Original Articles

Alvarado vs. Pediatric Appendicitis Score (PAS) in Acute Appendicitis of Children

Davoud Badebarin, Sina Parsay, Saeed Aslanabadi

Iranian Journal of Pediatric Surgery, Vol. 6 No. 1 (2020), 11 August 2020, Page 1-9

Introduction: Acute appendicitis in children is associated with morbidity and mortality due to late diagnosis. Several scoring systems, such as Alvarado and PAS have been developed to help diagnose acute appendicitis in children to make the most accurate and prompt decision. The purpose of this study was to compare the efficacy and diagnostic value of these scoring systems.

Materials and Methods: In this cross-sectional study, 130 children aged 5-14 with suspected acute appendicitis were included. After the collection of demographic data, all patients were scored by Alvarado and PAS systems. The decision for surgery was made by a surgeon, independently of these scores. The diagnosis of acute appendicitis was affirmed by surgical and pathologic findings.

Results: Male: Female ratio was 1.32:1, and the average age of the patients were 9.2±2.7 years. The mean Alvarado and PAS scores were higher in patients with positive pathologic findings. Neutrophilia >75% and RLQ tenderness had the highest relationship with the diagnosis of the disease. The diagnostic value of Alvarado was higher than PAS concerning the area under the ROC curve. The cutoff point of 7 was associated with a sensitivity of 74.5% and specificity of 66.7% for the Alvarado score, and a sensitivity of 58.5% and specificity of 79.2% for the PAS score.

Conclusions: The results showed the high sensitivity of Alvarado and the high specificity of PAS. However, the sensitivity, specificity, PPV, and NPV of these criteria were not satisfactory for the confirmation of the diagnosis.

Comparison of Outcomes of Scrotal and Inguinal Incision Orchiopexy for Undescended Testis

Ahmet Atıcı, Gül Doğan, Çağatay Evrim Afşarlar

Iranian Journal of Pediatric Surgery, Vol. 6 No. 1 (2020), 11 August 2020, Page 10-18

Introduction: The aim of this study was to compare the results of treating undescended testis with conventional inguinal orchiopexy or by scrotal orchiopexy (in selected cases with undescended testis that can be rubbed up to the top of scrotum in their examination under general anesthesia).

Materials and Methods:  Physical examination files of 66 palpable undescended testes patients performed by two pediatric surgeons at a 5th level hospital in Kenya/Kiambu within the scope of the program (29/09/2018-07/10/2018) were retrospectively reviewed.

Result: There was a statistically significant difference between the groups in terms of surgery time (p = 0.001).  In both groups, there was no recurrence, testicular atrophy, and hernia or hydrocele formation complications. Scrotal hematoma was observed in one patient in each group.

Conclusion:  Scrotal orchiopexy is a comfortable method that can be preferred in children because it requires less dissection, shorter operative time, no need analgesia, a single scrotal incision, and the fact that inguinal canal is not opened.

Predictors of the Late Renal Outcome after Posterior Urethral Valves Ablation in a Developing Country: Long Term Study

Nancy Abdel-Salam, Wally Mahfouz, Mohamed El-Sayed Youssef, Mahmoud Mohi-Eldin El- Kersh, Mahmoud Adel Abdel-Moneim

Iranian Journal of Pediatric Surgery, Vol. 6 No. 1 (2020), 11 August 2020, Page 19-29

Introduction: Posterior urethral valves are the commonest form of obstructive uropathy in pediatrics and a common cause of chronic kidney disease (CKD) during childhood with estimated renal failure rate of 25-40%. This study aims at evaluating long term changes in kidney and bladder functions of children with posterior urethral valves after ablation, and at assessing predictors of late renal outcome, considering challenges in Egypt as a developing country.   Materials and Methods: A retrospective study of 30 surgically managed  PUVs patients who attended at Alexandria University Children’s Hospital for follow up. Patients underwent surgery between 2005 and 2016. Mean postoperative follow up period was 6.7±3.8 years (range 3.1 to 14.6 years). Data collected included age at presentation, clinical presentation, serum creatinine (initial, nadir, and last follow up), eGFR at last follow up, renal ultrasound (initial, and last follow up), voiding cystourethrogram (initial, and last follow up), and urodynamic studies at last follow up.   Results: Thirty patients underwent PUVs ablation at a median age of 9 months. Ten (33.3%) patients were diagnosed antenatally. At the last follow up visit, 14 (46.7%) patients had moderate-severe CKD. Twenty-five (83.3%) patients had abnormalities in their urodynamic studies. Univariate analysis showed the need for re-ablation, use of anti-cholinergics, high initial serum creatinine, high nadir creatinine, presence of VUR, history of febrile UTIs and presence of proteinuria were significantly associated with low eGFR. Multivariate analysis showed that high nadir creatinine and presence of VUR were independent factors associated with lower e-GFR at last follow-up. Antenatal diagnosis was significantly associated with better e-GFR. Conculsion: Nadir creatinine and vesicoureteral reflux have high prognostic value for late renal functions, and antenatal diagnosis is associated with better renal functions in patients with posterior urethral valves. Increasing family awareness, antenatal care facilities,and referal to tertiary care centers are priorities for promoting the antenatal diagnosis and management in developing countries.Facilities and training for prenatal intervention should be encouraged.

Single Stage Management of Anorectal Malformation in Male Neonates: Experience of a Tertiary Care Centre

Vinit Kumar Thakur, Zaheer Hasan, Vijayendra Kumar, Ramdhani Yadav, Sandeep Kumar Rahul, Digamber Chaubey

Iranian Journal of Pediatric Surgery, Vol. 6 No. 1 (2020), 11 August 2020, Page 30-36

Introduction: Anorectal malformation [ARM] can be treated either by staged procedures or by a single stage procedure. In the present study we have performed single stage surgery of ARM in male neonates.

Materials and Methods: Retrospective review of cases of ARM operated over 4 years at Indira Gandhi Institute of Medical Sciences, Patna, and Bihar from January 2015 to December 2018 were undertaken. In this study we have compared the results of single stage repair of Anorectal malformation with that of staged procedures performed earlier. Fifty four patients of Anorectal malformation were operated by single stage procedure (category 1) this was compared with staged procedures (category 2). Forty three patients underwent primary PSARP (posterior sagittal anorectoplasty) and the remaining 11 primary APP (abdomino-perineal pull through) procedure. The result of these single stage procedures were compared with that of staged procedures (category 2) in which a total of 39 cases were operated from 2012 to 2014.

Result: Mean post-operative hospital stay in category 1 was 11 days and 32 days in category 2. In category 1, 20 patients were analysed. In which PSARP procedure was done in 15 and in 5 patients APP procedure was performed. The Rest of the patients are in follow up. Kelly score was good to fair in 17 patients (85%) and poor in 3 (15%) patients. In category 2 it was good to fair in 28 (71.7%) cases and poor in 11 cases (28%).

Conclusion: Single stage surgical repair of anorectal malformation in male neonates is reliable and can be safely performed. Early results are encouraging; however, a long term follow-up is required to get any definite conclusion.

Value of Oxygenation Index in Selecting Neonates for Thoracoscopic Repair of Congenital Diaphragmatic Hernia

Mostafa Kotb, Sherif Shehata, Sameh Shehata, Ahmed Khairi, Aliaa Rabie, Tamer Ghonaim

Iranian Journal of Pediatric Surgery, Vol. 6 No. 1 (2020), 11 August 2020, Page 37-43

Introduction: The major obstacles for routine application of thoracoscopic repair for congenital diaphragmatic hernia (CHH) in neonates include intraoperative hypercarbia, acidosis and conversion to open surgery. Therefore, strict preoperative selection criteria should be followed for successful primary thoracoscopic repair of the diaphragm and achievement of minimal conversion rate.

Materials and Methods: A prospective study was conducted from April 2016 to March 2018, where all neonates confirmed to have CDH were assessed by a specialized anaesthesia team for the possibility of undergoing thoracoscopic repair. In order to assess the severity of persistent pulmonary hypertension (PPH), oxygenation index (OI) was used and babies who had OI <5 were considered to have mild pulmonary hypertension; and consequently underwent thoracoscopic repair.

Results: Twenty nine CDH cases met the selection criteria; hence, they underwent thoracoscopic repair. Primary diaphragmatic repair was successfully performed thoracoscopically in all neonates without perioperative complication. Conversion to open repair occurred in 3 cases, with causes related to surgical factors. Recurrence was discovered in 1 case only.

Conclusion: While choosing candidates for thoracoscopic CDH repair in neonates, OI is a reliable indicator as it clarifies neonates who have good preoperative pulmonary function

Surgical Technique

Stealth Surgery in Pediatric Age Group-an Aesthetic Alternative

Saurabh Garge, Geetika Paliwal

Iranian Journal of Pediatric Surgery, Vol. 6 No. 1 (2020), 11 August 2020, Page 44-49

Introduction: We used a subcutaneoscopic technique that places incisions at unnoticeable sites to avoid unsightly scars.

Materials and Methods: This is a review of five consecutive cases operated by stealth approach between January 2015 and December 2016. Three cases underwent subcutaneoscopic excision of dermoid cyst and two underwent stealth tenotomy for torticollis. All patients underwent stealth surgery as previously described with few technical modifications.

Results: All five cases underwent successful subcutaneoscopic surgery without the need for conversion. The mean operative duration of the procedure was 45 min.(Range,40-50min) for the external angular dermoid excision and 67.5 min(Range,60-75 min.) for the sternomastoid tenotomy. There were no complications, and all patients had excellent cosmesis.

Conclusion:Subcutaneoscopic excision of dermoid cyst is a technically feasible procedure in pediatric patients and provides excellent cosmesis.

Case Report

Splenogonadal Fusion Discovered by Testicular Torsion

Nahla Hmidi, Dorsaf Makhlouf, Rachida Laamiri, Nahla Kechiche, Badii Hmida, Amine Ksia, Lasaad Sahnoun, Mongi Mekki, Mohsen Belguith, Abdellatif Nouri

Iranian Journal of Pediatric Surgery, Vol. 6 No. 1 (2020), 11 August 2020, Page 50-53

Splenogonadal fusion, which is adherence of splenic tissue to gonads, is an uncommon congenital anomaly which mainly affects males. Herein, we report a case of splenogonadal fusion in a 20-month-old boy presenting with acute scrotal pain and inflammation. With the suspicion of left testicular torsion, an emergent left scrotal exploration was carried out. It revealed a necrotic left testicle along with a 360° rotation of the spermatic cord and three accessory structures in the lower pole of the testicle. Histology showed the presence of a splenic tissue. Splenogonadal fusion can present as an acute condition mimicking a testicular torsion. But, one should always bear in mind the possibility of this association. Splenogonadal fusion should be included in differential diagnosis of testicular mass to avoid unnecessary orchidectomy.

Malrotation with Distal Duodenal Necrosis in a Neonate

Vinit kumar Thakur, Digamber Chaubey, Vijayendra Kumar, Ramdhani Yadav, Deepak Kumar, Sandip Kumar Rahul

Iranian Journal of Pediatric Surgery, Vol. 6 No. 1 (2020), 11 August 2020, Page 54-58

Malrotation with midgut volvulus often results in gangrene of midgut with relative sparing of duodenum. An extremely unusual case of Malrotation with isolated necrosis of distal duodenum is described with brief review of literature. Isolated duodenal necrosis in association with malrotation is very rare; it increases the complexity of surgery and prolongs hospital stay.