Iranian Journal of Pediatric Surgery

Introduction- Trauma is the third common cause of death in children below the age of 14 years, worldwide. Systematic management of an injured child is essential to reduce mortality due to trauma. Differences between children and adults concerning patterns of injury, physiologic presentation, and management must be understood by the treating surgeon to address the special needs of the paediatric age group.

Materials and Methods- Present study is a Prospective Observational study conducted at Department of Pediatric Surgery, Niloufer Hospital, over a period of 2 years. 231 cases with blunt trauma to chest and abdomen were collected from the Trauma registry and prospectively studied based on the trauma questionnaire and treated according the ATLS protocols. The final statistical analysis was done using the Statistical Package of Social Sciences (SPSS software).

Results- Of the 231 cases, most of the injuries to the abdomen and/or chest were seen in the age group of 3-6yr and the boys in the age group of 6-9 years were injured more commonly. 45% injuries were due to RTA’s followed by fall from height. 12% cases presented to the department after 48hrs. Abdomen was the most common site of injury with Liver being injured in 25% cases and these cases were mostly managed conservatively. Overall, 30% of the cases underwent intervention in the form of surgery or tube thoracostomy placement. There was 2% mortality in the study.

Conclusion- Traumatic injuries being the major health problem need a properly framed trauma registry system and strict protocol-based management of injuries according to the concerned epidemiology and resource setting which would be beneficial for the treating surgeon, injured child and perhaps, the whole nation. This will enable properly triaged trauma management, reducing the burden.

Introduction:

Neonatal gastric perforation(NGP) is a rare but life threatening condition affecting the neonates. The exact mechanism of NGP is poorly understood but its often associated with preterm birth, hypoxia and sepsis. But spontaneous cases of NGP are unpredictable resulting in complicated diagnosis and management. In the present study we elucidate the risk factors, clinical findings,management strategies and the outcomes in patients restrospectively over a period of 10 years

Materials and methods:

A retrospective study of all the patients presenting with NGP was conducted over a period 10 years from march 2013 to march 2023 at our institution and a complete data of 87 of these patients were accrued and analysed. A compete demographic data, preoperative chateristics, clinical presentation,intraoperative characteristics, clinical outcomes and postoperative complications were recorded and analysed. Besides comparison was made between the surviving and non-surviving neonates to elucidate the risk factors in morality.

Results :

A total of 87 cases  of neonatal gastric perforation were included in our study. The majority of NGP patients were male (73.56%, M:F = 2.78:1), preterm (59.77%), and of low birth weight (51.72%). Common clinical presentations included abdominal distension (88.5%), vomiting (71.26%), and respiratory distress (57.47%). Key laboratory findings included mean hemoglobin of 15.84 ± 1.2 g/dl, leucocyte count of 18.71 ± 4.12 × 10³/µl, and serum pH of 7.26 ± 0.14. Radiological findings prominently showed the "football sign" (93.1%) and gas under the diaphragm (74.71%). Gastric perforations predominantly involved the greater curvature (36.78%) and were mostly single (82.75%) and small (<5 cm, 65%). Spontaneous perforation was the most common cause (65%), followed by trauma (21%) and necrotizing enterocolitis (NEC, 10%). Surgical management included gastric repair with peritoneal lavage and venting gastrostomy. Postoperative complications included respiratory issues (74 cases), sepsis (54 cases), and wound infections (25 cases). Neonatal mortality was 42.53%, with significant predictors including male sex(p value=0.004), prematurity(p value=0.002, low birth weight(p<0.001), thrombocytopenia(p value<0.001), high CRP levels(p value<0.001) acidosis(p value<0.001), and elevated lactate levels(p<0.001).

Conclusion:

Neonatal gastric perforation presents a substantial risk of mortality, particularly among male, preterm, and low birth weight infants. Early recognition of clinical signs, prompt surgical intervention, and vigilant postoperative care are crucial to improving survival rates. Monitoring laboratory indicators such as platelet counts, CRP levels, pH, and lactate levels can aid in assessing prognosis and guiding treatment strategies.

Introduction: Undescended testes (UDT) is the congenital anomaly affecting children and is one of the most common anomaly. The failure of the testes either unilateral or bilateral to reach the processus vaginalis or scrotum 10-12 weeks after birth is termed as undescended testes or cryptorchidism. Impalpable undescended testes presents diagnostic and management challenges in the pediatric population.     

AIM: Evaluating the role of laparoscopy in managing impalpable undescended testes.

Materials and methods: The observational prospective study, conducted in the Department of General Surgery between January 2021 and December 2023. Patients who complained of absent or impalpable testes were clinically assessed and those with impalpable testes were included. Depending on the findings of diagnostic laparoscopy, testes were either brought down to the scrotum in the single- or two-staged procedure (Stephen Fowler) or removed.

Results: 25 patients with impalpable undescended testes were included, and 28 procedures were performed. Of the 25 patients, 14 had right-sided UDT, eight had left-sided UDT, and three had bilateral UDT. All the patients underwent diagnostic laparoscopy. Fourteen (50%) had high intra-abdominal testes, 10(35.7%) had low intra-abdominal testes, 3(10.7%) entered the deep ring with vas and vessels, and one patient had nubbin testis. Fifteen patients underwent single-stage laparoscopic orchidopexy, 7patients underwent two-staged procedures, three patients had vas and vessels entering the deep ring and underwent open inguinal orchidopexy, while three patients underwent orchidectomy.

Conclusion: Ultrasonography (USG) and magnetic resonance imaging (MRI), are the imaging modalities which play a crucial role in localization of impalpable testes. However, laparoscopy provides the most accurate interventional option by demonstrating anatomy. 

Abstract
Purpose
This study introduces a compelling alternative to traditional pediatric laparoscopic cholecystectomy.
Method
We conducted a three-year prospective study from 2020 to 2022 in two different centers. This preliminary descriptive and analytic study included a randomized trial and statistical analysis to determine whether Minimally Invasive Open Cholecystectomy (MIOC) is comparable to laparoscopic surgery, using the Pearson coefficient test with significance set at better than 1%. Children were randomly selected and the “open” cholecystectomy was performed by the same pediatric surgeon for all cases. We conducted tracking and tracing to identify the gallbladder's projection on the abdominal skin. Our surgical procedure involved tracking and tracing to identify the gallbladder’s projection on the abdominal skin, followed by retrograde dissection towards gallbladder’s neck, with cholecystectomy either anterograde or retrograde.
Results
Twenty-seven children aged from zero to fifteen were recorded (19 cases at ARCH and 8 cases at IPGH) among 1,965 treated in the two departments during the study, resulting in an incidence rate of 0.0137. The average age of the children was three years, with a range from eighteen months to eleven years. The most represented age group was six to eight years old. Our series included 15 boys and 12 girls, giving a sex ratio of 1.25. The most common reason for surgery was cholelithiasis, accounting for 74.1% of the cases. The mean operating time was 65 minutes (range 50-92 minutes), and celiotomy length varied from 20 to 28 mm. Anterograde cholecystectomy was performed in 92.6% of cases, with bile drainage needed in two patients (7%). The median follow-up period was 24 months, and all patients experienced good postoperative results. The minor complications were infection and jaundice. The average length of hospital stay was 3 days (range 2-6 days). There was a positive correlation between cosmetic and functional outcomes for open surgery (P=0.3). Conclusion : the authors present an effective minimally invasive open cholecystectomy.
Keywords: Minimally invasive surgery; Pediatric mini-laparotomy; Cholelithiasis; Cholecystectomy.

Abstract: 

Background: Empyema thoracis, the accumulation of purulent fluid in the pleural cavity, remains a significant cause of pediatric morbidity in developing regions despite global advancements in treatment. This study examines the epidemiology, clinical presentation, microbiological profile, and therapeutic outcomes of pediatric empyema in Baghdad, Iraq, providing comparative insights with regional and international data. 

Methods: A retrospective cohort analysis was conducted across three tertiary care centers in Baghdad—Ghazi Al-Hariri Surgical Specialties Hospital/Medical City, Ibn al-Nafees Hospital, and Al-Imamain Al-Kadhmian Medical City—from January 2022 to December 2023. Patients were stratified into uncomplicated and complicated empyema groups based on clinical and radiological criteria. 

Results: Among 50 pediatric cases (62% male, 38% female; ratio 1.6:1), the predominant age group was 1–5 years (46%). Universal fever (100%), dyspnea (84%), and cough (76%) were the most frequent symptoms, with bronchopneumonia as the leading predisposing factor (32%). Microbiological analysis identified pleural fluid pathogens in 38% of cases, predominantly Streptococcus pneumoniae (16%) and Staphylococcus aureus (14%). Complications included pyopneumothorax (26%) and pneumothorax (8%). Tube thoracostomy with antibiotics achieved treatment success in 90% of patients, while 10% required surgical decortication. Seventy percent of cases had hospital stays under 14 days. 

Conclusion:  

Pediatric empyema in Baghdad exhibits distinct characteristics, including delayed presentation, high complication rates, and a unique microbiological profile. The 90% efficacy of tube thoracostomy supports its role as a first-line, resource-adapted therapy in comparable settings. These findings underscore the need for tailored management protocols in high-burden regions. 

Introduction: A subgroup of children with chronic idiopathic constipation continues to have persistent symptoms after treatment with high-dose laxatives, suppositories, and enemas. This study aims to determine the surgical outcome of anorectal myectomy as a treatment for these patients.

Materials and methods: The study included 46 children with refractory constipation who were not responsive to diet, laxatives, or enemas. Children with Hirschsprung disease, documented metabolic disease, diabetes, and hypothyroidism were excluded from the study. Posterior anorectal myectomy was performed in every included case. Children were followed up for 1 to 3 years after the surgery, and their frequency of fecal evacuations, fecal consistency, straining during defecation, and fecal diameter were monitored using the Bristol Stool Scoring system.

Results: Out of 46 cases that underwent surgery, 29 were boys, with an average age of 5.4 ± 2.5 years (range, 3 to 12 years). The mean duration of constipation was 13.7 ± 4.1 months (6 to 17 months). The duration of medical treatment for constipation was 13.9 ± 8.3 months (6 to 22 months). There was an overall improvement in 84% of the children, and the results were statistically significant (P<0.0005). Three (6.52%) of the patients continued to experience severe constipation 6 months postoperatively. Ganglion cells were found in 34 children, hypoganglionosis in 9, and absent in 2.

Conclusion: Improvement is observed in fecal consistency, fecal diameter, the number of bowel movements per day, and straining before and during defecation after anorectal myectomy.

Background: Trauma-induced recto-vesical fistulas are uncommon and may result from gunshot wounds, insertion of foreign objects into the rectum, traffic accidents, and rarely, blunt trauma. Managing RVF is challenging, and treatment options should be considered on an individual basis.
Case Report: We report the case of a 10-year-old boy arrived at the emergency department with rectal bleeding two hours after accidental perineal trauma at home, involving the introduction of a metallic foreign object. A rectal exam showed no active bleeding, and lab tests were normal. Due to the unavailability of CT imaging, Exploration under general anesthesia revealed an anterior rectal injury with urine leakage. Laparoscopy exploration confirmed the absence of intra-peritoneal injury. Colostomy and urinary diversion were performed. The bladder catheter was removed after four weeks, with normal cystography findings. At the two-month follow-up, colostomy closure was completed. No recurrence was observed during the six-month follow-up period.
Conclusions: No standardized technique has been established in the literature for the surgical treatment of traumatic RVF. For small traumatic fistulas, particularly in children, urinary and fecal diversion can be effective with low recurrence rates.

Background: Epidermolysis bullosa (EB) is defined as a group of rare inherited medical conditions resulting in easy blistering of the epithelial tissues in response to mechanical trauma. EB is occasionally associated with systemic presentations.

Case presentation: A newborn was referred to Shahid Rahimi hospital in Khorramabd, Iran, on 11/2/2021 due to skin lesions and poor feeding. The patient was later diagnosed with EB and coexisting pyloric atresia and underwent pyloric resection and gastroduodenostomy. Owing to the reported hydronephrosis on the ultrasound, the diagnosis of epidermolysis bullosa-pyloric atresia-obstructive uropathy (EB-PA-OU), a multisystem variant of EB, was made.

Discussion: A high phenotypic variability has been found among EB cases. One of the variants is EB-PA, which is an autosomal recessive genodermatosis. In some cases, ureteral and renal abnormalities coexist with EB-PA leading to a more complex variant named EB-PA-OU.

Conclusion: Given the known association between EB and multiorgan abnormalities, a systemic evaluation is required to detect these disorders and prevent them from progressing to the irreversible stages.

Abstract:

Background – Fetus in fetu (FIF) is a rare pathological condition, mostly presenting as a fetiform, calcified abdominal mass in its living host which is usually a fetus or a newborn. Due to its rarity with an incidence of 1:500000, FIF is often missed in the differential diagnosis of an intra-abdominal mass in a newborn. Condition can be diagnosed in-utero as well as preoperatively in a newborn by imaging. FIF should also be differentiated from a teratoma because of the malignant potential of the latter. Surgical excision is almost always curative. The presence of vertebral segments and an encapsulating cyst can reliably distinguish FIF from teratoma. Condition can be diagnosed in-utero as well as preoperatively in a new born by imaging. Surgical excision is curative. Recurrence is extremely unusual.

Case presentation – An 8-month-old, full-term, male infant was brought with gradually increasing abdominal distension. Examination revealed a distended abdomen with a non-tender, irregular, firm mass in the right flank. Initial US imaging revealed the presence of a large foetoid tumor - like mass which was later confirmed as FIF on CT scan. There was evidence of a vertebral column along with bony appendages and formed organs. A laparotomy was done where sac was found to be loosely attached to the posterior abdominal wall. The entire mass was successfully removed. Baby made good recovery.

Conclusion - At the end of six months of follow-up, he is doing well with no new symptoms. 

Keywords: Parasitic twin, teratoma, newborn.