Iranian Journal of Pediatric Surgery

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Introduction: Double aortic arch (DAA) is a rare congenital malformation. Strategies for diagnosis and treatment are different. Reports of thoracoscopic treatment of DAA are rare. We report a description of our diagnostic and therapeutic approach and evaluate outcomes.

Material & Methods: We reviewed charts of infants with double aortic arch who were hospitalized in our department from 2008 to 2014. Age at symptom onset, clinical presentation, diagnostic modality, operative details and post operative outcomes were retrieved.

 Results: We identified 7 patients presenting at a median age of 11,8 months (range: 2 months-27 months) and median weight of 10kg. Respiratory symptoms were present in all cases. Difficulties in feedings were present in 3 cases. Chest radiography, oesophagogram and Computed Tomography (CT) with three-dimentional (3D) reconstructions were performed for all patients. One patient had laryngo tracheoscopy and 3 patients echocardiography. The dominant branch was the right one in all cases. Associated cardiac anomaly was found in 1 case. Operative approach was thoracotomy in 3 cases and thoracoscopic video assisted surgery (VATS) in 4 cases. Median operative time was 132 min. Only one patient required conversion. Median hospital stay was 4,1 days.

Conclusion: Double aortic arch is a rare malformation which can cause persistent non specific respiratory symptoms in infants. The use of 3D-CT scan reconstruction facilitates diagnosis and the operative approach. Thoracoscopy and thoracotomy are effective procedures even for patients with low body weight. The operative time seems similar for both approaches. Thoracoscopy offers less post-operative analgesia requirement, shorter hospital stay and good cosmetic results.

Introduction: Management of pediatric blunt abdominal trauma in resource-restricted settings requires precise clinical expertise. In this study, we reviewed pediatric patients who were suspected to have blunt abdominal trauma in a level III trauma center in Iran.

Materials and Methods: In a cross-sectional study, 66 injured children were studied from October 01, 2014 to October 01, 2015 in Nikshahr, Sistan-va-Balouchestan, Iran. Patient characteristics, type of trauma, initial evaluation and final decisions were analyzed.

Results: Mean age was 8.2 ± 13.3 years. Thirty five patients (53%) were boys and 31 patients (47%) were girls. Focused Assessment with Sonography for Trauma (FAST) was done for all patients. Diagnostic Peritoneal Lavage (DPL) was done on five patients (7.6%). Laparatomy was conducted on seven patients (10.6%). Ten patients (15.2%) were referred to a higher level trauma center. There were three mortalities (4.5%). Positive FAST was associated with hemodynamic instability (p<0.05) and the need for laparatomy (p<0.05). Positive FAST was also associated with more admission days (5.9 ± 5.1 days versus 2.1 ± 2.6 days; p<0.05). There was also a significant relationship between the length of hospital stay and associated traumas (p<0.001).

Conclusion: Computed tomography and intensive care unit may be unavailable in resource restricted settings with level III and IV trauma centers. However, physical examination, FAST and DPL are useful diagnostic tools for assessment of injured children with blunt abdominal trauma.

Introduction: Hospitalization and surgery are among the most difficult experiences which children and their parents have to face. Many parents experience preoperative anxiety during the hospitalization of their children. This study attempts to assess preoperative anxiety in parents of children admitted for elective surgery and to evaluate factors associated with increased anxiety. 

Material and Methods: In a cross-sectional study, all parents consecutively admitted to the study hospitals (Shahid Beheshti hospital in kashan and Imam Hossein hospital in Esfahan) were assessed. We used standard anxiety assessment questionnaires [Amsterdam Preoperative Anxiety and Information Scale (APAIS) and Spielberger’s State-Trait Anxiety Inventory (STAI)] to quantify the anxiety of parents just before their child entered the operative theater. For mean comparison between variables, independent t-test, ANOVA and Chi-square analysis were used. Multiple regressions were conducted to determine the factors attributed to pre operative anxiety. A P-value of less than 0.05 was considered significant.

Results: In this study 100 parents (60 cases from Shahid Beheshti hospital and 40 patients from Imam Hossein hospital) were evaluated. The mean anxiety score was 51.05±1.19 for STAI, 15.27±2.83 for APAIS (anxiety), and 8.07±1.7 for APAIS (information) respectively. Parents education was a factor that significantly affected the STAI (p=0.042), but its effect on APAIS was not significant. In regression analysis for anxiety severity, child age was a significant factor of anxiety status (p=0.043).

Conclusions: This study showed that anxiety is relatively high in our centers and parent’s education and children age are the most important predictive factors for this condition

Introduction: Foregut duplication cysts along with vertebral anomalies are called neurenteric cyst. About 30 cases have been reported in the literature so far. Posterior mediastinal neurenteric cysts are very rare and few studies could be found in the literature even after extensive search. Due to this rarity we are prompted to present 7 cases of posterior mediastinal neurenteric cysts to further add on to the literature.

Material and Methods: All details regarding patients with neurenteric cysts who underwent surgery, in the department of paediatric surgery from 2010 to 2015 were gathered from patient case files.

Results: There were 7 patients with neurenteric cyst including 3 males and 4 females with an age range of 4 months to 8 years. The most common presentation was recurrent respiratory infection. In two cases, patients also suffered from dysphasia. In 5 cases there were right sided cysts while two had cyst on left side in posterior mediastinum. In 2 cases the cysts extended to the abdomen while one patient had separate ileal duplication cyst. Another case had mediastinal cyst which had a communication with ileum. All the mediastinal cysts were excised through posterior thoracotomy and subsequently confirmed on histopathology.

Conclusion: When considering the differential diagnosis of mediastinal cysts in children, neurenteric cysts should be in mind.

Introduction: In this retrospective study radiographic review was undertaken in patients treated for AIS (Adolescent Idiopathic Scoliosis), in order to determine the most important preoperative factors that are seen with postoperative junctional kyphosis.

Material &Methods: Sagittal spine profiles were measured on the standing radiographs before surgery, after surgery and in the last follow-up postoperative visit of the patients with AIS. The following parameters were measured on lateral views: lumbar lordosis, thoracic kyphosis, the sagittal offset distance of C7 to a vertical line from postero-superior edge of S1 (Sagittal Vertical Axis-SVA) and T9 sagittal offset angle.

 Results: One hundred and twenty patients with a mean 42 months of follow-up (24-112 months) were included in the study. Mean values of the parameters before corrective surgery were: lumbar lordosis 45° ± 13.6°, thoracic kyphosis 28°±18.4°, SVA 35 ± 27.2 mm and T9 offset angle, 7.8°± 5.1°. Mean values at last follow-up were: lumbar lordosis 49± 9.8°, thoracic kyphosis 35 ± 16.4°, SVA 39 ± 24 mm and T9 offset angle, 8.6°±5.8°. There were 10 upper junctional kyphosis (8.4%). T test statistics revealed significant correction of lumbar lordosis and thoracic kyphosis after fusion in all patients (P<0.001, P=0.006 respectively). Preoperative mean of T9 sagittal offset angle was higher in the patients with proximal junctional kyphosis (P=0.006).

Conclusion: Normal sagittal balance of spine is essential for the optimum function of the intervertebral disks and preventing sagittal postoperative complication like proximal junctional kyphosis. More attention to preoperative sagittal parameters of the spine like T9 offset may be important to prevent such complications.

Introduction: Ulcerative colitis (UC) is a debilitating disorder of colon. The incidence of UC peaks in the age group of 15 to 25, and only 1% are infantile. Despite initial medical treatment, in refractory cases, colectomy is needed. There are few studies regarding surgical results of treatment of UC in infancy.

Material & Methods: In our descriptive retrospective study we reviewed medical files of infants with ulcerative colitis that consulted with us for surgery between 2009 and 2014. Age at onset, family history of inflammatory bowel disease, symptoms of onset, colonoscopic findings, duration of Medical treatment, Indication of surgery, Type of operation, surgical complications and their Management and mortality was recorded.

Results: We found five patients with the diagnosis of UC in their first year of life; 4 boys and 1girl. The mean age of onset of the disease was 35 days (range 3-60). The mean age of patients at the time of surgical consult was 7 months. The disease began in 3 patients with watery diarrhea. Family history was positive in only one of our cases. He had sever FTT with no response to medical treatment which was an indication for surgery and he underwent total proctocoletomy, ileoanal anastomosis and loop ileostomy which failed and 3 days after the first operation we performed an end ileostomy. Two cases had colon perforation following their colonoscopy and one of them (a 4 month girl) expired before laparotomy and the other (a 12 month boy) underwent colostomy creation while he was in septic shock. The fourth patient was a 2 day old neonate with abdominal distention and intestinal obstruction. Rectal biopsy showed agangliosis so he underwent a transanal pull through procedure with a diagnosis of hirschsprung’s disease. After surgery he experienced recurrent watery diarrhea and further diagnostic investigations brought about the diagnosis of UC. Our last patient was a 3 day old neonate that underwent ileostomy in the initial surgery with suspicion of total colonic agangliosis and underwent subtotal colectomy when he was 2 months old. At 1.5 years he developed toxic mega-colon in the remnant of colon when he was old and thus was referred to us and underwent colostomy. After 3 month the final surgery was carried out.

Conclusions: If a child presents with recurrent bloody or watery diarrhea even in infancy, UC should be considered as a differential diagnosis. The pattern of the disease in infancy appears more rigorous. Evidence-based management of UC presenting in infancy is incomplete but early surgical attempt can reduce catastrophic results.

Introduction Peritoneal inclusion cyst (PIC) is a cyst lined with mesothelium and usually full of fluids in the pelvis and it is most usually seen in young women and rarely, they may occur in males.

Case Presentation A 12 year old boy was referred with a two-day history of abdominal pain. Abdominal examination revealed lower abdominal tenderness. Laboratory tests were normal. Imaging by abdominal ultrasound and CT scan showed collection of fluid in the pelvis with some septations and lymphadenopathies. Shapeless cystic mass with thin membrane which was independent of abdominal organs was found during laparoscopy and extracted from pelvic cavity. Histopathologic examination established the diagnosis of peritoneal inclusion cyst.

Conclusion peritoneal inclusion cyst should be in mind as differential diagnosis in a patient with intra-abdominal cystic fluid collection even in childhood and male gender.

Urinary bladder hemangiomas are very rare and accounting for 0.6% of all urinary bladder tumors. An 8-year old boy presented with gross hematuria. After obtaining history and physical examination and imaging studies; transurethral resection biopsy reported hemangioma in association with an exteravesical cyst.