Iranian Journal of Pediatric Surgery

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Introduction: Hypertrophic pyloric stenosis (HPS) is among common GI disorders in young infants, with an incidence of 1-2:1000 live births in the world. In this study, we wanted to investigate the correlation between duration of symptoms before surgery and eradication of symptoms after pyloromyotomy in HPS.

Materials and methods: One hundred and twenty five (102 boys and 23 girls) patients with suspected infantile HPS were treated surgically by Ramstedt pyloromyotomy between 2004 and 2014 at pediatric surgery ward of Tabriz Children’s Hospital, Iran. The demographic features, clinical findings, diagnostic work-up and postoperative specifications of the patients were studied retrospectively.

Results: We studied 125 patients with HPS. Male to female ratio was 4:1. The patients were 16 to 90 days of old and the mean age was 39±1.42 days. The range of pyloric canal length was 7.60 to 29.00 mm and the mean length was 19.54±3.42 mm. Pyloric muscle diameter was 2.70 to 9.00 mm and the mean diameter was 4.86±1.14 mm. Seventy two percent of patients had episodes of vomiting after operation. Mean time of persistence of vomiting after pyloromyotomy was 15.73±0.15 hours. Mean discharge time was 55.22±0.08 hours. Radiologic findings did not show any significant correlation with persistence of vomiting or discharge time. 

Conclusion: The present study revealed that duration of vomiting before surgery and continuing symptoms could not predict postoperative symptom eradication after pyloromyotomy in HPS.

Introduction: Replacement of esophagus can be accomplished using different parts of the gastrointestinal tract, in various positions and in single and multiple stages. The aim of this study is to present the results of gastric tube interposition in children with congenital esophageal anomalies and severe acquired esophageal stricture.

Material and Methods: This series describes 22 patients who underwent gastric tube interposition procedures for esophageal replacement at Mofid Children’s Hospital Tehran, Iran between 1996 and 2014. Clinical data including the indication for esophageal replacement, technique and timing of repair, early and late complications, and long-term follow-up were retrospectively gathered from patients’ medical records.

Results: Patients consisted of 17 Male and 5 female, aged 8 months to 14 years (mean 47.8 months). Twenty one patients had normal oral feeding and proper weight gain. The mean time of follow up was 9.25 years (9 months to 18 years). One of our cases developed failure to thrive although he had no difficulty in swallowing and was eventually put on supplementary feeding by gastrostomy.There were 3 strictures: one in the neck anastomosis which was treated by dilatation and revision of anastomosis, one in the hiatal level which was because of tight hiatus and was treated by widening of hiatus. The last patient had a stricture at mid-portion of gastric tube, and was treated by dilatation, which resulted in perforation and was treated by stricturoplasty. Three leaks occurred at the neck anastomosis, two healed spontaneously and one resulted in intra thoracic leak and mediastinitis that led to death after 3 months. Another child with lymphocyte adhesion deficiency died due to infected neck wound and severe bleeding from carotid artery 22 days postoperatively, a third death occurred many years after the original operation due to mediastinitis which was the result of dilatation for stricture formation.

Conclusions: Although gastric tube replacement in posterior mediastinum seems an ideal replacement because of adequate length which makes it easily reachable to pharynx, good blood supplies, straight and proper size; the management of complicated cases such as mediastinal leaks and strictures is very challenging and rules out this method of esophageal replacement as the best option possible.

Introduction: Undescended testis is a common problem in children. Cryptorchid testis is frequently accompanied by gross morphologic changes with regard to the size and shape of the testis, various degree of detachment between the epididymis and testis. We assessed the epididymal anomalies and patency of process vaginalis in boys with UDT.

Material & Method: It is a prospective study which was performed on all cases of UDT operated in a social security hospital between June 2006 and October 2007. All patients were operated on by one surgeon. In addition to general demographic data, the association between the patency of processus vaginalis and epididymal adhesion to testis was evaluated.

Results: There were 81 patients. The mean age of patients was 30 months (3 months to 10.9 years). Forty eight patients had unilateral and 33 patients had bilateral UDT. In the unilateral group 79.2% and in the bilateral group 78.8% had palpable testis. The mean (±SD) size of testis in the palpable group was 10.8± 3.1 mm and in the nonpalpable group was 8.5±3.3mm (t=2.89, p=0.005). The Spearman ‹s correlation coefficient showed that with increasing age the size of testis is also increased (rho=0.41, p<0.001).The mean size of testis in patients with normal epididymal adhesion was 12.6±3.3mm, with partial adhesion 10.8±3mm, and in patients without epididymal adhesion was 8.9±2.5mm (F=18.4, p<0.001). Of 110 UDT, the process vaginalis was patent in 101 cases (91.8%).

Conclusion: Process vaginalis is patent in most of cases of UDT. There is a meaningful correlation between testis size and epididymal adhesion. Testis abnormality (in size and epididymal adhesion) is seen more commonly in non-palpable cryptorchid patients.

Background: Congenital diaphragmatic hernia (CDH) occurs due to a failure in closing pleuroperitoneal membrane thus resulting in an incomplete diaphragm formation1, which allows passage of the abdominal viscera into the thorax.1,3 Until 1995, the standard method for treatment of CDH was performed by open surgery through the abdomen or thoracic cavity. Minimally invasive approach via thoracoscopy or laparoscopy is applicable for treatment of CDH since 1995.4 Now a day’s thoracoscopic repair of CDH (T’Scopy CDH) is performed in many centers. In this paper, we present our experience of T’Scopy CDH repair from Iran.

Patients and Methods: From 2011 to 2015, 74 patients with CDH were admitted to Pediatric Surgery Department of Dr. Sheikh (Sarvar) Pediatric Hospital. Twenty one patients (28%) met our inclusion criteria and underwent T’Scopy CDH repair. The median age at the time of repair was 5 days (2-daysold to 4-years-old patients). Inclusion criteria were weight over 2 kg and stable hemodynamics and arterial blood gas. Fourteen cases were intubated before entering the operating room. The defect was in the left side except in two cases. In 8 cases, we used thoracic wall as part of repair. Also, mesh support was utilized in 8 cases even in cases were primary repair of diaphragm was possible in order to reinforcing the repair (5 cases). Of these 8 cases, in 3 patients, whole repair was accomplished by mesh due to presence of a large defect.

Results: The mean time of operation was 80 minutes (40-230 minutes). Intraoperative mortality was zero. In hospital, mortality occurred in two cases due to septicemia in one and respiratory and cardiac failure in another. Conversion to open surgery was required in 6 cases. Late recurrence was observed in 2 cases. The mean time of follow up was 14.6 months (3-36 months).

Conclusion: It seems that appropriate case selection and liberal use of thoracic wall and mesh as a part of repair may cause better results and decreased chance of early and late recurrence.

Introduction: Penile agenesis (PA) and diphallus (DP) are extremely rare genital anomaly in children. Numerous associated anomalies have been described with these malformations. These patients need several investigations and finally surgical intervention.

Material & Methods: In a retrospective study, 14 patients who were treated for phallus malformation in Mofid Children’s Hospital from January 2004 to December 2013 were studied. Detailed history was taken and para clinical examinations were performed in each patient and diagnosis was confirmed by laboratory tests, abdominal ultrasonography, voiding cystourethrography (VCUG), and karyotype study. Data regarding age, sex, clinical findings, associated anomalies and treatment were collected.

Results: From 14 patients, eight cases had PA (aged 2 to 4320days), and six had DP (aged 2 to 5040 days).Karyotype in all PA’s patients was 46XY. Five of DP cases had completed, and one had bifid phallus type. All patients were treated surgically after complete investigations, and followed within period of study.

Conclusion: All patients with phallus anomalies need extensive evaluations and surgical intervention. No surgical intervention should take place without counseling the parents.

Background: Teratomas arise from three germ cell layers, the ectoderm, endoderm and mesoderm1, 2, and have several degrees of differentiation. We report our experience with teratomas at a tertiary pediatric surgery center.

Patients and Methods: The hospital records of all patients with the pathological diagnosis of teratoma treated during 10 years between 2004 and 2014 were reviewed and the following information was obtained: Sex, site of tumor, treatment and outcome.

Results: Sixty seven patients consisting of 49 girls (73%) and 18 boys (27%) were treated with teratomas at various sites of the body. These included: sacrococcygeal (SC) 32 patients (27 females& 5 males), ovarian 12 cases, cervical 4 patients (1 females & 3 males), retroperitoneal 9 (5 females & 4 males), Nasopharyngeal 2 patients both of which were females, mediastinal 2 cases (1 female & 1 male) and 5 testicular teratoma patients. All patients underwent surgery, and the most common procedure was total resection in 63(94%) of patients. Twenty eight (42%) received chemotherapy. In follow-up 52(77%) patients were in complete remission, 8(12%) had died, and 4 cases did not attend follow-up visits.

Conclusions: Teratomas are a group of tumors with similar histological picture but different behaviors. Sacrococcygeal teratomas are the commonest and the majorities are benign but the risk of malignant transformation increases with age. Management of teratomas is a combination of surgery and chemotherapy which may lead patients to a better prognosis.

Superior mesenteric artery syndrome is a very uncommon disorder in which acute angulation of superior mesenteric artery (SMA) at its origin from aorta results in compression of the third part of the duodenum leading to partial or complete obstruction of the duodenum. Other terminologies for this condition are Cast syndrome, Wilkie syndrome, arteriomesenteric duodenal obstruction, and chronic duodenal ileus.1 The disease is extremely rare in the pediatric population. Here we report a case of SMA syndrome in an 11 year old boy who was admitted with hepatitis, subsequently developed primary peritonitis and during his admission at the hospital he developed SMA syndrome. The case is being reported for its extreme rarity, to highlight the role of imaging in establishing the diagnosis and to review the literature in the subject.