Iranian Journal of Pediatric Surgery

Introduction: The primary aim of surgical procedures for Hirschsprung's disease is to establish proper bowel movement without fecal incontinence, constipation and entrocolitis. In this study we evaluated short and mid-term outcomes in children with Hirschsprung's disease undergoing different surgical procedures.

Method and materials:  In a prospective singe blind study, 50 children with Hirschsprung's disease were selected. Patient eligibility included age under ten years and an elective single stage Duhamel (D group) or trans- anal procedure (T group).Primary end point data collected included the development of post-operative constipation and fecal incontinency in groups. Secondary end points of study were intra-abdominal infection, anastomotic leak, wound infection and Hirschsprung associated enterocolitis .

Results: Post-operative constipation persisted in 14 (56%) after 1 month in D group and in 7(28%) in T group (p =0.04).  Post –operative constipation persisted in 16 (64%) after 6 month in D group and in 10(40%) in T group (p =.08). There was no significant difference in fecal incontinency rates between groups.

Conclusion: For young children with Hirschsprung's disease who scheduled for operation, we had found no clear difference in mid-term outcome.

Introduction:

Trauma is a serious global health issue, and children are among the world's most vulnerable victims. Pediatric Trauma Score (PTS) is a rating for the prediction of death in pediatric with trauma .This study aimed to evaluate the predictive power of PTS in predicting death in children with trauma.

Methods: This prospective study was part of a national study to develop a primary model for estimating mortality by adjusting the severity of injury in Iran. Which was performed on 92 pediatric trauma participants. To predict the predictive power of PTS, the Area under the Curve (AUC), 95 % confidence interval (95 % CI), sensitivity, specificity, coefficient of determination and, odds ratio were utilized. All tests were carried out with a significance level of 0.05.

Results: The mean age of patients participating in this study was 11.86 ± 4.94 years and 68 (73.91%) of them were male. The most common injury type was head and face (53.26%) trauma and the most common cause of trauma was motorcycle accidents (27.17%), respectively. The AUC value for PTS score was 0.911 and its coefficient of determination (R2) was 38%.

Conclusion: PTS is a good score for predicting trauma death in children in Iran. PTS can be used especially for triage of children with trauma in hospitals.

Introduction: Caustic esophageal injuries often lead to severe strictures untreatable with endoscopic methods which necessitate surgical interventions. The aim of this study was to evaluate the outcomes and efficacy of these different techniques including trans-hiatal gastric pull up, gastric pull up via thoracotomy, reverse gastric tube, and colonic interposition and compare their complications.

Materials and Methods: This reto- and prospective study was conducted from 2014 onward at Mofid Children Hospital in Tehran. Data of patients who had undergone esophageal replacement surgery from 2007 to 2017 was retro- and prospectively retrieved from the hospital archives and the newly referred patients during the study. Required data were extracted from medical records. Data analysis was performed with SPSS 21 software package.

Results: 27 patients (mean age: 4.01 years, 59.3% males) were included in this survey. Average time from ingestion to surgery was 8.44 months. All patients had dysphagia. 5.8 sessions of endoscopic dilatation were performed for each patient, on average. 70.4% of patients underwent thoracotomy and gastric pull-up. ICU stay duration was 6.88 and time to extubation was 2.25 days. The most common complication was post-discharge stricture. Surgical methods were all the same regarding different parameters except post-discharge stricture and iatrogenic esophageal perforation.

Conclusion: Overally, surgical methods did not differ in terms of outcomes and complications.

Introduction: Rectal prolapse is a relatively common disorder in childhood. In this phenomenon, the whole layers of the rectum protrude throughout the anus. Self-limiting cases of rectal prolapse are more common in children below four years old, and overall prevalence is higher in the first year of life, with a predominance of male children. Formerly, the therapeutic efforts insisted on surgery. Nowadays, noninvasive methods like Sclerotherapy have entered the arena.

Materials and Methods: This study aimed to compare the efficacy and postoperative complications of 56 children suffering from full-thickness rectal prolapse retrospectively randomized in two groups of conventional surgery and Sclerotherapy referring to the Mofid children's hospital from 2017 to 2020. The authors have used Lockhart mummery rectopexy and Sclerotherapy methods with hypertonic dextrose 50%.

Results: Our results revealed a statistically significant difference in mean hospital stay (P-value <0.0001) and follow-up time (P-value=0.009) in the sclerotherapy group compared to other group, but surgical complications (P-value=0.58) and recurrence rate (P-value= 0.62) were statistically non-significant in both groups.

Conclusion: careful selection of patients based on symptoms has a vital role in the success of the chosen method for treating rectal prolapse in children.

Introduction: In the medical world, acute appendicitis is one of the common surgeries. The Aim of this study is determining reliability of ultrasound in acute appendicitis.

Materials and Methods: The ethical code has been gotten in this research firstly. Based on the archives at Mofid Hospital, the list of appendectomy children in a six- months period has been extracted when they used the ultrasound prior to surgery. Demographic data, medical history and findings of appendicitis, even during the surgery, have been recorded using designed questionnaire based on patients’ documents. According to the surgeon report, not only have appendicitis patients  been operated but also confirmed. The ultrasound results have been compared with surgical results (as the gold standard). For each of the ultrasound findings, based on SPSS software as has used for analyzing, some parameters have been calculated such as sensitivity index, specificity, positive and negative predictive value, accuracy and area under the ROC curve. 

Results:     In this study, 111 children with diagnosis of appendicitis have been operated. Based on the ultrasound prior to surgery, 71 patients (64%) with purulent appendicitis showed direct sonographic signs of appendicitis, 11 patients (9.9%) showed indirect signs, 6 patients (5.4%) revealed complicated signs, 7 patients (6.3%) with mesenteric lymphadenopathy and 16 patients (14.4%) negative in ultrasound. Also, according to the final diagnosis after surgery, 105 patients (94.6%) had appendicitis and 6 people (5.4%) were negative for appendicitis. The significant relationship was found between the ultrasound results prior to surgery and the final diagnosis after surgery for patients (p<0.05). The diagnostic value of ultrasound results prior to surgery in order to determine the appendicitis in children undergoing surgery has been revealed by different factors such as sensitivity, specificity, positive predictive value, negative predictive value and accuracy . These factors are at 83.8%, 100%, 100%,83% and 92.3%, respectively (p< 0.05).

Conclusion:   It seems that Ultrasound prior to surgery is the useful method to determine the children appendicitis.

Introduction: Posterior urethral valve represents the most common etiology of congenital urethral obstruction in boys. 35-50% of PUV cases have vesicoureteric reflux at the time of diagnosis. Endoscopic ablation of valves is the treatment of choice. In this study we evaluated the association of primary kidney function and VUR in patients with PUV and assessed the rate and timing of resolution of VUR after valve ablation.

Materials and Methods: A prospective, observational study was done in which children with VUR secondary to PUV were included. A clinical history was taken. Preoperative work up with complete blood picture, renal function tests, ultrasonography, voiding cystourethrogram was done. All patients underwent cystoscopy and fulguration of the posterior urethral valves. The patients were followed up with ultrasound, MCUG and DMSA scan. Resolution of VUR was studied.

Results: 56 patients were included in the study. 38 out of 56 cases had an antenatal history of HDN. Bilateral VUR was seen in 33 cases (59%).  Unilateral VUR was seen in 23 cases. Each side of reflux was considered as an individual unit in bilateral cases.The total number of units was 89. Resolution of reflux was seen in 27 units. Downgrading of reflux was seen in 53 units. 9 units neither showed resolution nor downgrading.

Conclusion: VUR is the major cause of postnatal damage in PUV. Early resolution of reflux after valve ablation was seen in cases with low grade reflux. Resolution of reflux is more in cases with unilateral reflux than with bilateral reflux. 

Chylous ascites refers to the leakage of lipid rich milky fluid into the peritoneal cavity. This usually occurs following trauma or obstruction of the lymphatic system. Moreover, an existing clear ascitic fluid can turn chylous as a secondary event. Milky appearance on gross appearance along with high fat (triglyceride) content usually suggestive of the diagnosis. We are reporting a 3 months infant with chylous ascites diagnosed during bilateral inguinal herniotomy. The patient presented bilateral scrotal with umbilical swelling for last one month. Examination showed bilateral inguinal hernia, umbilical hernia with mild abdominal distension. Bilateral herniotomy and subsequent ultrasound guided paracentesis revealed milky peritoneal fluid. Biochemical analysis revealed plenty of lymphocytes,   high  triglyceride  content  with  increased cellularity and no abnormal cells suggestive of chylous ascites. Lymphoscintigraphy revealed leak from retroperitoneal   lymphatics.   Child   improved   following dietary modification and octreotide therapy without any surgical intervention. The aim of this case report is to describe the unusual presentation, it’s clinical and biochemical factors and role of conservative treatment of a patient with congenital chylous ascites.

Splenic cyst is a rare occurrence especially in paediatric age group, hence challenging to treat. It is usually diagnosed incidentally while doing scans for other abdominal complaints. We report a minimally invasive approach of treating a large splenic cyst with review of the literature.

A teenage boy presented to the emergency room who complained of pain in the left upper quadrant of abdomen of 2 days duration, with a history of blunt abdominal trauma 2 years back. Clinical examination and relevant radiologic investigations were done for the proper diagnosis.

Patient underwent laparoscopic deroofing of the large splenic cyst followed by omental pedicle insertion. Histopathological exam showed presence of an epithelial cyst.

Prune belly syndrome (PBS) is a rare congenital disorder, consists of three symptoms: anterior abdominal muscle deficiency, cryptorchidism, and genitourinary malformation. These patients have cardiovascular and musculoskeletal abnormalities, mental retardation, chest deformities, and scoliosis that lead to pulmonary dysfunction. Anesthesia plan in patient needs to rule out any anomalies. For airway management, Laryngeal mask airway (LMA) should be preferred to avoid the use of muscle relaxants. The use of short-acting anesthetics can accelerate recovery from anesthesia.  To reduce postoperative pain, regional techniques are preferred. We report a 6-month- old boy with PBS, and its airway management and anesthesia during surgery.