Iranian Journal of Pediatric Surgery

Introduction: Acute appendicitis (AA) is the most common surgical abdominal condition and the leading cause of acute abdomen in the pediatric population. It requires rapid diagnosis, and many clinical scoring systems have been developed to aid in the diagnosis of AA. These scoring systems represent simple, non-invasive, and readily available diagnostic tools. The most commonly used scoring systems in children are the Alvarado score (MANTRELS) and the Pediatric Appendicitis Score – PAS (Samuel). The aim of this study is the determine and compare the diagnostic value of clinical scoring systems (Alvarado and PAS) in pediatric acute appendicitis.                                                                                      

Materials and Methods: A retrospective study was conducted for the period from January 1, 2023, to December 31, 2024. The study included 182 patients diagnosed with AA who underwent surgery and were hospitalized at the Pediatric Surgery Clinic of the Clinical Center of the University of Sarajevo (CCUS).                                                                                                     

Results: The average age of patients with appendicitis was 11 years, corresponding mostly to school-age children, while 13.7% of the 182 patients were under 6 years of age. Based on histopathological findings, higher score values generally indicated more severe forms of appendicitis (gangrenous and perforated), while lower values were most often associated with phlegmonous appendicitis. The highest diagnostic value of the scores was observed in the time interval of 6–12 hours from the onset of symptoms. ROC analysis results showed that neither the Alvarado nor the PAS score had significant discriminative power in this sample. The average value of both Alvarado and PAS scores was 9. A statistically significant positive correlation was found (rho = 0.986; p = 0.000**) between Alvarado and PAS variables in patients with appendicitis. A statistically significant difference was also observed between the values of the Alvarado and PAS scores (p = 0.046, p < 0.05).                              

Conclusion: Although easy to apply, the Alvarado and PAS scores cannot be considered the sole and exclusive method for deciding on surgical treatment. The diagnosis of acute appendicitis can be improved by combining scoring systems with radiological diagnostics.

Introduction: Door fingers injuries account for 3.5% of child domestic accidents. The aim of our study was to describe the epidemiological, anatomo-clinical, therapeutic features and results of door fingers injuries in children.

Materials and Methods: This was a cross-sectional study with a descriptive and analytical purpose carried out over a period of 10 years, (January 2010 to September 2020), in the Paediatric Surgery Department. We included all children aged 0 to 15 years old admitted for digital trauma following crushing by a door, a car door, a window, drawers.

Results:  We collected 55 cases. The mean age was 5.36 ± 4.12 years (extremes of 1 and 15 years). The male gender accounted for 60% of cases with a sex ratio of 1.5.  The lesions were subungual hematoma (38.18%), nail avulsions (14.54%), pulpal wounds (38.18%) with distal amputations in 40% of cases. Distal phalanx fractures were observed in 47.27% of cases. Therapeutically, directed healing was indicated in 16.36% of distal amputations, while flaps were used in 25.45% of cases. Pinning was performed in 69.23% of cases. The evolution was uneventful in 94.54% of cases.The results were excellent in 10.90% of cases and good in 63.63% of cases.

Conclusion: Door fingers are common in children. A careful clinical examination with meticulous radiological analysis allows appropriate and well codified management. The restoration of a good quality pulpo-ungual complex is the best guarantee of a good long-term functional and aesthetic result.

Introduction: Pediatric inguinal hernia is commonly treated through surgical intervention. Minimally invasive techniques, such as laparoscopic inguinal herniotomy (LIH), are gaining popularity. However, the single incision bilateral open herniotomy (SIBOH) offers an alternative with smaller single incision and potentially similar outcomes. This study compares the safety, efficacy, operative time, and cosmetic outcomes of SIBOH and LIH.

Materials and Methods: A prospective randomized study was conducted involving pediatric patients with bilateral inguinal hernia. Patients were allocated into two groups: Group A underwent SIBOH and Group B underwent LIH. Primary outcomes included operative time, complications, recurrence rate, postoperative pain, and cosmetic satisfaction.

Results:  SIBOH demonstrated a significantly shorter operative time (32.4±5.8 minutes) as compared to LIH group (47.9±7.3 minutes) (p<0.001). Complication and recurrence rates were comparable between both groups. Hospital stay was shorter in SIBOH group as compared to laparoscopic group (p< 0.05). Parents reported comparable cosmetic outcomes in both the groups, but differences were not statistically significant. Postoperative pain was similar in both groups.

Conclusion:     SIBOH is an effective and safe alternative to LIH for bilateral inguinal hernia in children. It offers shorter operative times with similar outcomes, making it a viable technique where laparoscopic resources are limited.

Abstract

Introduction: Postoperative delirium and agitation is a distressing event that occurs in most children. This study aimed to compare of postoperative delirium in children undergoing elective herniorrhaphy following general anesthesia by sevoflurane and isoflurane.

Materials and Methods: In this double-blind randomized clinical trial, 50 children aged 2 to 6 years; candidates for inguinal herniorrhaphy were divided into two groups of general anesthesia induced by sevoflurane and isoflurane. Anesthesia was induced by administering 5-7 mg / kg sodium thiopental and 0.5 mg / kg atracurium. They were monitored every 10 minutes to 30 minutes for postoperative delirium (POD) using Pediatric Anesthesia Emergence Delirium (PAED) scale.

Results:  The POD frequency was in the isoflurane and sevoflurane groups 1 (4%) and 18 (72%), respectively and this difference was significant between two groups (P=0.001). According to PAED, the POD severity in isoflurane group was less than sevoflurane group at minute 10 (P = 0.001). Also, there was a significant difference between the two groups in terms of POD severity at minute 20 (P= 0.001). The highest POD severity was seen in the isoflurane group at minute 30 (P =0.001).

Conclusion:     The results of the present study showed that the use of sevoflurane in the anesthesia maintenance phase for children less than 6 years of age leads to higher POD incidence as compared to isoflurane

Introduction: Congenital pelviureteric junction obstruction (PUJO) is a leading cause of pediatric hydronephrosis and potentially reversible renal dysfunction. Pre-operative imaging plays a crucial role in surgical decision-making, yet its correlation with histopathologic renal injury remains underexplored.

To evaluate the relationship between pre-operative sonographic and nuclear scan parameters with intraoperative renal histopathology in children with congenital PUJO and identify imaging predictors of significant renal damage.

Materials and Methods: A prospective observational study was conducted among 60 children (<12 years) with unilateral PUJO undergoing Anderson–Hynes pyeloplasty. Pre-operative ultrasound parameters—Society for Fetal Urology (SFU) grade, anterior–posterior pelvic diameter (APD), cortical thickness, and Doppler resistive index (RI)—and nuclear parameters—differential renal function (DRF), drainage half-time (T½), and renogram curve—were recorded. Renal cortical biopsies were graded using Elder’s histopathology scoring system. Significant histologic damage was defined as moderate/severe injury (score ≥6). Statistical correlations and ROC analyses were performed.

Results:  High-grade hydronephrosis (SFU III–IV) was seen in 70%, APD ≥20 mm in 66.7%, and RI ≥0.70 in 45%. Nearly half had DRF <40%. On biopsy, 73.3% showed significant damage. Strong associations were observed for APD ≥20 mm (p=0.017), SFU ≥III (p=0.018), and RI ≥0.70 (p=0.030). ROC analysis showed fair predictive accuracy—AUC: SFU = 0.707, RI = 0.697, APD = 0.640.

Conclusion:     SFU grade ≥ III, APD ≥ 20 mm, and RI ≥ 0.70 strongly correlate with histopathologic injury in PUJO and serve as practical, non-invasive predictors of parenchymal damage. Integrating these with renography may optimize surgical timing and preserve renal function.

Introduction: Perineal trauma in female children presents unique diagnostic and therapeutic challenges due to its relative rarity, varied modes of injuries, psychosocial implications and diverse presentation patterns. This study aims to analyze the management strategies based on grade of injuries and outcomes compared with contemporary literature.

Materials and Methods:  A retrospective analysis was conducted on female patients (age <12 years) presenting to our institute with perineal trauma between January 2021 and December 2024. Injuries were graded using the Genital Injury Score (GIS). Primary outcomes included wound healing, functional recovery, and complications. A systematic literature review was performed.

Results:  Nineteen patients (mean age 6.32 years) were included. Primary etiologies were straddle injuries (falls from height) (42.1%) followed by sexual assault (36.84%). Grade III injuries predominated (47.4%), most commonly presenting with vaginal bleeding (73.68%). Primary closure using absorbable sutures was successful in 89% of cases. One patient (5.2%) required temporary diversion colostomy and one was referred with sigmoid colostomy. Mean follow-up was 6.2 months (range: 3-12). One patient (5.2%) experienced early post-operative bleeding requiring re-suturing. No cases of permanent fecal or urinary incontinence were recorded.

Conclusion: Early examination under anesthesia and systematic injury grading are crucial for optimal outcomes

 in perineal trauma in female children. Primary closure yields excellent results in most cases even in higher grades of injuries with selective use of fecal diversion. A standardized management protocol based on injury grade improves outcomes.

Isolated male epispadias (IME) is a rare entity with incidence of approximately 1 in 120,000 live births. Continent epispadias is an extremely rare entity with an incidence of less than 10percent of all cases. It is characterized by failure of the urethral plate to tabularize on the dorsum of the penis with defect ranging from glandular to penopubic region.The greatest challenge in treating epispadias is creating adequate penile length, straightening of penis and a penopubic angle that would allow comfortable penile penetration. A total of three male patient aged 6, 8 and 9 years with continent isolated penopubic epispadias underwent surgical repair with Modified Cantwell-Ransley reconstruction procedure. Postoperatively, there was no fistula and urine stream through neomeatus was adequate and the shape of the penis was cosmetically acceptable.

Umbilical evisceration is an uncommon extreme surgical emergency. The authors report the case of an infant.

A two-month-old male infant was presented with umbilical evisceration following ulceration of infectious origin on a parietal defect. The intestine was reintegrated through the umbilical ring. The post-operative course was complicated by a relapse. In the face of this complication, a laparotomy, an intestinal reintegration and a parietal repair were performed. The 2-week follow-up after discharge was satisfactory with no sign of relapse.

Spontaneous umbilical evisceration is an uncommon and unpredictable complication that should not be overlooked in the follow-up of umbilical hernia in children. Treatment is surgical by laparotomy, intestinal reintegration if the eviscerated intestinal mass is not ischaemic and parietal repair.