Original Articles

Early Versus Delayed Feeding in Paediatric Patients Following Stoma Reversal in a Resource Limited Environment

Muhammad Javaid Iqbal, Asif Iqbal, Mohammad Sajjad Anwer, Sajid Hameed Dar

Iranian Journal of Pediatric Surgery, Vol. 6 No. 2 (2020), 7 December 2020, Page 59-65

Introduction: Institution of early enteral nutrition is essential after stoma reversal. There is no consensus on the time feeding should be started after closure of a stoma in children. It is established that after stoma reversal early achievement of full feed and early discharge affects the overall cost in resource limited countries.

Materials and Methods: This Randomized control trial was conducted in the Paediatric Surgery Department of Services Hospital, Lahore. Over a period of 1 year, from April 2016 to March 2017, a total of 100 cases were included.  In group A, early feeding (after 36 to 48hours) and in group B delayed (after 5days) feeding was given to the patients. Time for restoration of full feed and length of hospital stay and complications were compared in both groups. Each patient was observed in the ward till discharge and followed up to 30 days in the out-patient department. The data was recorded and analyzed in SPSS version 20. Independent sample t-test was applied to obtain the p-value for comparing the means. P-value ≤ 0.05 was considered significant.

Results:  In both groups age, weight and etiology of stoma was comparable.  The full feed was achieved within 56.66 ± 7.77 hours in group A and 156.76 ± 7.96 hours in group B (P<0.005). Mean length of hospital stay was 5.84 ± 0.84 days in group A, while it was 9.50 ± 0.76 days in group B (P<0.005).

Conclusion: Early enteral feeding after stoma reversal is well tolerated and beneficial. It is suggested that early feeding protocol should be encouraged in a resource limited environment.

High Dose Botox Injection for Patients with Internal Anal Sphincter Achalasia Persistent to Posterior Internal Anal Sphincter Myectomy

Leily Mohajerzadeh, Amirmohammad Zakeri, Mehdi Zanganeh kia, Ahmad Khaleghnejad Tabari, Naghi Dara

Iranian Journal of Pediatric Surgery, Vol. 6 No. 2 (2020), 7 December 2020, Page 66-73

Introduction: one of the most common reported chief complaints in visits to pediatricians is constipation. Although in a majority of cases with no anatomical defect, dietary manipulation, stool softeners, and oral laxatives are successful, some patients fail to respond.

Internal Anal Sphincter (IAS) Achalasia is one of the causes of constipation.It results in failure of IAS relaxation and has similar clinical presentation to Hirschsprung’s disease with absence of rectosphincteric inhibitory reflex on anorectal manometry (ARM) and presence of ganglion cells on rectal biopsy.

Although posterior internal anal sphincter myectomy (ISM) is considered the standard treatment for IASA, some cases fail to respond and present with intractable constipation which may be associated with soiling.

This research aims to assess the role of botox injection for treatment of patients who presented with intractable constipation and have already beentreated by posterior IAS myectomy.

Materials and Methods:Internal anal sphincter Botox injection was performed (with a dose of 20 U/Kg) in 14 patients with internal anal sphincter achalasia (IASA); who had presented with intractable constipationafter being treated by posterior internal anal sphincter myectomy. Patients were followed for 2 years after injection.

Result: of all 14 patients with persistent constipation (resistant to oral laxatives), 12 patients (85.7%) had regular bowel function for more than 6 months after botox injection therapy (P < 0.05).

Of all 14 patients that had needed rectal enema for defecation, no patient needed rectal enema after botox injection therapy (P < 0.05). Of 5 patients with fecal soiling before botox injection therapy (4 had occasionalsoiling, and 1 had soiling every day without social problems) only a single patient experienced transient fecal soiling for 2 weeks after botox injection therapy (P < 0.05).

No patient needed another botox injection in 2 years of follow up.

Conclusion: IAS Botox injection therapy (BIT) was successfully used to manage IASA patients who had presented with intractable constipation after posterior myectomy. This method significantly reduces the need for laxatives and rectal enema; and improves constipation, fecal soiling and bowel movements at the same time.

Comparison of Combination of Sclerotherapy and Tiersch's Procedure with Perineal Rectopexy with Mesh in Children

Reza Ebrahimi, Baharah Ahmadi, Mehrdad Hosseinpour

Iranian Journal of Pediatric Surgery, Vol. 6 No. 2 (2020), 7 December 2020, Page 74-80

Introduction: Perineal rectopexy is a method for surgical treatment of rectal prolapse in children, but its accomplished using different techniques. We investigated the combination therapy of Tiersch's operation and sclerotherapy and compared its outcome with mesh rectopexy with talc.

Materials and Methods: A total of 80 children with rectal prolapse were selected and divided in two groups. In the control group rectopexy was performed by perineal mesh rectopexy with talc. In the case group, injection of 30% saline and, Tiersch’s operation were performed. The parameters used to compare the success of interventions were improvement of incontinence and constipation and a low rate of recurrence.

Result: Our results showed that the rate of improvement in constipation and incontinency was not significantly different in the two groups. The recurrence rate was 1.6 % in both groups in one year of follow up. Fifteen patients (37.5%) in the control group had severe anxiety and pain during the extraction of mesh. The length of hospitalization was 6.2± 0.94 in the controls and 0.86± 0.63 days in case group.

Conclusion: Our study suggests the combination perineal therapy (T+S) as an alternative approach for children who have limitations regarding talc rectopexy or the high hospital charges related to this approach.

Laparoscopic Transumbilical Appendectomy in Nonperforated Appendicitis in Pediatric Age Group

Leily Mohajerzadeh, Alireza Mahdavi, Sepehr Mirsepasi, Javad Ghoroubi, Sayeh Hatefi, Nazanin Khalili, Mehdi Sarafi, Amir Mohammad Zakeri

Iranian Journal of Pediatric Surgery, Vol. 6 No. 2 (2020), 7 December 2020, Page 81-91

Introduction: Laparoscopic appendectomy has recently been trended to be performed by using a less trocar technique. In children, appendectomy is performed more by open approach; so this study was designed to compare benefits of non-invasive laparoscopic appendectomy with usual open technique.

Materials and Methods: After obtaining institutional review board approval, from 2015 to 2018, 73 children with acute, nonperforated appendicitis were treated by single-incision laparoscopic or open approach. The patients were randomized to two treatment groups: 36 patients underwent open operation, and 37 by laparoscopic approach via single-incision in umbilicus. 3 cases of laparoscopic approach were converted to open surgery and removed from the study. In patient selection, cases of complicated appendicitis confirmed by imaging modalities were excluded. The outcomes were investigated in both groups by length of operation, duration of hospital stay, presence of postoperative fever, wound infection, ileus after operation, and pelvic abscess after surgery. 

Results: 73 appendectomies were carried out totally by single surgeon, 37 were single-incision laparoscopy and 36 underwent open procedure. Total anesthesia time and duration of operation showed significantly longer in the laparoscopic group. On the other hand, time to tolerate liquid diet was significantly shorter in the laparoscopic group. The duration of hospital stay showed similar duration in both groups. No mortality occurred in the study. Overall complications demonstrated no significant difference between two groups. Also there was no difference in infectious complications between the laparoscopic group and the open group

Conclusion: Our study suggests that Assisted Transumbilical laparoscopic appendectomy is a reasonable alternative to open surgery for appendicitis in acute none ruptured condition. All analyzed complications were similar between the groups, suggesting that Assisted Transumbilical laparoscopic appendectomy is a suitable ingrained method in pediatric cases with appendicitis

Comparative study of porting complications by implantation under and on the pectoral muscle in cancer patients at Shahid Beheshti and Hazrat Masoumeh hospitals during the years 2010-2014

Amrollah Salimi, Faeghe Mollaabassi, Sajjad Rezvan, Enayatollah Noori, Amirhossein Naderi; Nargess Kalhor, Sara Afshari

Iranian Journal of Pediatric Surgery, Vol. 6 No. 2 (2020), 7 December 2020, Page 92-99

Introduction: Porting is one of the invasive processes that is usually associated with significant complications in patients. Therefore, this study was conducted to compare the effects of porting in two ways: implanted under the muscle and on the pectoralis muscle of cancer patients.

Materials and Methods: In this retrospective cohort study, a comparison was made between patients whose ports were implanted under the muscle and patients whose ports were implanted on the pectoralis muscle. The level of significance was considered to be 0.05.

Results: The mean age of the patients was 17.83±19.1 months. 51.2% (42 patients) were boys and 48.8% (40 patients) were girls. Comparison of the average success (percentage) of the ports (P = 0.419), the incidence of infection (P = 0.241), the incidence of skin necrosis (P = 0.077) and the rate of displacement (P = 0.005). P) In patients between the two groups, there was no significant statistical difference in terms of port location.

Conclusion: The present study showed that there was no statistically significant difference in the amount of successful porting and comparison of infection, skin necrosis and port displacement in the studied patients, despite the higher incidence of porting group effects on the pectoralis muscle compared to the sub muscular.

Surgical Technique

Case Report

Microcystic Mesenteric Lymphatic Malformation, a Mimicker of Solid Masses in Pediatrics

Shamim Tayebi, Masoud Mahdavi Rashed, Majid Shams, Mona Maftouh

Iranian Journal of Pediatric Surgery, Vol. 6 No. 2 (2020), 7 December 2020, Page 113-117

Mesenteric microcystic lymphangioma is a rare benign abdominal mass. It appears as a solid mass which may mimic a solid mesenteric or omental mass. Pure microcystic lesions are ill-defined and hyperechoic due to abundant wall interfaces.

A case of mesenteric microcystic lymphangioma is presented in combination with appendicitis. A 6-year-old boy presented with rapid onset of abdominal pain accompanied by nausea and vomiting. Ultrasound showed a hyperechoic solid mass without vascularity at Doppler evaluation. Computed tomography showed a mass in the small bowel mesentery with attenuation values in the range of water. In the pathologic evaluation, mesenteric lymphangioma with small and medium-sized cysts was reported.

Microcystic lymphatic malformation could be considered in the differential diagnosis of a solid abdominal mass in pediatrics and imaging features can be helpful to differentiate between them.

Perforated Gastric Diverticulum in a Preterm Newborn: A Case Report

Seyed Amir Kazem Vejdan, Malihe Khosravi, Zahra Amirian

Iranian Journal of Pediatric Surgery, Vol. 6 No. 2 (2020), 7 December 2020, Page 118-122

Gastric diverticulum in newborn infants is the rarest (0.04%) of gastrointestinal diverticula. Most of them especially in this age group are asymptomatic or cannot be diagnosed based on examinations and symptoms. However, if it becomes symptomatic, the symptoms can range from vague abdominal pain to bleeding, perforation or torsion. The present case report discusses a preterm newborn with a perforated gastric diverticulum.