Iranian Journal of Pediatric Surgery

Introduction: The diagnosis of acute appendicitis in children up to the age of five is very difficult because the child at this age is not able to adequately express the discomfort and pain they feel and the clinical picture in this period is atypical. The aim of this study is the evaluation of clinical characteristics and outcomes of treatment in children under five years of age who underwent appendectomy because of acute appendicitis.

Patients and methods: A retrospective, clinical study was conducted, which included 92 patients under the age of five who underwent appendectomy in the period from 01.01.2010. to 31.12.2021. at the Clinic for Pediatric Surgery of the Clinical Center of the University of Sarajevo. Patients were into two groups depending on the intraoperative finding: uncomplicated and complicated appendicitis group . Comparisons between groups were made based on demographic data, inflammatory and blood picture parameters recorded at admission, clinical history, type of treatment and treatment outcome as well as frequency and type of complications.

Results: Of 1428 appendectomies in this period, 92 (6.44%) were performed in children younger than five years. Of these, 71 (77.2%) patients had complicated appendicitis. A statistically significant association was found between increased leukocyte count (p = 0.035) and CRP (p <0.01) in the complicated appendicitis group. Median body temperature (37.5 °C and 38.4 °C; p <0.01), symptom duration (24h and 48h; p < 0.004) and duration of hospitalization (5 days and 8 days; p<0.001) were significantly elevated in complicated compared to uncomplicated appendicitis. The most common symptoms were: pain (96.74%) and vomiting (85.87%). Postoperative complications were reported in 8 (8.70%) cases. There was no mortality.

Conclusion: The clinical presentation of acute appendicitis for children aged five years or younger is often unusual, and establishing the proper diagnosis is often delayed. Early diagnosis and prompt surgical intervention can reduce morbidity and mortality rates associated with complicated appendicitis.

Introduction: Congenital anomalies and related surgeries are common in neonates, especially in developing countries. In recent years, early feeding after surgery has become more popular. Postoperative care protocols should be updated to reflect these changes and improve outcomes. This study aimed to assess the onset of feeding after surgical procedures in newborns with congenital anomalies and its related factors.

Material and Methods: This cross-sectional study was conducted on 90 neonates who underwent surgical procedures between 2011 and 2019 at Valiasr Hospital, Iran. The neonates’ demographics, including gender, weight, type of anomaly, presence or absence of heart disease, sepsis, prematurity, duration of surgery, volume of nasogastric tube secretions, time of defecation, and time of onset of feeding were recorded. The relationship between these factors and the early onset of feeding was analyzed in the neonates using the independent t-test, Kruskal-Wallis test, and logistic linear regression (P≤0.05).

Results: A total of 90 neonates underwent surgical procedures during the specified period, of which 43% were female, 49% had heart disease, 46% had sepsis, and 34% were premature. The mean weight of the neonates was 2726.94 (806.19) grams. The mean time to the onset of feeding was 5.92 (3.97) days after surgery. Sepsis (P=0.000), prematurity (P=0.000), type of anomaly (P=0.000), weight (P=0.000), time of defecation (P=0.000), duration of surgery (P=0.000), and volume of nasogastric tube secretions (P=0.000) had significant correlations with the time of onset of feeding, but gender (P=0.559) and heart disease (P=0.210) had no such correlation.

Conclusions: Regardless of the neonates’ gender and the presence of cardiac anomalies, feeding can be started earlier in full-term and overweight infants. The amount of return secretions of the nasogastric tube and the type of surgery should be considered in making this decision.

Introduction: Congenital Duplex anomaly of the ureters is a challenging clinical disorder, which is described in approximately 1 % of children with higher prevalence in girls. It arises from abnormal location of ureteric bud from wolffian duct during embryogenesis. A condition that can be diagnosed antenatally. The upper moiety usually ends with either a ureterocele or an ectopic ureter.

Management options include expectant conservative management, transurethral ureterocele incision (TUI), ipsilateral ureteroureterostomy, upper pole hemi nephrectomy and total reconstruction with common sheath reimplantation.

 Evaluation of the short-term effect of lower ipsilateral ureteroureterostomy procedure for the management of ureteric duplication anomalies in children.

Material and Methods: A prospective study including thirty-two children with complete duplex anomalies in which the ipsilateral upper moiety ureter is affected from March 2023 to March 2024 were included in the study. All patients underwent open ipsilateral lower ureteroureterostomy.

Results: Thirty-two children (21 male, 11 female patients) underwent ipsilateral Ureteroureterostomy, 75% of the patients had ureterocele and the remaining had ectopic ureter. Mean age was 20.6 months.

Urinary tract Infection was the most common presenting symptom in 59.4%, Other presentations include antenatal hydronephrosis in 28.1% and incontinence in 12.5%.

Median follow up was 10.43 months (IQR:8.1-14.3). The percentage of children experiencing adverse events is 15.6%, in the form of post-operative UTI in 4 cases (12.5 %) and one case, in which the operator could not pass a JJ stent intraoperatively and performed subsequent reoperation.

Conclusion: Ipsilateral ureteroureterostomy has a low risk of surgical morbidities and low rate of complementary redo operation in children. We recommend performing it in duplex anomalies whose primary pathology is an ectopic ureter.

 Abstract

Introduction: Urological anomalies are the most common associated anomalies in patients with anorectal malformations (ARM). Most publications state an incidence between 30% and 50%, with the frequency of the coincidence increasing proportionally with the complexity of anorectal malformations. Therefore, in order to enable early diagnosis and management of these abnormalities, a high index of suspicion is needed. In addition, long-term follow-up of patients with anorectal malformations and surveillance of their kidney function and urinary tract anatomy is of great importance to prevent damage to the urinary system.

To identify and classify the urological anomalies associated with anorectal malformation patients admitted to Pediatric Surgery department in Alexandria University Children’s Hospital from June 2021 to June 2023 and to correlate urological anomalies with the level of anorectal malformation.

Material and Methods: This study involved collection of data of all patients diagnosed with anorectal malformations between June 2021 and June 2023 who attended at Alexandria Pediatric Surgery Department of Alexandria University Children’s Hospital. Including: patients who were diagnosed with anorectal malformations and underwent urological screening. The following data were extracted from the patient’s files who met the inclusion criteria: neonatal presentation, age at presentation, weight, sex and findings of genital examination.

Results: In 66 patients with ARM, 19(28.7%) patients had low anorectal anomaly (LARA) and high rectal anomaly (HARA) were found in 47(71.2%) patients. The incidence of ARM was higher in male patients than in female patients regardless the level of ARM. The most common genital anomaly among male patients was bifid scrotum, which was found in 3 out of 15 with genital anomaly, followed by hypospadias. In female patients, isolated cloaca anomaly was the most frequent genital anomaly.

Conclusion: screening of associated urological anomalies is vital to prevent renal damage and reduce morbidity and mortality in patients with anorectal malformations.

Introduction: The clinical, radiologic and cystourethroscopic (CUS) findings regarding the colonic pouch, its terminal colovesical fistula (CVF) and lower urinary tract (LUT) in 27 boys with congenital pouch colon (CPC) and associated anorectal malformation (ARM) are described and discussed.

Material and Methods: Records of 27 boys with CPC in whom radiologic studies and/ or CUS yielded information about the colonic pouch, CVF, and the LUT were studied. Relevant clinical findings were recorded.

Results: CPC subtypes were Type I (n=1); Type II (n=13); Type III (n=1), and Type IV (n=12). Five patients (18.5%) had hypospadias and 3 (11.1%) unilateral undescended testis. X-Rays spine (n=25) showed normal sacrum (n=21) and partial sacral agenesis (n=4). Ultrasound (n=27) showed normal kidneys (n=21), unilateral malrotated kidney (n=1), unilateral hydronephrosis (n=2), and hydroureteronephrosis (n=3). Micturating cystourethrogram (n=12) showed a large, lobulated, smooth-walled urinary bladder (n=7) and vesicoureteral reflux (n=6). Contrast study of the colonic pouch (n=16) showed the pouch ending in a long wide CVF opening at the bladder neck with, in 11 patients (68.75%), filling of a large, lobulated urinary bladder. CUS (n=22) showed a competent bladder neck and an abnormal verumontanum pulled-up into the bladder neck. In 16 patients, the CVF opened in the trigone, just cranial to the right (n=13) or left (n=3) of the verumontanum.

Conclusion: CPC likely results from an early, ‘localized’ error in cloacal septation by the uro-rectal septum with faulty development of adjacent developing structures. The long-term clinical consequences on bladder dynamics and male fertility need attention.

Introduction:

 In neonates, the use of hypotonic fluids is a widely accepted practice to maintain hydration and electrolyte balance, particularly after surgery. However, this approach can increase the risk of hyponatremia due to the lower sodium content in hypotonic solutions compared to blood plasma. This makes neonates more vulnerable to sodium imbalances if not properly monitored. While hypotonic fluids are commonly used, there is growing consideration of isotonic alternatives to reduce the risk of electrolyte disturbances and improve safety in neonatal care.

To evaluate and compare the outcomes of using isotonic versus hypotonic fluids in neonates receiving maintenance fluid therapy following surgery.

Study place and duration: Department of Pediatric Surgery, Holy Family Hospital, Rawalpindi from January 2023 to December 2023.

Material and Methods: Total 84 cases were enrolled in the study who underwent surgery and admitted in neonatal intensive care unit. Infants were randomly divided in two groups. Group I was given isotonic/normal saline with 5% dextrose in 0.9% saline. Group H was given hypotonic saline with 5% dextrose in 0.45% saline. Neonates were followed up and hyponatremia was noted. Data analysis will be done by using SPSS software version 25.0.

Results: In Isotonic saline solution, the mean age of neonates was 6.21 ± 6.19 days. In Hypotonic saline solution, the mean age of neonates was 3.84 ± 3.50 days. In Isotonic saline solution, hyponatremia was developed in 2 (4.8%) cases, hypernatremia in 9 (21.4%) cases, while 31 (73.8%) neonates maintained normal serum sodium level. In Hypotonic saline solution, hyponatremia was developed in 11 (26.2%) cases, hypernatremia in 0 (0%) cases, while 31 (73.8%) neonates maintained normal serum sodium level. The difference in both groups was found to be significant (p<0.05).

Conclusion: The risk of hyponatremia is higher with hypotonic saline solution when used as maintenance fluid after surgery in pediatric population.

Chylothorax is a known complication of postoperative congenital diaphragmatic hernia repair in neonates. We herein report a successful povidone pleurodesis for bilateral chylothorax post congenital diaphragmatic hernia repair for a 3.24kg term male baby. He was noted tachypniec and was subsequently intubated soon after birth. Diagnosis of left congenital diaphragmatic hernia was confirm by chest x ray and corrective surgery was done after a period of stabilisation. Post operatively he made a poor recovery and serial chest images show features of effusion. Drains were inserted and fluids drained were confirmed to be chyle. Initially child was treated conservatively. However, due to persistent high output showing signs of refractory to conservative management we decided to use povidone as pleurodesis. During the course of povidone iodine instillation into both chest tubes, the amount of drain was reducing and subsequently child recovered well.

Abstract
Background: Variants of bladder anomalies are rare and often associated with other
abnormalities of the genitourinary system. Covered bladder exstrophy, a rare variant
within the exstrophy-epispadias complex, is one such example.
Case Presentation: We report a case of a 2-year-old female presenting with covered
exstrophy of the bladder. The patient exhibited intermittent swelling over the anterior
abdominal wall since birth, which increased in size during urination. Examination
revealed a midline abdominal wall defect covered by skin in the hypogastric region.
Diagnostic imaging, including a micturating cystourethrogram and ultrasound,
confirmed the presence of an anterior abdominal wall defect with diastasis of the
pyramidalis muscle and a focal bladder mucosal defect with intact detrusor muscle
continuity.
Intervention: Surgical exploration revealed a smooth, globular structure with thinned
walls and a vascular appearance herniating through the defect, confirmed to be the
urinary bladder. Primary repair was performed, augmented with an onlay mesh
hernioplasty using a polypropylene mesh.
Outcome: The intraoperative period was uneventful, and the patient was alert and
active postoperatively. Follow-up showed no complications, and the patient exhibited
normal urinary function.
Conclusion: This case highlights the importance of early diagnosis and surgical
intervention in managing covered bladder exstrophy. The successful repair of the
defect and the favorable postoperative outcome underscore the efficacy of the surgical
approach used.

Giant hydronephrosis (GH) is an uncommon urological disease, and ureteropelvic junction obstruction (UPJO) is counted as one of the most common etiologies among children.

This report presents a giant hydronephrosis resulting from a neglected complication of ureteropelvic junction obstruction in a 2.5-year-old girl with a history of gross hematuria and abdominal distention who underwent nephrectomy.

A kidney that constitutes more than 1.6% of the overall body weight is counted as a giant hydronephrotic kidney. The possible differential diagnoses may include ovarian, mesenteric, pancreatic, and adrenal cysts, extra-renal tumors, Echinococcal cysts of the liver, non-renal retroperitoneal cysts, tuberculous peritonitis, and ascites. Due to the possibility of pyelonephritis, sepsis, and shock, paracentesis is not recommended in these cases. Ultrasonography is the primary modality employed for distinguishing the diagnoses mentioned above. Our survey of the pediatric population revealed that aside from UPJO, the most common anomalies were renal system duplication.

Care for patients with GH is tailored to each individual, with significant differences between children and adults.