Original Articles

Outcomes of Hepaticoduodenostomy over T-tube against Roux-en-Y Hepaticojejunostomy to Restore Bilio-enteric Continuity after Choledochal Cyst Excision in Children

Vinit Kumar Thakur, Ramdhani Yadav, Digamber Chaubey, Rupesh Keshri, Zaheer Hasan, Vijayendra Kumar, Ramjee Prasad, Rakesh Kumar, Sandip Kumar Rahul

Iranian Journal of Pediatric Surgery, Vol. 7 No. 2 (2021), 12 Khordad 2021, Page 68-80

Introduction: Any surgical procedure which would restore the bilio-enteric continuity after excision of the choledochal cyst with minimal complications would be a feasible alternative to Hepaticojejunostomy using a Roux loop of jejunum. To determine the outcomes of Hepaticoduodenostomy done over T-Tube against Roux-en-Y Hepaticojejunostomy for bilio-enteric reconstruction after excision of choledochal cyst.

Materials and Methods: This study was retrospectively done on all patients of choledochal cysts (Types 1 and 4) operated between January, 2014 and December, 2019. The clinical details, intra-operative and post-operative results of patients who underwent Roux-en-Y Hepatico-Jejunostomy (Group-1) and Hepatico-duodenostomy over T-Tube (Group -2) for establishing bilio-enteric continuity after excision of choledochal cyst were compared and analyzed statistically.

Results: 78 patients of choledochal cysts were operated during this period with 31 patients in Group-1 and 47 in Group-2; there was no difference in the mean age or size of the cysts in the two groups; Type 1 cysts were the most common with female preponderance in both groups. Group-2 patients had lesser intra-operative time andfewer numbers of sutures were used during surgery. There was no difference in the incidence of anastomotic leaks, strictures, cholangitis or adhesive obstruction and reoperation rates between the two groups. Group 2 showed increased nasogastric bilious aspirates in 19.15% of cases which improved on conservative management.

Conclusion: Bilio-enteric reconstruction using Hepaticoduodenostomy over T-Tube is a simpler, lower pressure and less time taking anastomotic technique with comparable complication rates when compared to Roux-en-Y Hepaticojejunostomy in the management of choledochal cysts.

Comparison Outcomes of Divided End Loop Versus Separate Double Barrel Colostomy in Neonates with Imperforate Anus

Shahnam Askarpour, Mehran Peyvasteh, Khalil Kazemnia, Hazhir Javaherzadeh

Iranian Journal of Pediatric Surgery, Vol. 7 No. 2 (2021), 12 Khordad 2021, Page 81-89

Introduction: the aim of current is to compare clinical outcomes between the divided end loop and separate double barrel colostomy in neonates with imperforate anus.

Materials and Methods: This is a retrospective study to review 184 patients who presented with imperforate anus and were managed with a divided end loop or separate double barrel colostomy between 2017 and 2020. Complications were compared in the two groups.

Results: There was more skin excoriation in separate double barrel colostomy compared to divided end loop colostomy (p=0.001).  The mean of scar size in patients of divided end loop colostomy group was lower than that of separate double barrel colostomy significantly (p<0.0001).

Conclusion: Our results suggest that divided end loop colostomy may be more acceptable than separate double barrel colostomy for neonates with imperforate anus.

Outcome of Surgical Approach and Speech Therapy on Quality of Speech in Patients Suffering Cleft Palate

Leily Mohajerzadeh, Iman Harirforoosh, Reyhaneh Kazemi, Ahmad Khaleghnejad Tabari, Mohsen Rouzrokh, Javad Ghoroubi, Mehdi Sarafi

Iranian Journal of Pediatric Surgery, Vol. 7 No. 2 (2021), 12 Khordad 2021, Page 90-97

Introduction: A patient suffering from cleft palate has speech problems even after undergoing surgical procedures to correct it. These problems can be improved by some modality of speech therapy. In this study we aimed to evaluate the outcome of our surgical approach and also the impact of speech therapy on quality of speech in patients who suffered from cleft palate and had undergone surgical correction in Mofid hospital since2011 to 2015.

Materials and Methods: We evaluated the quality of speech in the patients suffering cleft palate, older than 3 years who had undergone surgical correction since 2011 to 2015 in our center. Parameters were evaluated in this study included hypernasality, audible nasal emission and disarticulation due to velopharyngeal insufficiency. This process was performed by our center’s speech professionals and informed consent was obtained from the patient's parents.

Results: We studied 202 children, 101 males and 101 females. The first surgical procedure was done in the average age of 16 months. Among the postoperative complications, 90.1% of the patients had hypernasality and 66% of the patients had velopharyngeal insufficiency. All these patients were referred to speech therapy and it was shown that there is a significant improvement in the quality of their speech. There was no significant relationship between gender and prevalence of postoperative complications orhypernasality as one of the speech quality elements (P value: 0.34) and there was no significant difference between the age of first surgical reconstructive surgery and speech quality outcomes, but the early reconstruction had strong relation with reduction in postoperative complications and overall final result (P value: 0.043).According to Kruskal-Wallis statistical analysis, there were no significant superiority on speech quality outcome among the three mentioned different surgical methods (P value: 0.203).Also there was a significant improvement in correcting hypernasality as one of the main complications after speech therapy courses (P value:0.0087).

Conclusion: In this study, supportive measures such as speech therapy have been shown to improve post-operative complications of cleft palate, such as hypernasality, nasal emission and disarticulation due to velopharyngeal insufficiency. Duration of speech therapy was also significantly effective on speech improvement.

Evaluation of Congenital Diaphragmatic Hernia Repair with Thoracoscope in Neonates

Leily Mohajerzadeh, Morteza Aghajani, Mohsen Rouzrokh, Mehdi Sarafi, Minoo Fallahi, Samira Borhani

Iranian Journal of Pediatric Surgery, Vol. 7 No. 2 (2021), 12 Khordad 2021, Page 98-106

Introduction: congenital diaphragmatic hernia (CDH) is one of the most common congenital anomalies with significant morbidity and mortality. The most common form of CDH is Bochdaleck type of the anomaly, with the defect located in poster lateral part of the diaphragm. The aim of this retrospective study was to compare the outcome of open repair (OR) with thoracoscopic repair (TR) for Bochdaleck CDH at Mofid Children Hospital.

Materials and Methods: neonates with Bochdaleck CDH at Mofid Children Hospital from 2015 to 2018 were studied. After meeting the criteria, the information during and after surgery was recorded in the questionnaire. We compared the data with independent T- test and Chi-square.

Results: a total number of 18 patients were included, of whom 9 underwent thoracoscopic repair and 9 underwent open repair. Mean age at the operation was 5.3 days in TR group vs. 3.89days in OR group(P= 0.9). In TRgroup 37.5% of the patients were female and 62.5% male, versus OR group with 22.2% female and 77.8% male (P= 0.62).Gestational age at birth in TR group was 37.2 weeks vs 37.89 weeks in OR group (P= 0.85).Birth weight in TR group was 2904.22 g vs. 2988.88gin OR group (P= 0.96). Delivery type in TR group was NVD in 22.2% and C/S in 77.8%;vs. 33.3% NVD and 66.7% C/S in OR group (P = 1). In TR group none had prenatal diagnosis, while in OR group 11.1% had and 88.9% didn’t have prenatal diagnosis (P= 1). Entrance status to Mofid Children Hospital: all of them were nonintubated, with no family history of CDH. CPR Hx: TR one vs. OR none (P= 1), recurrence: TR 0vs. 1 OR (P= 0.3), Echo abnormal results: TR 44.4 % vs. OR 66.7 (P=0.63), brain abnormal US: TR 0 vs. OR 1 (P= 0.38), skeletal anomaly: 1in TR (P= 1), post-op admission: TR 18d vs. OR 25d (P= 0.04),commencement of enteral feeding: TR 8.7d vs. OR 5.7d (P= 0.78), complications: 1 in OR (P =0.3), survival: 1 death in TR & 1 in OR (P= 1),death age: TR at 270d vs. OR 81d (P= 1).

Conclusion: thoracoscopic repair appears to be as effective as open repair for treating cardiopulmonary stable patients. Thoracoscopic repair is in some way much better than open repair such as wound cosmetic and hospital stay.

Early Detection and Aggressive Management Is a Key to Success in Management of Childhood Constipation

Akshay Kalavant, Swathy A R, Shrinath Shetty, Venkatesh Annigeri

Iranian Journal of Pediatric Surgery, Vol. 7 No. 2 (2021), 12 Khordad 2021, Page 107-120

Introduction: Functional constipation is an emerging problem in childhood of Indian subcontinent. If diagnosed early and managed aggressively along with lifestyle modification the success rate of disease treatment improves.
• To assess whether the pain abdomen is the early feature of constipation
• To determine the relationship between good follow ups and the outcome
• To determine the minimum duration of laxative therapy in management of constipation

Materials and Methods: A retrospective analytical study of 150 children with constipation. Various parameters were considered namely demographic details, eating habits, clinical examination, abdominal radiographs and abdominal ultrasonography. Patients were divided into two groups based on the symptoms at the presentation. The first comparison was between constipation group vs pain abdomen group. Second comparison was between the patients with good follow-ups and bad follow-ups. The finally the duration of laxative therapy was assessed. Data was entered into Microsoft Excel and analysed using SPSS version 25. The categorical variables are presented using frequency and percentages. Chi square tests were used for statistical analysis. p<0.05 is considered as significant value for interpretation of results.

Results: All the 150 patients were treated for constipation 70% showed improvement. Eighty percent of pain abdomen group patients also showed improvement in their symptoms suggesting that they might be the subset of larger constipation group. 97.1% patient with good follow-up followed the dietary advice. The study reveals that there is an association between following dietary advice and final improvement. 70.5% who followed dietary advice had good outcome irrespective of the use of regular laxatives. Most of the patients (78 %) showed the improvement with 3- 6 months of laxative therapy.

Conclusion: Pain abdomen with stool stasis must be considered as early feature of constipation. Patients with better follow and good dietary habits have significant improvement. Aggressive therapy with two laxatives for 3-6 months can increase the success.

Pediatric Patients Undergoing Surgery with Peroperative SARS-Cov-2 Infection: An Iranian Case Brief Report

Shahnam Askarpour, Mohsen Yousofzadeh, Mahmud Khoshkhabar, Hoda Ilkhani pak, Fakher Rahim, khalil kazemnia

Iranian Journal of Pediatric Surgery, Vol. 7 No. 2 (2021), 12 Khordad 2021, Page 121-125

Introduction: The present study aimed to assess COVID-19 disease complications and its related 30-day mortality in pediatric patients with perioperative SARS-CoV-2 infection who had surgery.

Materials and Methods: A multi-center, prospective, brief report of pediatric patients who had surgery at 6 hospitals in 4 cities of Khuzestan Province, South-western Iran, one of the provinces with the highest prevalence and death rates due to COVID-19 disease. COVID-19 status and its effect on the course and outcome of the patients was investigated.

Results: 246 pediatric patients who had surgery between Jan 20 and Jun 01, 2020 with a 30-day follow-up period enrolled in the study. Four (1.62%) of the 246 patients who underwent surgery had perioperative COVID-19 infection. The most common symptoms included dyspnea, fever, and cough. Surgical procedures included total gastrectomy and esophagojejunostomy, bilateral pleural effusions tap, catheter placement for dialysis, and CV-line placement. Three patients had comorbidities including congestive heart failure (CHF), end-stage renal disease (ESRD), and diabetes.

Conclusion: Based on our results, it can be said that the prevalence of this disease in children is lower than the average of the society; and the outcome in younger patients seems to be better. Though it seems that COVID-19 disease is a low risk and somehow benign condition in children undergoing surgery, but due to the unpredictable nature of the disease, public health recommendations at both general and special levels have been made by the World Health Organization (WHO) to prevent the disease. Further studies with larger samples are necessary to confirm our findings and to clarify which age groups are at increased risk for developing severe COVID-19 infection and its related morbidities and death.

Case Report

Death Due to Late Onset Diaphragmatic Hernia

Dandeniya Arachchige Harshani Samadhi , Pradeep Rohan Ruwanpura

Iranian Journal of Pediatric Surgery, Vol. 7 No. 2 (2021), 12 Khordad 2021, Page 126-132

Diaphragmatic hernia is usually congenital, nevertheless it can also be acquired, particularly following trauma. Most of late onset hernias are acquired and reported cases of congenital type are rare. This case explicates a late onset congenital diaphragmatic hernia (CDH) where the diagnosis was made at the time of autopsy. Autopsy revealed the stomach and the proximal small intestines to be present in the left hemi thorax through a 4.5cm X 5cm defect in left hemi-diaphragm. Left lung was found to be collapsed and 60 g in weight. Histology revealed pulmonary hypoplasia. The Cause of Death was declared as CDH complicated with lung hypoplasia.

Simultaneous Antegrade and Retrograde Intussusceptions in a Child: A Rare Condition and Literature Review

Jean Baptiste Yaokreh, Sounkéré-Soro Moufidath, Helen A Thomas, Yapo GS Kouamé, Bertin D Kouamé, Ossénou Ouattara

Iranian Journal of Pediatric Surgery, Vol. 7 No. 2 (2021), 12 Khordad 2021, Page 133-138

Intussusception is one of the major abdominal emergencies in children under two years of age. Double intussusceptions are rare, and the simultaneous ante grade and retrograde occurrence is even rarer. Fewer than 10 such cases have been reported in the pediatric population.

An 8-month-old girl was presented to a peripheral health center with paroxysmal abdominal pain for two days, as well as postprandial vomiting and four mucous stools. She was diagnosed with amoebic dysentery. Faced with the appearance of glairy-bloody stools, she was admitted to our pediatric emergency unit. After examination and abdominal ultrasound, the diagnosis of intussusceptions was made. On the fourth day, operative findings showed a double ante grade and retrograde pattern. A manual reduction followed by an appendectomy was performed. The postoperative course was uneventful.  

Continuing education of peripheral practitioners will allow early diagnosis and appropriate treatment as this misdiagnosis could have compromised the vascular reserve of the bowel, resulting in intestinal ischemia and possibly perforation.

Lip Commissure Reconstruction with the Facial Artery Muscular-Mucosal (FAMM) Flap: A Case Report of a Child with Electrical Commissural Injury

Jamshid Yousefi; Fariba Tabrizian Namini; Seyed Mohammad Ali Raisolsadat

Iranian Journal of Pediatric Surgery, Vol. 7 No. 2 (2021), 12 Khordad 2021, Page 139-145

Electrical burn damages constitutes of 4% of all burn trauma. Approximately 20% of total electrical burn injuries occur in children. Most electrical injuries in children occur at home. When the child bites or chews an electrical cord, it results in oral and commissural injury. It is also noted that male children are predominantly affected with electric current injuries than female children. We introduce an immigrant 3-year-old boy admitted in the hospital one week after an electrical injury of the oral cavity due to biting a television cord. He had a necrotic lesion on his right oral commissure. There is controversy about the time and relevant management of mouth commissure injury. In this case, because of lack of parents’ consent, we did the reconstruction of his oral commissure very late without any molding intervention. There is more than 200 techniques in the management of lip and oral commissural injury; we used a Facial Artery Mucosal-Muscular (FAMM) flap for the repair with good result. Although with the improvement of burn care and its management outcomes, prevention is still the best way of minimizing the prevalence and severity of electric current burn injuries.