Department Of Pediatric Surgery Research Articles

Umbilical keratinous cyst in a 7-year-old girl: A case report

Keratinous cysts, the most common kind of epidermal cysts, are filled with keratin originating from the epidermis, most often from the hair follicle. Keratinous cyst is one of the most common skin lesions and occurs most commonly in the face, head, trunk, extremities, and genitals. A 7-year-old girl reported to the pediatric surgery department with a painless, small tumor arising from her umbilicus. There was no history of trauma, and it has been slowly growing for the past many years. Clinical examination revealed a 3-cm-long skin tag with three small interconnected tumors from the umbilicus. It was soft, and the parts of the tumors looked like they contained whitish material inside. Her general and other systems, including the abdominal examinations, were within the normal limits. The tumor was resected through a sub-umbilical skin incision. She made an uninterrupted recovery. The excised specimens subjected to histology were reported as superficial keratinous cysts. Keratinous cysts are one of the most common benign skin lesions, but not the most common, at the umbilicus. Clinicians need to be aware of such pathology during the evaluation of the umbilical swellings and tumors, especially in children.

Use of Ultrasound in Pediatric Caudal Anesthesia: A Randomized Comparative Study

Objective: The aim of this comparative study was to evaluate the efficacy and safety of ultrasound-guided caudal anesthesia compared to blind caudal anesthesia for subumbilical surgery in pediatric patients. Methods: This prospective study included pediatric patients undergoing subumbilical surgery in the Department of Pediatric Surgery. Patients were divided into two groups: the ultrasound-guided caudal anesthesia group and the blind caudal anesthesia group. Primary outcomes assessed included the success rate of block placement, onset and duration of sensory and motor blockade, analgesic requirements, and perioperative complications. Results: A total of 40 patients were included in the study, with 20 patients in the ultrasound-guided group and 20 patients in the blind group. The success rate of block placement was significantly higher in the ultrasound-guided group compared to the blind group (p < 0.001). The ultrasound-guided group also demonstrated faster onset of sensory and motor blockade (p < 0.05) and longer duration of analgesia (p < 0.05) compared to the blind group. Postoperative analgesic requirements were significantly lower in the ultrasound-guided group (p < 0.001). No significant differences in perioperative complications were observed between the two groups. Conclusion: Ultrasound-guided caudal anesthesia was found to be more effective and reliable than blind caudal anesthesia for subumbilical surgery in pediatric patients. It provided a higher success rate of block placement, faster onset and longer duration of sensory and motor blockade, reduced postoperative analgesic requirements, and comparable safety profile. Ultrasound guidance should be considered as the preferred technique for caudal anesthesia in this patient population.

Comparison of Outcome of SAC Ligation Versus No SAC Ligation in Pediatric Patients Undergoing Inguinal Orchidopexy for Incompletely Descended Palpable Testes: A Randomized Control Trial

Background and Objective: The case of undescended Testis (UDT) is one of the most common condition presented to a pediatric surgeon. The standard procedure to rectify UDT is known as Orchidopexy. The main objective of this study is to examine and compare the results of orchidopexy surgeries conducted with or without sac ligation in palpable undescended testis of pediatric patients.Methods: This randomized controlled trial was done over a period of 12 months (July 2018 to July 2019) atthe Department of Pediatric Surgery, Children's Hospital & Institute of Child Health, Lahore. The selection of cases was made dependent upon fulfillment of departmental criteria and approval by ethical review committee. Consequently, 280 cases divided into two equal groups i.e. Group-A and Group-B (140 cases in each group) were shortlisted for the study after detailed scrutiny. The allotment of patient to above mentioned groups was randomized by lottery method. The patients in Group-A underwent orchidopexy with ligation of sac while the patients of Group-B were operated without sac ligated. The surgeries were performed under general anesthesia by consultant surgeons of same caliber and competence. Moreover, in order to quantify and analyze the results of surgeries parameters such as Mean Operative Time, Postoperative Manifestations and recurrence of UDT were recorded on proforma. Subsequently, SPSS version 25 statistical software was utilized for calculating the mean and standard deviation of numerical variables such as age and operative time. Additionally, the frequency and percentage of variables such as recurrent UDT were also calculated. Chi-square test was applied to recurrent UDT and development of inguinal hernia. It is highlighted that P-value ≤0.05 was taken as significant.Results: Among 140 patients of sac ligation group, 40.7% were 1-4 years old and among 140 patients of nosac ligation group, 42.9% were 1-4 years old. In sac ligation group, 60.0% patients had right undescended testis while in no sac ligation group, 67.1% patients had right undescended testis. In sac ligation group, the mean operative time was 37.81 + 8.82 minutes while in non-sac ligation group; the mean operative time was24.34 + 4.12 minutes. In sac ligation group, no patient had post-operative hernia while in non-sac ligation group, 1.4% patients had post-operative hernia (p=0.15). In sac ligation group, 1.4% patients had recurrent UDT while in non-sac ligation group, 2.1% patients had recurrence. (p= 0.65)Conclusion: Study concluded that non-sac ligation technique is more effective than sac ligation technique interms of operative time and should be preferred for patients by surgeons.Keywords: Orchidopexy, undescended testes, testicular atrophy, inguinal hernia, recurrence  

Upper Gastrointestinal Endoscopy by Pediatric Surgeons: Our Early Experience

ABSTRACT Introduction: Pediatric upper gastrointestinal (UGI) endoscopy is an important procedure in the management of gastrointestinal pathologies. Conventionally, it has been the forte of medical gastroenterologists. However, unlike adults, the availability of pediatric gastroenterologists is limited, especially during emergency hours. We present our early experience of UGI endoscopy done by the department of pediatric surgery. Aims: The aim of this study was to study the feasibility and benefits of UGI endoscopy by pediatric surgeons. Materials and Methods: A retrospective descriptive study was carried out by the department of pediatric surgery of a tertiary-level medical college, from January 2017 to January 2022. Data were collected from electronic and physical medical records. Parameters included age, gender, indication for endoscopy, and procedures done endoscopically or based on endoscopic findings and complications. Results: One hundred and thirty endoscopies were done in 95 patients aged 1–16 years, from January 2017 to January 2022. The most common indication for UGI endoscopy was esophageal stricture (71 procedures in 41 patients), followed by UGI foreign body (18 cases). All other indications were mostly diagnostic, other than four patients with achalasia. Thirty of these patients underwent UGI endoscopy as an emergency procedure. Seventeen patients were followed through or had added procedures, with UGI endoscopy. There was one perforation when dilating an esophageal stricture who responded to conservative management. Conclusion: UGI endoscopy is a valuable diagnostic and therapeutic procedure, which can be performed by pediatric surgeons after necessary training. It supplements decision-making in management, avoids waste of time in referring, avoids additional anesthesia, and is valuable in emergencies.

Responding to the need: An evaluation of the subspecialty units in a pediatric surgical department in a limited resource setting using selected optimal resources for children's surgery strategies.

The Global Initiative for Children's Surgery group published the Optimal Resources for Children's Surgery (OReCS) document outlining the essential criteria and strategies for children's surgical care in low-resource settings. Limited data exist on subspecialties in pediatric surgery and their contribution to global surgery efforts. The study aimed to evaluate the development of subspecialty units within Chris Hani Baragwanath Academic Hospital (CHBAH) Department of Pediatric Surgery (DPS) from January 1, 2018 to December 31, 2021 using selected OReCS strategies for the improvement of pediatric surgery. A retrospective descriptive research design was followed. The study population consisted of CHBAH PSD records. The following data were collected: number of patients managed in PSD subspecialty unit (the units) clinics and surgeries performed, number of trainees, available structures, processes and outcome data, and research output. Of the 17,249 patients seen in the units' outpatient clinics, 8275 (47.9%) burns, 6443 (37.3%) colorectal, and 2531 (14.6%) urology. The number of surgeries performed were 3205, of which 1306 (40.7%) were burns, 644 (20.1%) colorectal, 483 (15.1%) urology, 341 (10.6%) hepatobiliary, and 431 (12.8%) oncology. Of the 16 selected strategies evaluated across the 5 units, 94% were available, of which 16.4% was partly provided by Surgeons for Little Lives. Outcome data in the form of morbidity and mortality reviews for all the units is available, but there is no data for timeliness of care with waiting lists. There were 77 publications and 41 congress presentations. The subspecialty units respond to the global surgical need by meeting most selected OReCS resources in the clinical service provided.

Safety and Feasibility of Enhanced Recovery after Surgery in Pediatric Colostomy Closure

ABSTRACT Aims: To study the safety and feasibility of enhanced recovery after surgery (ERAS) protocol in pediatric colostomy closure. Materials and Methods: Retrospective observational study of children who underwent colostomy closure. Data were collected from the electronic medical records and telephonic follow-up calls of patients from October 2013 to October 2023, in the Department of Pediatric Surgery of a Tertiary level Medical College. The parameters obtained were age, gender, type of stoma, primary diagnosis, discrepancy in luminal diameters, time to reach full feeds, postoperative hospital stay, and complications. The protocol followed for colostomy closure included the following-no bowel preparation or nasogastric tube, no overnight fasting, single dose of antibiotic prophylaxis, avoiding opioids, packing proximal stoma till mobilization and starting early oral feeds postoperatively. The continuous parameters were expressed as mean ± standard deviation or median (range) while the descriptive parameters were expressed as number and percentage. Results: A total of 90 patients were included in the study. Most of the patients had colostomy for anorectal malformation. Five of them had significant luminal discrepancy of 4 or more times. Full feeds were reached within 2 days in 79 patients. Postoperative hospital stay was 2–3 days in 62 patients. Six patients stayed for more than 5 days, due to complications requiring further management. We noted surgical site infection in 6 patients all of whom were managed with regular wound dressings and fecal fistula in 4 cases, two of which resolved spontaneously. Conclusion: ERAS protocol in colostomy closure reduces the hospital stay and is cost effective, with early recovery and no added complications.

Tamarind Seeds in Tracheobronchial Tree: Challenges during Rigid Bronchoscopy

ABSTRACT Background: Tamarind seed aspiration is not frequent in children and is usually observed in kids from rural backgrounds, with easy access to tamarind fruits and their by-products. Materials and Methods: We report a retrospective review of five patients managed in the pediatric surgery department for tamarind seed aspiration into the tracheobronchial tree. The data were analyzed based on age, clinical presentation, bronchoscopic observations, and the challenges faced during the rigid bronchoscopic retrieval and postoperative course. Results: There were four boys and one girl with a median age of 10 years. High-resolution computed tomography thorax was done in all patients. The foreign body was identified in the right main bronchus in one and the left main bronchus in four patients. All five patients underwent rigid bronchoscopy and retrieval of the seed. Two patients had an early presentation (within a week) - they needed temporary tracheotomy as the swollen seed could not be negotiated through the narrow glottis. Two patients had a late presentation (around 15 days) - they required removal in piecemeal using crushing forceps and multiple insertions of bronchoscope prolonging surgical time. One patient presented at 22 days posttamarind aspiration. It was soft enough for easy disintegration with crocodile forceps and expeditiously removed in three to four pieces. All patients recovered uneventfully. Conclusion: Removal of tamarind seed foreign body from the tracheobronchial tree is challenging. Anticipating the difficulties and being prepared well, helps to reduce the intraoperative difficulty, and allow successful removal with favorable patient outcomes.

Management of paediatric surgical patients during the COVID-19 pandemic: Our challenges

Purpose: Here we describe the challenges and procedures adopted to ensure safe paediatric surgery services during the COVID-19 pandemic at the paediatric surgery department in non-Covid-19 wing of Dhaka Medical College Hospital-1. Materials and Methods: Design: Retrospective study. Setting: Department of paediatric surgery in non-Covid- 19 wing of Dhaka Medical CollegeHospital-1, a tertiary care academic medical center in Dhaka, Bangladesh. Participants and duration: All patients who were admitted in the department of paediatric surgery in Dhaka Medical College Hospital-1 from March 1 through June 30, 2020. Methods: We identified patients with or without a rRTSARS- CoV-2 PCR receiving care at the department of paediatric surgery. The healthcare professionals were trained to clean, disinfect, use of PPEs, and other wastes were disposed of as per waste management protocols. Data collection & analysis: Patient data were manually abstracted from the medical record for evaluation. Responses were analysed using Microsoft Excels & SPSS, and presented as categorical data and percentages. Main outcome measures: We describe patient characteristics including demographics, presenting symptoms, type of treatment (Surgery vs Non Surgery), outcomes (morbidity & mortality), hospital stay, and distance travelled for treatment. Results: A total of 320 paediatric surgical patients were included in this study, among all patients about 66.87% patients were male child and 79.06% patients required surgeries. There were 5 patients with confirmed COVID- 19, who were transferred to the Covid-Surgical unit. During this period, there were 4 (1.25%) children who died due to non-COVID related causes. In surgical group only 24(7.5%) patients developed postoperative complications. Length of hospital stay of 44 (13.75%) of non-surgical patients were less than 72 hours, whereas 141 (40.06%) of surgical patients were more than 72 hours. Majority of patients of both groups travelled more than 100 km distance for treatment. Conclusions: This corona crisis has provided an opening for rational health care and formulating global policies. So that in future such pandemics can be tackled more carefully and consistently with advancing knowledge and better preparation. Journal of Paediatric Surgeons of Bangladesh (2019) Vol. 10 (1 & 2): 15-21

Histopathological study of the fertility components of undescended testes in boys of different age group

Background: Undescended testes presents the most common male developmental abnormalities, with infertility frequently observed in unilateral as well as bilateral forms. In that study, we evaluated the histological parameters of Undescended testes based on patient’s age and we recommended for the optimal timing for orchiopexy. Objective: To evaluate the histological parameters of undescended testis and determine the optimal timing for orchiopexy. Methods and Materials: This cross-sectional study included 30 patients with undescended testis(es) in the department of paediatric surgery, BSMMU. After taking relevant history, examination findings and investigation reports of all the study subjects were recorded in the pretested data collection sheet. Then biopsy specimens were collected from the selected testes during orchiopexy and analyzed the parameters including mean tubular diameter (MTD), mean tubular fertility index (MTFI) germ cell count (GCC), Sertoli cell index (SCI) and interstitial fibrosis index (IFI) Results: The MTFI and GCC in children <1 years of age were significantly higher than those of other older age group. (P= 0.011 & P= 0.003) The MTFI, GCC and IFI were significantly better in patients <2 years of age when compared to those of > 2years. IFI in the > 5-years group was significantly higher than those of any of the other younger age groups (P < 0.05). Other parameters such as testicular volume, MTD and SCI showed no statistically significant difference between the age groups studied. Conclusions: This study revealed that higher number of germ cells exists in the tubules between 6 months and 1 year. After first year of life, the major germ cell parameters deteriorate continuously, thus we recommended that orchipexy should be performed, between 6 months and 1 year but no later than 2 years for preserving future fertility. Journal of Paediatric Surgeons of Bangladesh (2019) Vol.10 (1 & 2): 26-31

Result of simple versus layered repair of urethro-cutaneous fistula developing after hypospadias surgery

Background: Urethro-cutaneous fistula (UCF) after hypospadias surgery occurs regardless of the location of the meatus, procedure performed or experience of the surgeon. Hypospadias repair continues to be a singularly demanding form of surgical expression with considerable artistic latitude. The commonest complication of hypospadias surgery is fistula formation, which almost always requires repeat and similarly demanding surgery. Aims and Objectives: The aim of our study was to compare the result between simple and layered repair of UCF developing after hypospadias surgery. Materials and Methods: This comparative type of study was carried out in the Department of Paediatric Surgery, BSMMU, Dhaka from June 2015 to August 2016 for a period of 15 (fifteen) months. Forty (40) diagnosed cases of UCF were included in the study. All the participants were randomized into two groups named Group A & Group B. Group A was assigned to the simple repair technique & Group B was assigned to the layered repair technique. Relevant data were collected in a predesigned questionnaire. Results: The recurrent fistula formation rate was much higher in Group A (30%) than in Group B (05%), which was statistically significant in between the two groups. The majority of the fistulae recurred within a few days of the removal of the stent (from 7th to 10th POD). 6, out of 7 recurrent UCF were observed in this period. No recurrent fistula was observed beyond 4 weeks after operation. Conclusions: This study revealed that, the layered repair technique, with the addition of vascularized dorsal dartos fascia reduces the recurrent fistula formation rate in a significant number. Though more time consuming and technically difficult, we recommend wide application of layered repair technique in the management of post hypospadias UCF. Journal of Paediatric Surgeons of Bangladesh (2019) Vol. 10 (1 & 2): 37-42

Safety and advantages of early oral feeding after intestinal anastomosis in children: Our experience

Background: Restoration of enteral feeding is believed to enhance recovery after surgery, but intestinal anastomosis is a matter of apprehension for surgeons to start enteral feeding early. Before 2022, our standard practice was to wait three to four days to begin oral feeding after intestinal anastomosis. Since 2022, we have allowed oral feeding to start within 24 hours of intestinal anastomosis. This study compares the safety and benefits of early oral feeding after intestinal anastomosis in children. Methods: This retrospective study was done in the neonatal and paediatric surgery department, BSH&I, from January 2021 to December 2022. Children who received early oral feeding in 2022 compared with children who received oral feeding after three days in 2021. Children with duodenal anastomosis and anastomosis with a covering stoma were excluded. Demographic and clinical data were extracted from hospital records using a predefined questionnaire. Data were analyzed in SPSS 26, and a p-value <0.05 was considered significant. Results: One hundred thirty-three children (90 in 2022 and 43 in 2021) underwent intestinal anastomosis. Fiftynine (44.4%) children had small gut anastomosis, 62 (46.6%) children had large gut anastomosis, and 12 (9%) children had ileocolic anastomosis. There was no difference in gender and mean age at the surgery between the two groups. The mean time to start oral feeding was 19.9±0.59 hours in the case group and 79.1±13.9 hours in the control group (p<0.001). The mean time to full oral feeding was 61.05±4.5 hours in the case group and 125.67±25.51 hours in the control group (p<0.001). The mean hospital stay was 4.16±1.18 days in the case group and 7.06±1.96 days in the control group (p<0.001). The two groups had no significant differences in anastomotic and wound complications. Conclusion: Early oral feeding after intestinal anastomosis is safe in children and reduces postoperative hospital stay without any added risk. Journal of Paediatric Surgeons of Bangladesh (2019) Vol. 10 (1 & 2): 22-25

The Intraperitoneal Use of Cephazolin: A Novelty in the Prevention of Intra-abdominal Abscess after Laparoscopic Appendectomy in Children.

Laparoscopic appendectomy followed by postoperative intravenous (IV) antibiotics is the standard of care for acute appendicitis and postoperative prevention of intra-abdominal abscesses. The aim of or study was to determine if intraperitoneal irrigation with antibiotics could help prevent intra-abdominal abscess formation after laparoscopic appendectomy for complicated appendicitis in pediatric patients. A retrospective study was conducted on consecutive pediatric patients with acute appendicitis who had appendectomy in our Pediatric Surgery Department between August 2020 and February 2022. We compared two groups with similar age and symptoms. The first group (A) was treated with the normal standard of care, i.e., laparoscopic appendectomy and postoperative IV antibiotic therapy. For the second group (B) intraperitoneal cefazoline irrigation was added at the end of the laparoscopic procedure. Postoperative intra-abdominal abscess was diagnosed with ultrasound examination, performed after clinical suspicion/abnormal blood test results. One hundred sixty patients (males:females 109:51; median age 10.5 years [range 3-17 years]) who had laparosopic appendectomy for complicated appendicitis were included, 82 in group A and 78 in group B. In the first 7 days after surgery, 18 patients in group and 5 in group B developed an intra-abdominal abscess (p < 0.005). Drains were positioned in 38 patients in group A vs. 9 in group B. One patient in group A had a different complication which was infection of the surgical incision. Intraperitoneal cefazoline irrigation at the end of the laparoscopic appendectomy in pediatric patients significantly reduces the formation of intra-abdominal abscesses.

Totally implantable venous ports in infants and children: a single-center retrospective study of indications and safety.

Totally Implantable Venous Access Devices (TIVADs) contribute significantly to the treatment progress and comfort of patients requiring long-term therapy. However, the procedure for implanting TIVADs, as well as its very presence, may be associated with complications. This study evaluates the indications, safety, and complication rates of venous port implantations in pediatric patients. It also explores factors influencing the occurrence of early and late complications post-implantation. The study included 383 pediatric patients treated at the Department of Pediatric Surgery, Traumatology, and Urology in Poznan between 2013 and 2020 who underwent 474 implantations of intravenous ports. Venous access was achieved using the Seldinger technique. Statistical analysis was performed using Statistica 13 with TIBCO and PQStat 1.8.2.156 with PQStat. Venous ports were used in 345 oncology patients requiring chemotherapy (90% of the total group) and in 38 children (10%) with non-oncology indications. There were 36 early complications (7.6%) and 18 late complications (3.8%), excluding infectious complications. The most common early, non-infectious complications included pneumothorax (15 patients; 3%) and port pocket hematoma (12 patients; 2.5%). The most common late, non-infectious complications observed were venous catheter obstruction (8 children; 1.7%) and port system leakage (5 children; 1%). Infectious complications occurred in 129 cases (27.2%). Children with a diagnosis of non-Hodgkin's lymphoma, acute myeloid leukemia, and acute lymphoblastic leukemia had a significantly higher incidence of port infections. Venous ports equipped with a polyurethane catheter, compared to systems with a silicone catheter, functioned significantly shorter. The Seldinger method of port implantation is quick, minimally invasive, and safe. The type of port, including the material of the port's venous catheter, and the underlying disease have an impact on the durability of implantable intravenous systems. The experience of the surgeon is related to the frequency of complications associated with the procedure.

Case Report: Holistic dental care for a child with Hunter syndrome: Addressing dental ramifications, overcoming challenges, and enhancing quality of life

Abstract: Hunter syndrome (MPS II), an X-linked recessive lysosomal storage disorder, is a result of deficiency of the iduronate 2-sulfatase enzyme (IDS), leading to cognitive impairment, systemic organ involvement, and increased dental problems. This case report describes the management of a child with Hunter syndrome who was referred to the Department of Paediatric and Preventive Dentistry for pain in the upper front teeth. Intraoral examination revealed severe early childhood caries, prompting planning for full-mouth rehabilitation under general anaesthesia due to the child’s uncooperative behaviour. In response to recommendations from the Department of Otolaryngology and the Department of Paediatric Surgery, a comprehensive treatment plan consolidated full-mouth rehabilitation in addition to adenoidectomy and inguinal and umbilical herniotomy procedures during a single session of general anaesthesia. Successful interventions were reflected in the uneventful one-month follow-up of the patient, highlighting the efficacy of the interdisciplinary approach. The key takeaway underscores the importance of collaborative interventions, emphasising singular intubation for patients requiring recurrent hospitalisations, providing both monetary relief and reducing post operative healing time. Designed to address global developmental delay in the child, a personalised home care plan was also implemented. Evaluation of plaque and gingival indices before and after the home care regimen demonstrated a notable improvement, indicating an enhanced oral quality of life.

Symptomatic Intraparenchymal Epididymal Cysts: Description of 11 cases.

Epididymal cysts are benign cystic formations of the epididymis that usually appear in adolescence or early adulthood. Their frequency doubles after the age of 14-15. Obstruction in the epididymal efferent ductules with subsequent prostenotic dilatation of them, as well as dysgenesis due to hormonal disorders during fetal or postnatal life, are possible. At the 1st Department of Pediatric Surgery of A.U.Th. we treated 11 cases of boys at the age of 11-16 who presented with acute scrotum because of an epididymal cyst. The diagnosis was confirmed by ultrasound scanning . Due to persistent symptomatology, patients underwent surgical exploration and removal of the cyst. The postoperative care of the patients was uncomplicated with immediate remission of symptoms. In one case, ipsilateral acute epididymitis occurred after 10 days, which was successfully treated with antibiotic therapy. It is reported that approximately 50% of epididymal cysts involute within an average of 17 months. In conclusion, using the data obtained from the review, of the small in number of international bibliography studies, it is proposed conservative treatment of asymptomatic cysts with diameter smaller than 1 cm and surgical excision [1] of large asymptomatic cysts with diameter greater than 1 cm, which do not regress after a follow-up of 24-48 months, cysts, regardless of their diameter, responsible for persistent symptoms and in the manifestation of acute scrotal symptoms due to inflammation, intravesical bleeding or secondarily torsion of the epididymis.

Fifteen Years' Experience of Thoracoscopic Sympathetic Chain Interruption for Palmar Hyperhidrosis in Children and Adolescents: Evaluation of Different Techniques.

Background: Thoracoscopic sympathetic chain interruption is a definitive and effective therapy for severe primary palmar hyperhidrosis (PPH). Well-known methods include sympathectomy, sympathotomy, and clipping, but the occurrence of compensatory sweating offsets these methods. This study aims to report our experience with thoracoscopic sympathetic chain interruption in a large group of patients of age <18 years with PPH, focusing on surgical outcomes, complication rates, and patient satisfaction. Patients and Methods: This retrospective study included patients who underwent thoracoscopic sympathectomy, sympathotomy, or clipping for severe PPH between April 2008 and March 2023 at the Pediatric Surgery Department, Al-Azhar University Hospitals. Demographic and clinical data, operative steps, postoperative outcomes, complications, and patient satisfaction were reviewed from the patients' medical records. Results: During the 15-year study period, 420 children with PPH underwent bilateral thoracoscopic sympathetic chain interruption by either sympathectomy, sympathotomy, or clipping, with a sex ratio of 60% being females. The mean ages were 12 ± 3.48, 13 ± 2.45, and 13 ± 2.45 years, respectively. Sympathectomy was performed in 190 patients (45.2%), sympathotomy in 170 patients (40.5%), and clipping in 60 patients (14.3%). All patients had completed follow-up, with mean periods of ∼43 ± 5 months, 45 ± 3 months, and 42 ± 6 months, respectively. Complete palmar dryness was achieved in 405 patients (overall 96.4%) (97.8% after sympathectomy, 97.05% after sympathotomy, and 90% after clipping), whereas 2.1%, 2.9%, and 10% of patients experienced symptom recurrence, respectively, denoting significant statistical differences. Overall, 94 patients (22.4%) experienced compensatory sweating. Eventually, 409 patients (97.4%) were satisfied with the outcome, whereas 11 patients (2.6%) reported dissatisfaction, yet no significant differences found. Conclusion: The presented three modalities of thoracoscopic sympathetic chain interruption for PPH in children and adolescents are safe and effective, with overall very high postoperative satisfaction, despite a relatively high rate of compensatory sweating in sympathectomy group. Other major complications in this age population were scanty.

Interstitial Cells of Cajal and P2X3 Receptors at Ureteropelvic Junction Obstruction and Their Relationship with Pain Response.

Introduction: Etiopathogenesis and the symptomatology of ureteropelvic junction obstruction (UPJO) in the pediatric population has not yet been definitely clarified, suggesting a multifactorial nature of the condition. The aim was to analyze the association between the number of Interstitial Cells of Cajal (ICCs), as well as P2X3 receptors in ureteropelvic junction (UPJ) and the pain response in pediatric patients with hydronephrosis. Methods: 50 patients with congenital hydronephrosis underwent open or laparoscopic pyeloplasty at one of two departments of pediatric surgery and urology in Poland. Patients were divided into two groups according to the pain symptoms before surgery. A total of 50 samples of UPJ were obtained intraoperatively and underwent histopathological and immunohistochemical (IHC) analysis. Quantitative assessment of ICCs was based on the number of CD117(+) cells of adequate morphology in the subepithelial layer and the muscularis propria. Expression of P2X3 receptors was evaluated as the intensity of IHC staining. Results: Patients with hydronephrosis and accompanying pain were on average 60 months older (77 vs. 17 months) than children with asymptomatic hydronephrosis (p = 0.017). Symptomatic children revealed higher numbers of ICCs in both the subepithelial layer and in the lamina muscularis propria. In particular, symptomatic patients aged 2 years or more exhibited significantly higher numbers of ICCs in the subepithelial layer. Significant differences in the distribution of ICCs between the subepithelial layer and the lamina muscularis propria were observed in both groups. Expression of P2X3 receptors was limited to the urothelium and the muscle layer and correlated between these structures. There was no relationship between pain response and the expression of P2X3 receptors. Conclusions: ICCs and P2X3 receptors may participate in the pathogenesis of UPJO and in the modulation of pain response to a dilatation of the pyelocaliceal system. Explanation of the role of ICCs and P2X3 receptors in propagation of ureteral peristaltic wave and the modulation of pain stimuli requires further studies.

Clinical Relevance of Pathological Diagnosis of Hirschsprung's Disease with Acetylcholine-Esterase Histochemistry or Calretinin Immunohistochemistry.

Hirschsprung disease (HD) manifests as a developmental anomaly affecting the enteric nervous system, where there is an absence of ganglion cells in the lower part of the intestine. This deficiency leads to functional blockages within the intestines. HD is usually confirmed or ruled out through rectal biopsy. The identification of any ganglion cells through hematoxylin and eosin (H&E) staining rules out HD. If ganglion cells are absent, further staining with acetylcholine-esterase (AChE) histochemistry or calretinin immunohistochemistry (IHC) forms part of the standard procedure for determining a diagnosis of HD. In 2017, our Institute of Pathology at University Hospital of Heidelberg changed our HD diagnostic procedure from AChE histochemistry to calretinin IHC. In this paper, we report the impact of the diagnostic procedure change on surgical HD therapy procedures and on the clinical outcome of HD patients. We conducted a retrospective review of the diagnostic procedures, clinical data, and postoperative progress of 29 patients who underwent surgical treatment for HD in the Department of Pediatric Surgery, University of Heidelberg, between 2012 and 2021. The patient sample was divided into two groups, each covering a treatment period of 5 years. In 2012-2016, HD diagnosis was performed exclusively using AChE histochemistry (AChE group, n = 17). In 2017-2021, HD diagnosis was performed exclusively using calretinin IHC (CR group, n = 12). There were no significant differences between the groups in sex distribution, weeks of gestation, birth weight, length of the aganglionic segment, or associated congenital anomalies. Almost half of the children in the AChE group, twice as many as in the CR group, required an enterostomy before transanal endorectal pull-through procedure (TERPT). In the AChE group, 4 patients (23.5%) required repeat bowel sampling to confirm the diagnosis. Compared to the AChE group, more children in the CR group suffered from constipation post TERPT. Elevated AChE expression is linked to hypertrophied extrinsic cholinergic nerve fibers in the aganglionic segment in the majority of patients with HD. The manifestation of increased AChE expression develops over time. Therefore, in neonatal patients with HD, especially those in the first 3 weeks of life, an increase in AChE reaction is not detected. Calretinin IHC reliably identifies the presence or absence of ganglion cells and offers multiple benefits over AChE histochemistry. These include the ability to perform the test on paraffin-embedded tissue sections, a straightforward staining pattern, a clear binary interpretation (negative or positive), cost-effectiveness, and utility regardless of patient age. The ability of calretinin IHC to diagnose HD early and time-independently prevented repeated intestinal biopsies in our patient population and allowed us to perform a one-stage TERPT in the first months of life, reducing the number of enterostomies and restoring colonic continuity early. Patients undergoing transanal pull-through under the age of 3 months require a close follow-up to detect cases with bowel movement problems.

Comparison of cystectomy and lobectomy of lung hydatid cyst in pediatrics: a retrospective study.

Hydatid cyst is an endemic disease in Iran. The treatment of choice for paediatric lung hydatid cysts is surgical removal of the cyst. However, due to its high prevalence the risk of recurrence after the surgery, cystectomy with capitonnage, which preserves the lung tissue, is a favourable surgical approach compared to lobectomy. Herein, the authors compared the outcome of cystectomy and lobectomy of lung hydatid cysts. This is a retrospective study conducted in the paediatric surgery department. Paediatric patients who had undergone surgery due to pulmonary hydatid cysts were enroled. The patients were divided into two groups including cystectomy and non-anatomic lobectomy. Then, the length of surgery, length of hospitalization, postoperative complications, and the time required to remove the chest tube were calculated in each group. A total of 32 patients were enroled in this retrospective study. Age, sex, location, and size of cysts were not significantly different between the two groups. The duration of surgery in the lobectomy and cystectomy groups was 116.3±33.7 versus 116.1±28.2 min, respectively (P=0.53). Surgery complications including the need for blood transfusion, pneumothorax, need for bronchoscopy and atelectasis were not different between the study groups. The mean time for first chest tube removal was significantly different between the groups with the lobectomy group having a shorter time (P=0.02). The length of hospital and ICU stay were not different between the two surgical procedures. The time to remove the first chest tube was significantly higher in cystectomy compared to lobectomy (P=0.02). The complications and outcome of the cystectomy are comparable to the lobectomy technique. However, the cystectomy method has the advantage of preserving the lung tissue, therefore it's a favourable technique in endemic areas for hydatid cysts where reoperation may be indicated.

Evaluation of Vermillion Symmetry and Scar Quality in Unilateral Cleft Lip Repair Using Modified Millard's Technique Versus Fisher's Technique

BackgroundSince the primary goal of cleft lip repair is to achieve a symmetrical, aesthetic lip, several surgical techniques have been utilized. Accordingly, in this study, a unilateral cleft lip was surgically repaired using two techniques: modified Millard's and Fisher's techniques. PurposeThis study was designed to compare the vermillion symmetry and scar quality in the surgical management of patients with unilateral incomplete cleft lip using the modified Millard's and Fisher's techniques. Study design, setting, and sampleWe conducted a prospective randomized controlled clinical study. The study involved 20 patients selected from the Department of Plastic Pediatric Surgery at the Specialized Pediatric Hospital, Faculty of Medicine, Cairo University. The patients included in the study were aged between 2 and 6 months old, had a primary non-syndromic unilateral incomplete cleft lip, and had no other associated anomalies. Predictor variableThe predictor variable was operative management of the cleft lip, and subjects were randomly assigned to either the modified Millard or Fisher techniques. Outcome variablesThe primary outcome, vermilion symmetry, was evaluated by computerized photogrammetric lip analysis with Image J software. Additionally, scar quality, considered a secondary outcome, was assessed with the Vancouver Scar Scale and the Image J software. Every measurement was meticulously recorded in millimeters. CovariatesAge, sex, and cleft side were considered. AnalysesThe study comprised 20 children (12 males and 8 females), with a mean age of 140.5 ± 23.7 days in the Fisher’s group and 137.4 ± 25.6 days in the modified Millard’s group (p = 0.8). No statistically significant differences (p = 0.6) were found in vermillion height and width between both groups at 1 week, 3 months, and 6 months. Similarly, there were no statistically significant differences (p = 0.4) between both groups in terms of scar length and width at the 3- and 6-month follow-up periods. Conclusions and RelevanceThis study found no statistically significant differences in vermillion symmetry and scar quality between the two cleft lip repair techniques. Notably, one patient in the modified Millard group exhibited a notch on the vermillion border, which was not statistically significant.