to efficacy and procedural complications were compared among patients. The criteria for exclusion were duodenal obstruction, colonic atresia, intestinal perforation, malrotation, and also JIA patients with associated other anomalies like meconium ileous, gastroschisis and anorectal malformation.

Results: A total of 125 patients were diagnosed and 16 patients were excluded. Our patients were divided into a control group (n=52) and a TATTO group (n=57). The TATTO group had a significantly shorter postoperative hospital stay (12 vs. 23 days, p=0.001) and time to start feeding (9 vs. 13 days, p=0.003) compared with the control group. Sepsis (12.0% vs. 32.7% p=0.004), other complications (3.6% vs. 15.4% p=0.001) and the associated morbidity were significantly lower in the TATTO group.

Conclusion: The findings suggest that the TATTO technique was a better method for the treatment of children with JIA, as study showed lesser morbidity and mortality rates.

Introduction: Rectal prolapse refers to extrusion of mucosa or the full thickness wall of the rectum through the anal sphincter, which is more common between infancy and 4 years of age and has a high incidence in the first year of life. It is considered as a sign of an underlying clinical condition causing an increased intra‑abdominal pressure, pelvic floor weakness or poor root innervations as seen in Hirschsprung’s disease; and not a distinct entity. Also many different methods of surgery exist for treating this condition. We reviewed our experience with regard to treatment and outcome of rectal prolapse in a tertiary center.

Materials and Methods: All patients with rectal prolapse who were managed at Mofid Children’s Hospital between 2005 and 2014 were evaluated. Clinical information was obtained from their hospital records. Main study variables were age and sex, the type of prolapse, clinical findings and type of surgery performed and complications.

Results: Of a total 111 patients, 82 (73.9%) were boys and 29 (26.1%) were girls with a mean age of 3.5 yrs ± 2.3 SD at the time of diagnosis and a mean age of 4.3 yrs ± 3SD at the time of surgery. The most frequent type of rectal prolapse was mucosal. Conservative treatment mainly consisting of constipation therapy was carried out in 24.3% of our patients. The most common surgical procedures used in our center were Lockhart mummery and excision of the redundant mucosa (32.4%& 23.4% respectively). Performance of other methods depended on the attending surgeon’s preference.  Almost 90% of our patients showed no post operative complications. In our study we had 9 cases with recurrent prolapse after surgery. The mean hospital stay was 3.9± 3.2 (ranging from 1 to 24 days).

Conclusions: According to the obtained results, it could be concluded that treatment of rectal prolapse would result in improvement in nearly nine out of ten children and a low rate of postoperative complication are expected. However further studies should be performed to obtain more definite results.

Introduction: Gastro-esophageal reflux (GER) is common among children of different ages and treatment is necessary since it could turn in to Gastroesophageal Reflux Disease (GERD) and cause complications. In patients that do not respond to medical treatment and patients that have complications such as repeated apnea, pneumonia, stricture caused by esophagitis and failure to thrive, surgical treatment is indicated. In this article the rates of clinical presentations of the disease particularly the respiratory manifestations after operation with the loose Nissen Fundoplication technique are studied.

Material and Methods: In this descriptive retrospective study 76 cases of GERD underwent loose Nissen Fundoplication. Clinical presentations and diagnostic methods and the result of surgical treatment were studied.

Results: During March 1997 till August 2010, 76 patients were studied. Male to female ratio was 1.6. The mean age of patients was 24.5 months (ranging between 17 days to 18 years).  Fifty nine (78%) patients had respiratory presentations such as RAD (reactive airway disease) and respiratory distress with recurrent pneumonia and apnea. Thirty one (41%) cases had associated anomalies. The most used diagnostic studies were radiography (100%), endoscopy (41%) and PH metry (1.3%). Eleven patients (14.4%) had early or late surgical complications. Respiratory presentations in almost all the patients were controlled postoperatively. The success rate of the operation was 75 (98.6%). There was no operative mortality, but non-operative mortality occurred in one patient (1.3%).

Conclusion: LooseNissen Fundoplication technique has a good success rate with a low rate of complications.  Respiratory presentations are the most common presentations of GERD, and in all patients who have respiratory symptoms, GERD workup is necessary, and anti-reflux surgery can control nearly all of these symptoms.                                                                                          

Introduction: In order to assess our skill in the tubularized incised plate (TIP) urethroplasty technique in children with hypospadias.

Material andMethods: Of 307 children (mean age 38 month) who received a TIP urethroplasty, all had primary hypospadias. Patients who were referred with complication were eliminated from our study. The hypospadias defects were subcoronal in 25 (8%), distal penile in 236 (76%), midpenile in 25 (8%), proximal in 14(4%) and unknown in 7(2%) cases. Chordee was present in 53 (17.2%) patients. Presence of complications requiring reoperation and overall general appearance was recorded.

Results: The mean follow-up was 36 (19-72) months. Overall success rate was 70 % (215). Re-operation was required in 92 patients (30%): for urethrocutaneous fistula in 79 (26%), complete disruption of the repair in 2(0.6%) cases and meatal stenosis requiring meatoplasty in 12 (3%). Complete glans dehiscence occurred in 3 patients, which was repaired using the MAGPI technique. Partial breakdown of the glans occurred in 10 cases which did not require further surgery. One case had a huge urethral diverticulum.

Conclusions: This technique is relatively common compared to other accessible operations, but attention to details is necessary in order to achieve good results. It appears that complications, such as fistulas and meatal stenosis are more common in this method than other techniques, which require more research in the future.

Background: Burkitt’s lymphoma is a high grade B-cell neoplasm, which is a kind of small non-cleaved cell lymphoma. It is presumably the fastest growing human malignancy, and the patients are prone to develop tumor-lysis syndrome. Here we present findings on our patients with Burkitt lymphoma.

Materials and Methods: This descriptive retrospective study included 46 children with abdominal Burkitt's lymphoma who were treated during 15 years from June 1998 to Dec 2013 at Mofid Children’s Hospital.

Results: Offourty six patients 32 (70%) were boys and 14 (30%) were girls with ages ranging from 2 to 14 years. Surgical exploration was carried out in all cases, the lesions were located in the small intestine (N=17), large intestine (N=15), ileocecal region (N=12), and stomach (N=2). We performed a complete mass resection in 16 cases, debulking in 10 and lymph node/mass biopsy in 20 cases. Pathologic examination revealed Burkitt’s lymphoma for all patients. The majority were stageIIE and stage IIIE (24 and 19 respectively). Post-operative complications were seen in five cases with the most common being persistent ileus. All patients received a sort of systemic chemotherapy. The mean follow up duration was 6 years. Death occurred in 7(15%) of our patients, due to tumor lysis syndrome and acute renal failure.

Conclusion: The extent ofdisease at presentation is the most important prognostic factor in abdominal Burkitt’s lymphoma. Children with BL are at a high risk of tumor lysis syndrome before or during chemotherapy. Surgery still plays an important role in this pathology, and chemotherapy offers an excellent chance for long term disease free survival.

Background: Children with cleft lip and palate generally suffer from inappropriate and inadequate feeding, resulting in insufficient weight gain leading to malnutrition and poor growth. We aimed to evaluate the nutritional and growth status of cleft lip and palate children before and after reconstructive cleft lip and palate surgery.

Methods: All cleft lip and palate children aging from birth up to 36 months who were admitted to a referral Children's Hospital were investigated by a nutritionist. Data were collected using a questionnaire. About 5-6 months after surgery, data regarding their height, weight, feeding status and feeding difficulties were collected by telephone. Statistical analysis was performed using SPSS 18 software. For qualitative variables we used frequency and percentage and for quantitative variables we measured mean and standard deviation. We used Paired Sample T-test for comparing weight differences before and after surgery.

Results: In this study, formula was the most common type of feeding before and after surgery. Nasal regurgitation and insufficient sucking was the most common complaint of mother's before surgery, and also nasal regurgitation was reported as the most common difficulty after surgery, probably due to the need for reoperation. Bottle feeding was the most common method of feeding before and after surgery. After surgery only one mother claimed that her child spent more than 30 minutes for feeding. Weight for age of 18 children before surgery was lower than 5th percentile while after surgery this was reduced to 13 children. Also, there were significant differences between mean age before and after surgery which could implicate increase of weight after surgery.

Conclusions: Our study demonstrates the results of surgical repair of cleft lip and palate on nutritional status in children.

We had two cases of female complicated anorectal and genital malformations which underwent total mobilization of all structures of perinea to midline.

Case1:A 6 month old female with skin covered bladder, pubic diastasis, ectopic anus, vagina, and urethra to the right side of median cleft and lipoma on the left side. Closure of pubic diastasis with iliac osteotomy and double barrel sigmoid colostomy was done at 8 months age. In the second operation, right displaced anus, vagina and urethra and the entire muscle complex underwent total mobilization to the midline.

Case2:An 8 Month old female with complicated anorectal malformation who underwent double barrel colostomy on day 8 of birth. Median cleft lipoma was excised and total mobilization of anus, urethra, right hemivagina and muscle complex to the midline was done and the two hemivaginas were sutured together.

Unusual and bizarre anatomic arrangements can be seen in this group. Each case represents a unique challenge for the surgeon, with a different prognosis and therapeutic implications. No general guidelines can be drawn for the management of these patients. Each case must be cared for individually.