Perianal Excoriation Research Articles

Safety and Efficacy of Hook Diathermy in the Dissection of the Mesocolorectum During Laparoscopic-Assisted Pull-Through for Hirschsprung Disease in Low-Resource Settings.

Background: Surgical correction is the main line of treatment for the congenital disorder Hirschsprung's disease (HD). Laparoscopic techniques proved their safety and efficacy in previous studies. LigaSure™ is the gold standard for colorectal dissection. However, other sealing methods could be used during the unavailability of LigaSure. Purpose: This study aimed to assess the safety profile of the hook diathermy technique compared to LigaSure in colorectal dissection during laparoscopic-assisted pull-through for HD. Materials and Methods: This case-control study was held in the pediatric surgery department at Assiut University Hospitals between September 2017 and January 2023. The study included 57 HD patients who were surgically operated on during a laparoscopic-assisted pull-through. They were divided into 2 groups according to the sealing methods: the ligasure group included 25 patients, and the hook diathermy group included 32 patients. Results: Both groups had no statistically significant differences regarding age, sex, or weight. The transition zone was present in all patients, and most transition zones were rectosigmoid. No cases reported intraoperative blood transfusion or conversion to an open or transanal approach. Minimum intraoperative blood loss was reported in both groups, with no significant differences. As regards postoperative complications, including bleeding, leakage, perianal excoriation, and enterocolitis, no significant differences between both groups were found. Conclusion: The LigaSure and hook diathermy techniques are safe and effective sealing methods for colorectal dissection during laparoscopic-assisted pull-through for HD.

Laparoscopic restorative proctocolectomy with ileal-J-pouch anal canal anastomosis without diverting ileostomy for total colonic and extensive aganglionosis is safe and feasible with combined Lugol's iodine staining technique and indocyanine green fluorescence angiography.

We present the surgical technique and outcomes of reduced-port laparoscopic restorative proctocolectomy with ileal-J-pouch anal canal anastomosis (IPACA) without diverting ileostomy for total colonic and extensive aganglionosis (TCA+). We retrospectively reviewed TCA+ cases between 2014 and 2022. Preoperative ileostomy was performed when transanal bowel irrigation was ineffective. Radical surgery for TCA+ was performed at approximately 6 kg. The surgery was performed using laparoscopy through a multi-channel trocar with or without an additional 3-mm trocar and IPACA reconstruction with indocyanine green fluorescence angiography (ICG) to assess anastomotic perfusion and Lugol's iodine staining to visualize the surgical anal canal. Ten patients with TCA+ were included. Ileostomy was performed in seven cases. The median operation time and blood loss were 274.5 min and 20 ml, respectively. No significant postoperative complications were found. All patients experienced frequent liquid stools and perianal excoriation in the early postoperative period, requiring anti-flatulence or codeine. The median follow-up period was 3.5 years. Three patients required irrigation management 1 year postoperatively, and the others defecated a median of 3.5 times per day. The median Kelly's clinical score was 5 in 5 patients aged >4 years. Reduced-port surgery, combined with Lugol's iodine staining and ICG, was safe, feasible, and had cosmetically and clinically acceptable mid-term outcomes.

Congenital chloride diarrhea presenting as dilated fetal bowel loops.

Congenital chloride diarrhea presenting as dilated fetal bowel loops.

P163 The cytokine horror: Kawasaki disease shock syndrome complicated with macrophage activation syndrome

Abstract Background/Aims Kawasaki disease (KD) is an acute febrile systemic vasculitis of unknown aetiology, affecting medium-sized vessels. It often occurs in children less than 5 years old. During the acute phase of the disease, less than 5% of children develop hypotension and shock. This severe form is called Kawasaki Disease Shock Syndrome (KDSS). Macrophage activation syndrome (MAS) is a heterogenous syndrome complex encompassing a broad spectrum of clinical features. MAS associated with KDSS is an extremely rare life threatening entity that warrants a high index of clinical suspicion, prompt and proper management. Methods We present our experience in the dilemmas and challenges faced in the diagnosis and management of KDSS complicated with MAS in a poor resource setting. It is our first experience of encountering MAS in KDSS. Results A 9-month-old baby with fever and a maculopapular rash involving palms and soles for 5 days duration was transferred from a peripheral hospital. A preliminary diagnosis of acute Kawasaki disease was made with the classical features that included the rash, cracked lips, pedal oedema, BCG scar inflammation, perianal excoriation and irritability. The fever did not settle following standard therapy that included three doses of intravenous immunoglobulins 2g/kg, aspirin and low dose dexamethasone. The child quickly began to decompensate. She developed cold clammy skin with hypotension on the 8th day of the illness. There was evidence of hepatosplenomegaly with transaminitis. 2D Echo revealed normal coronary vasculature without any dilatations or strictures. However, there was evidence of myocarditis supported by diffuse T inversions in the anterolateral leads and a highly positive troponin titre. Investigations revealed aa leucocytosis (22,100/dl), an abrupt drop in platelet count (350,000/dl to 80,000/dl), red blood cells, haemoglobin (11g/dl to 8g/dl) and erythrocyte sedimentation rate 95mm/hr to 50mm/hr. Hyperferritinemia, hypertriglyceridemia and hypofibrinogenemia supported the diagnosis of MAS. Blood culture was sterile. Initial bone marrow biopsy was inconclusive. High dose dexamethasone 10mg/m2/day and cyclosporine 2mg/kg/day was initiated. The circulatory collapse was managed with fluid boluses and a low dose adrenaline infusion. Subsequently there was dramatic clinical improvement and her cell counts and transaminases normalised on day 15. Conclusion We emphasise the importance of early recognition of refractory MAS in pediatric populations with rheumatic diseases and we suggest early initiation of cyclosporin as a rapid and effective treatment option in the poor resource settings where the ideal management with anakinra is beyond the realms of possibility. Disclosure L. Rajagopala: None. J. Jagoda: None. M.L. Gunatilaka: None.

Outcome Analysis of Single-Stage Transanal Endorectal Pull Through in Selected Patients with Hirschsprung Disease

Background:Hirschsprung disease is a notable cause of neonatal intestinal obstruction and constipation in older children. Transanal endorectal pull through (TEPT) is a newer technique of definitive management as against staged procedures. The aim of our study is to evaluate the feasibility and outcome of the procedure in selected children with Hirschsprung disease managed by this technique with review of the literature.Materials and Methods:Medical records of 12 children who underwent single-stage TEPT in a tertiary care centre over a period of 3 years from 2015 to 2018 were reviewed and retrospectively analysed on the basis of age, investigations, intraoperative parameters, complications, functional outcome and hospital stay.Results:The median age at surgery was 9 months. Nine patients were boys. The median weight of patients was 7.5 kg. The transition zone was observed at the level of the rectosigmoid in eight patients (66.6%) and sigmoid colon in four patients (33.3%). The mean length of muscle cuff was 3 cm, the mean length of resected bowel was 25 cm, the median operative time was 105 min and the mean hospital stay was 8 days. Perianal excoriation (n = 2) and enterocolitis (n = 1) were complications encountered postoperatively; however, no patient had cuff abscess, anastomotic leak or stricture. Stool frequency initially at 2 weeks was average of six to ten times a day, which gradually reduced to two to three times a day by 3 months postoperatively. None of the patients had faecal soiling or constipation on follow-up.Conclusion:Single-stage transanal endorectal pull through is an effective technique in the management of Hirschsprung disease with minimal complications.

Laparoscopic-assisted duhamel for hirschsprung's children older than 3 years.

Context:Hirschsprung's disease (HD) is a congenital anomaly affecting the enteric nervous system commonly the rectosigmoid region. Treatment is surgical where the aganglionic segment is resected, and bowel continuity is achieved by a colo-anal anastomosis. In 1999, Georgeson et al. proposed a new technique of primary laparoscopic-assisted pull through for HD as a new gold standard.Aim of the Study:To evaluate the outcome of the laparoscopic Duhamel procedure for the management of HD in children older than 3 years.Methods:This study was performed on 8 patients who were more than 3-year-old, with confirmed diagnoses of HD. Patients who initially presented with enterocolitis or obstruction were excluded from this study. In all cases, laparoscopic-assisted Duhamel was done.Results:We reported our results for the 1st year follow-up period and divided our results into early outcome for the first 3 months postoperative during which we had 2 cases complaining of enterocolitis that responded to conservative treatment, we observed 2 cases of perianal excoriation that responded to medical treatment while the late outcome was reported after 3 months postoperative: We had two cases with attacks of enterocolitis at 6 months and 9 months postoperatively that needed conservative treatment in the hospital in the form of parenteral antibiotics, rectal irrigation, intravenous fluids and NP0. There was neither anastomotic leak nor stenosis.Conclusion:Laparoscopic Duhamel for the management of HD in children older than 3 years is safe and useful procedure.

Hirschsprung Disease.

Hirschsprung Disease.

Enterobius vermicularis infestation causing terminal ileal gangrene

Enterobius vermicularis is one of the most common nematode infestations seen worldwide. This condition is commonly seen in children. Although asymptomatic, they present with symptoms of perianal itching commonly at night with perianal excoriations. In this case report we present a case 79 years old man with multiple co-morbidities who presented with non-bilious vomiting and severe abdominal pain. Emergency laparotomy was performed during which terminal ileal gangrene was noted. Ileo-caecal wall revealed multiple parasites (enterobius).

PRIMARY PROCEDURE FOR ANORECTAL MALFORMATIONS IN CHILDREN; A SINGLE CENTER EXPERIENCE

Tariq Waheed , Sajjad Ali , Muhammad Uzair ,Inayat Ur Rehman
 Objective: To share our experience with outcome of primary procedure for anorectal malformation (ARM) in children.
 METHODOLOGY: Retrospective study included 40 patients from both sexes operated between January 2018 and January 2019 for high and intermediate ARM in the department of paediatric surgery Khyber teaching hospital Peshawar. Patients with common cloaca and associated life threatening anomalies were excluded. Demographic and clinical data was tabulated and analyzed. Cost of the procedure was recorded in Pakistani Rupees and hospital stay in days. Continence was evaluated by Kelly’s score and parents’ satisfaction graded by Likert scale.
 RESULTS: Male to female ratio was 1.6:1. Mean hospital stay was 5.91±1.01 days and mean cost of 22950 ± 3234 PKR. Wound dehiscence was recorded in 3 (7.5%), 2 (5.0%) patients developed surgical site infection and 11 (35.48%) patients had perianal excoriation. Adhesive obstruction and mucosal prolapse were seen in 1 (2.5%) patient each while anal stenosis in 2(5.0%) Patients. After 6 months 28 (70%) patients had formed stools while 12 (30%) had loose stools. Stool frequency was 0-1 time/day in majority i.e. 20 (50 %) patients. Continence was fair in 24 (60%) patients. Parents of 20 (50%) patients were very satisfied, 17(42.5%) satisfied only. Continence for age and sex revealed insignificant P values of 0.213 and 0.07 respectively.
 CONCLUSION: Primary procedure for anorectal malformations may be a good alternative to traditional three stage procedure in selected patients with intermediate and high variety of ARM.
 KEY WORDS: Anorectal malformation (MeSH); Abdominoperineal pull through (Non-MeSH); Kelly’s score (Non-MeSH).

Duhamel’s procedure for Hirschsprung’s disease and the functional outcome in a tertiary care center

Introduction: Hirschsprung’s disease (HD) is a developmental disorder caused by the migration failure of neural crest cells during intestinal development, resulting in an aganglionic colon and causing a functional obstruction in children. Duhamel’s procedure (DP) which involves excision of the aganglionic segment with retrorectal pull through, and anastomosis of the ganglionated bowel above dentate line, is one of the classical surgical procedures for HD. Materials and Methods: This retrospective study was conducted in a tertiary care center in South India. The medical records and follow-up details of 17 patients, who underwent DP for HD between January 2014 and December 2018, were obtained and evaluated. Outcomes evaluated included incidence of post-operative constipation, incontinence/soiling, enterocolitis, anastomotic stricture, and leak. Results: There were 17 patients with HD who underwent DP during the study period, among which 76.47% of patients had classical HD and 23.52% were long-segment HD. A total of 58.82% of patients presented at birth, with overall 76.47% of male predominance. Fecal soiling (29.41%), perianal excoriation (17.64%), wound infection (11.76%), post-operative enterocolitis (11.76%), stricture formation (11.76%), constipation (11.76%), and hypertension (11.76%), and adhesive bowel obstruction (5.88%) were some complications observed in this study. Most of these complications were successfully managed. Conclusion: Staged DP is safe and can address the entire spectrum of HD. Complications are less and comparable to other techniques, and with close follow-up to address the post-operative complications, good quality of life can be achieved for the children with HD.

Delayed presentation of anorectal malformations in a tertiary care hospital in India.

To study delayed presentation of ARMs, management and its effect on surgical and functional complications. It is a retrospective study from March 2015 to March 2020. All the patients satisfying the criteria of delayed ARMs, i.e., presenting 7days after birth were included. Information regarding type of ARM, mode of presentation, time of presentation, associated anomalies, management strategy, postoperative complications and functional outcome was noted. Minimum follow-up period was 6months. Out of 102 patients with ARM, 44 patients presented late. Among the 44 patients, 9 were males and 35 were females. Associated comorbidities observed are low birth weight (n = 9) and preterm (n = 13). Associated anomalies observed were cardiac (n = 18), renal (n = 8), other gastrointestinal (n = 5) and skeletal (n = 1). (1) Male: rectourethral fistula-2 (staged repair), anal stenosis-3 (anoplasty) and anocutaneous fistula-4 (anoplasty). (2) Female: vestibular fistula: 15 (6 primary definitive surgery + 9 staged repair), ectopic anus: 3 (staged repair), anal stenosis: 2 (anoplasty), urogenital sinus: 4 (staged repair), H-type ARM: 8 (staged repair) and persistent cloaca: 3 (staged repair). Primary repair was done in 15 patients (34%), and staged repair was done in 29 patients (65.9%). Anoplasty was done in 9 patients, ASARP (modified tsuchida's procedure) in 8 patients and PSARP in 27 patients. Postoperative complications observed were constipation (n = 21, 47.7%), fecal incontinence (n = 12, 27.27%) with perianal excoriation in 2 patients, anal stenosis (n = 3, 6.8%) and rectal mucosal prolapse (n = 2, 4.5%) CONCLUSION: Delayed presentation of ARMs is not uncommon and is more common in females. Management is almost similar to those who present early. Those who present with chronic constipation and megarectum require staged repair. Complications were more frequent with delayed presentation. Hence, every newborn should have careful examination of perineum and screened for ARM to avoid possible morbidity and mortality.

Optimism for the Single-stage Transanal Swenson in Neonates.

Background:Hirschsprung's disease (HD) has been traditionally treated from infancy onward and different techniques have been used including Swenson, Soave, and Duhamel procedures. The purpose of this study was to evaluate the transanal Swenson's procedure for classical rectosigmoid HD in neonates.Patient and Methods:This was a prospective study in which neonates diagnosed with HD were recruited from January 2017 to December 2018. Cases with a transition zone proximal to the midsigmoid were excluded. All patients underwent a transanal Swenson's procedure in the neonatal period using a unified protocol. Intraoperative course and postoperative outcomes such as leak, pelvic abscess, soiling, perianal excoriation, stricture, enterocolitis, and constipation were evaluated and all patients were followed for at least 6 months.Results:Twenty-three patients (17 males and 6 females) underwent transanal Swenson's procedure. The mean age was 22 ± 5.7 days. Follow-up ranged from 6 to 30 months. No anastomotic leak, retraction, or prolapse was reported. Mild perianal excoriations occurred early in 9 (39%) cases and all responded to medical treatment and disappeared before 2 months postoperatively. Stricture occurred in 2 (8%) patients, enterocolitis in 3 (13%), and constipation in 3 (13%).Conclusion:Transanal Swenson's procedure is feasible and can be performed safely in neonates with rectosigmoid HD with good short-term outcomes. Proper patient selection and standard protocol following fine procedural hall-marks and details are keys for optimal results and patient satisfaction.

Laparoscopic-assisted transanal pull-through for hirschsprung's children older than 3 years: A case series.

Context:Hirschsprung's disease (HD) is a congenital anomaly affecting the enteric nervous system commonly the rectosigmoid region. Treatment is surgical where the aganglionic segment is resected, and bowel continuity is restored by a coloanal anastomosis. In 1999, Georgeson et al. proposed a new technique of primary laparoscopic-assisted pull-through for HD as a new gold standard.Aim:The aim of the study was to evaluate the outcome of the laparoscopic-aided transanal pull-through procedure for the management of HD in children older than 3 years of age.Methods:This study was conducted on 15 consecutive patients presented to a university hospital, diagnosed as having HD relying on their clinical features, barium enema study and rectal biopsy. In all cases, laparoscopic-assisted transanal pull-through was attempted. The laparoscopic part included transition zone identification, seromuscular biopsy for fresh frozen histopathology and sigmoid and rectal mobilisation as much as possible down the peritoneal reflection. The transanal part included mobilisation of the rectal lower segment by 2–3 cm, resection till the ganglionic segment, and full-thickness two-layer coloanal anastomosis was done.Results:Early complications occurred in eight cases: enterocolitis in four cases and perianal excoriation occurred in four cases. There were no cases of anastomotic leak. Late complications occurred in seven patients: four cases developed stricture at the site of coloanal anastomosis and three cases experienced enterocolitis at 6 and 9 months postoperatively.Conclusion:Laparoscopic-aided transanal pull-through procedure is a safe, feasible modality for the management of HD in children more than 3 years.

LAPROSCOPIC ASSISTED SWENSON PULL-THROUGH FOR CLASSIC HIRSCHSPRUNG’S DISEASE WITH SIGMOID COLOSTOMY: A SINGLE CENTER EXPERIENCE

OBJECTIVE: To share our experience of laparoscopic assisted Swenson pull-through for classic Hirschsprung’s disease (HD) with sigmoid colostomy. METHODS: Thirty-one patients with HD and sigmoid colostomy operated in Pediatric Surgery department, Khyber Teaching Hospital, Peshawar, Pakistan, between June 2014 and June 2018 were included. Patients with long segment HD, and those operated elsewhere were excluded from the study. Demographic characteristics, intraoperative findings and post operative course were retrieved from files. Post-operative outcome at 3rd, 6th and 12th month follow ups were taken from follow up charts. RESULTS: Mean age and weight of patients were 13.23±1.76 months and 7.89±1.42 kg, respectively. Male to female ratio was 6.75:1. Mean operative time, duration of urinary catheterization and hospital stay were 171.87±15.76 min, 0.79±1.02 days and 5.91±1.01 days, respectively. After surgery, stool consistency was liquid in 12 (61.29% ) and loose in 12 (38.7 %) patients. However, stool frequency was >3 times/day in 10 (32.25%) cases, 2-3 times/day in 18 (58.06%) patients and 0-1 time/day in 3 (9.67% ) patients. Surgical site infection and perianal excoriation were seen in 2 (6.45%) and 11 (35.48%) patients, respectively. Progressive improvement in stool consistency and frequency was noticed at 12th month follow up. Perianal excoriation was seen 11 (35.48%) patients at 3rd month, 6 (19.35% ) patients at 6th and 1 (3.22%) patient at 12th month follow up. CONCLUSION: Laparoscopic assisted Swenson pull-through is a good treatment option for patient with recto-sigmoid HD and bears a predictable and acceptable stooling pattern, optimum hospital stay and minimal complications.

Redo pull-through in total colonic aganglionosis due to residual aganglionosis: a single center's experience.

BackgroundReoperation for total colonic aganglionosis (TCA) may be required for residual aganglionosis after an initial radical operation. We aimed to investigate the symptoms, management, and outcomes of patients who required a redo pull-through (Redo PT).MethodsNine TCA patients underwent Redo PT at our center between 2007 and 2017. Their medical records were reviewed. Parental telephone interviews that included disease-specific clinical outcomes were conducted, and post-operative complications and long-term outcomes (including height-for-age/weight-for-age and bowel-function score) were compared to those of single-pull-through (Single PT) patients (n = 21).ResultsAll the nine Redo PT patients suffered obstruction within 1 month after the initial operation that could not be alleviated by conservative treatment. All abdominal X-ray/contrast barium enemas showed proximal bowel dilatation, indicating residual aganglionosis. The median ages at the initial operation and Redo PT were 200 and 509 days, respectively. Reoperation consisted of an intraoperative frozen biopsy and a modified laparotomic Soave procedure in all patients. Post-operative complications included perianal excoriation (n = 3), intestinal obstruction (n = 2), enterocolitis (n = 2), and rectovestibular fistula (n = 1). Seven Redo PT patients were followed up for a mean time of 7.1 ± 2.3 years; six (85.7%) had good growth and four (57.1%) had good bowel-function recovery. Post-operative complications and long-term outcomes were almost equal between the Redo PT and Single PT groups (all P > 0.05).ConclusionTCA patients with recurrent obstructive symptoms and dilated proximal bowel may have residual aganglionosis after an initial operation. Redo PT is effective and provides good long-term outcomes comparable to those of patients who benefited from Single PT.

Short Term and Long term Outcome of Single-Stage Trans-anal Pull Through for Hirschsprung's Disease in Neonates and Infants

Purpose: Hirschsprungs disease is common cause of intestinal obstruction in neonate and trans-anal pull through has drastically changed the treatment of Hirschsprungs disease. The aim of this study was to evaluate the short and long-term outcome of single-stage trans-anal pull through in neonates and infants. Material and methods: It was a prospective study of new-born’s and young infants with features of Hirschsprungs disease. Patients with weight more than 3 kg, transition zone at recto sigmoid and distal sigmoid region were included in the study. Patients with more dilated proximal colon, bowel obstruction not responding to washes and long segment Hirschsprungs disease were excluded from the study. Single-stage trans-anal pull through was done in all cases and short term variables include wound infection, leak, peri-anal excoriation and long term outcome variables included continence, constipation, stricture, enterocolitis and need of redo pull-through procedure were evaluated. Results: 24 patients were included in the study. There were 15 males and 9 females. Age of the patients ranged from 26 days to 4.5 months with mean age of 1.3 months. Weight of the patients ranged from 3 kg to 5.3 kg with mean weight of 4.8 kg. Wound infection and perianal excoriation was seen in 8.3% and 45.8% respectively. Enterocolitis, stricture, constipation and minor soiling were seen in 12.5%, 4.2%, 8.3% and 12.5% respectively. Follow-up period ranged from 10 to 120 months. Conclusion: Trans-anal pull through is feasible and safe option with excellent results in neonates and infants with short segment Hirschsprungs disease.

P395 Management of pouch vaginal fistulae in ulcerative colitis: A 35-year experience

Abstract Background Pouch vaginal fistulae (PVF) occur following restorative proctocolectomy with an incidence of 6%. The overall rate of pouch failure is 10% but may be as high as 29% with a PVF. PVF can be relatively asymptomatic, with low volume vaginal mucus discharge alone, or can cause considerable morbidity with persistent, passive leakage of faeces and gross perianal excoriation. Management is challenging with a range of reparative techniques reported and no gold standard. Despite a lack of evidence, anti-TNF agents are increasingly used. It is unclear whether there are factors which may predict fistula closure with anti-TNF therapy. The primary aim of fistula therapy should be fistula eradication or amelioration of fistula symptoms without worsening pouch function. Methods This is a retrospective analysis of the management of PVF in ulcerative colitis in a tertiary referral centre. Demographic, clinical history and presenting symptoms of fistula including pouch function were collected. Symptomatic burden related to the fistula and the presence or absence of gastrointestinal continuity were assessed. Results Fifty patients with PVF were identified between 1984 and 2019 and complete clinical notes were available and analysed for 30 of these. The median age at diagnosis was 36 (range 19–52) years. The median follow-up from pouch creation was 12.5 years. A PVF developed in 30% within 1 year of pouch creation and in 70% after 1 year. In this cohort, 17 (56%) maintained gastrointestinal continuity, of whom 13 were asymptomatic of fistula symptoms (11 after intervention), while 4 were symptomatic but declined intervention. Of the 11 patients who were asymptomatic following treatment, 3 had perianal pouch advancement, 1 had a redo transabdominal pouch, 2 had transvaginal repair, 2 had seton drainage and 3 patients were managed with anti-TNF therapy. Anti-TNF agents were used in 5 patients, 1 of whom was already defunctioned. Three achieved quiescence of symptoms, with 1 requiring pouch excision due to ongoing symptoms. Three patients with poor pouch function prior to anti-TNF therapy noted an improvement in pouch function. Pouch excision or permanent defunctioning was performed in 13 patients (predominantly due to the burden of fistula symptoms rather than poor pouch function). Conclusion Around 50% of patients with PVF required pouch excision or permanent defunctioning. The burden of fistula symptoms drove this decision, rather than overall poor pouch function. Anti- TNF therapy improved pouch function and fistula symptoms in a small group of patients but the evidence supporting its use and indications remain limited.

A case of infantile diarrhoea

Introduction: Diarrhoea is the second most common cause of deaths among children less than 5 years of age (15%) and half of the cases occur from 6 to 12 months of age. Deaths among hospitalised children, are mostly among the malnurished, demanding urgent diagnostic, therapeutic and nutritional intervention. Aim: To sensitise practicing pediatricians about such double dangers as high index of suspicion helps in early diagnosis and prompt intervention. Case: Eight month old baby presented with acute gastroenteritis (AGE) for 2 days. Exclusively breast-ded upto 6 monts of age. The child was treated with WHO recommended standard of care for AD such as oral rehydration solution (ORS), Zinc and usual complimentary feeds, including formula milk which the baby was on for last 2 months. Did show some initial improvemnt but worsened by week end; with large explossive stools, abdominal distension and perianal excoriation. Managed as secondary lactose intolerance post-viral AGE. Cow's milk protein allergy (CMPA) was thought unlikely in absence of any history of diarrhoea despite top feeds. Continued Zinc and complimentary feeding, but replaced formula milk with soy based feed. Th baby improved over next 4 days, started gaining weight and was discharged. Conclusion: Formula-fed infants with secondary lactose intolerance, when changed to lactose-free diet, may have early resolution of diarrhea and less scope of treatment failure. Being cheaper, Soy is considered a better alternative for short-term use in selected cases in developing countries as ours.

The outcome of single-stage management of Hirschsprung's disease at a tertiary care center

Background: Hirschsprung's disease (HD) was initially treated as a multistage procedure. Subsequently, it has been recognized that surgery can be done as a single-stage at an early age as this approach is safe, cost-effective, and avoids the morbidity associated with stomas. We study the effectiveness and safety of single-stage management of HD using Langer's or Georgeson's techniques, to analyze the outcome of surgery, and its comparison with other similar studies. Patients and Method: The study was retrospectively carried out in our institution from October 2016 to September 2019. They were operated in a single-stage either by Langer's procedure or by laparoscopy-assisted Georgeson's procedure. Inclusion criteria were clinically diagnosed cases of HD with an obvious transition zone. Patients without a funnel (on barium enema films) were excluded. Results were analyzed using IBM SPSS statistics 20.00 software. Result: The present series included 28 patients. The mean age of the patients was 16.24 months. Mean intra operative blood loss for Langer's series was 30 ml and Georgeson's series was 20 ml. The mean operative time for Georgeson's procedure was 150 min and for Langer's, it was 90 min. Postoperative enterocolitis 3 (10.7%), persistent constipation 2 (7.5%), and perianal excoriation 9 (32.14%) were some of the important complications noted. Conclusion: Single-stage surgery for HD is safe and avoids the need for multiple operations including stoma and its related complications.

Feasibility and efficacy of home rectal irrigation in neonates and early infancy with Hirschsprung disease.

A single-stage pull-through (SSPT) is the most commonly performed procedure for Hirschsprung disease (HSCR) and has been shown to be better than multi-stage procedures. However, performing a SSPT in the neonatal period or early in infancy is a risk factor for an inaccurate diagnosis, post-operative enterocolitis, and a protracted post-operative recovery. The present study was primarily designed to evaluate the feasibility and efficacy of home rectal irrigation in the neonatal period and early in infancy, followed by a delayed and planned SSPT in a prospective cohort with HSCR. Between January 2014 and December 2016, a total of 147 neonates diagnosed with HSCR were enrolled in the study. Six patients were excluded as a result of ganglion cells found in second rectal biopsies after the neonatal period. One hundred twenty-two patients successfully underwent 2-4months of home rectal irrigation during the neonatal period, followed by a SSPT procedure after the neonatal period (group A, n = 122). Nineteen patients were not candidates for home rectal irrigation, and thus, colostomies were performed during the neonatal period followed by multi-stage procedures after the neonatal period (group B, n = 19). One hundred twenty-two healthy children, age- and gender-matched to group A were enrolled as the healthy control group for assessment of nutrition status (group C, n = 122). The birth weight, gender ratio, aganglionic segment, age, and Hirschsprung-associated enterocolitis (HAEC) score at the time of HSCR diagnosis were measured to evaluate the feasibility of home rectal irrigation in neonates and early in infancy. The nutritional indices, including weight, body length, serum albumin, serum prealbumin, serum retinol-binding protein, and incidence of HAEC after 2-4 successful home rectal irrigation, were used to assess the efficacy of home rectal irrigation. Anastomotic strictures or leakage, perianal excoriation, frequency of defecation, and morbidity of post-operative HAEC were recorded to evaluate the beneficial effects to pull through (PT), which were facilitated by home rectal irrigation. Higher HAEC scores and older age at the time of diagnosis of HSCR were associated with group B, compared to group A (4.34 ± 1.25 vs. 11.0 ± 2.56 [t = 18.20, p < 0.05] and 2.8 ± 1.46days vs. 12.1 ± 5.3days [t = 16.10, p < 0.05], respectively). The ratio of rectosigmoid HSCR to non-rectosigmoid HSCR was higher in group A than group B (104/18 vs. 4/15 [χ2 = 34.29, p < 0.05]). There were no differences in birth weight, weight at the time of diagnosis of HSCR, and gender ratio between groups A and B. There were no differences in birth weight, birth length, post-home rectal irrigation age, post-home rectal irrigation weight, post-home rectal irrigation length, and post-home rectal irrigation serum albumin between groups A and C (3.47 ± 0.42kg vs. 3.48 ± 0.40kg [t = 0.10, p > 0.05], 50.02 ± 0.49cm vs. 50.05 ± 0.46cm [t = 0.61, p > 0.05], 98.59 ± 13.34days vs. 97.83 ± 13.58days [t = 0.44, p > 0.05], 6.77 ± 0.66kg vs. 6.97 ± 0.87kg [t = 1.95, p > 0.05], 61.55 ± 2.14cm vs. 61.70 ± 2.07cm [t = 0.59, p > 0.05], and 41.78 ± 2.42g/L vs. 41.85 ± 2.37g/L [t = 0.22, p > 0.05], respectively). The rate of HAEC in the period of home rectal irrigation in group A was low; however, the post-home rectal irrigation serum prealbumin level and retinol-binding protein were significantly lower in group A than group C (0.15 ± 0.04g/L vs. 0.17 ± 0.05g/L [t = 3.50, p < 0.05] and 22.51 ± 7.53g/L vs. 30.57 ± 9.26g/L [t = 7.46, p < 0.05], respectively). There were no anastomotic strictures or leakage after definitive PT performed in group A. The frequency of defecation ranged from 2-6 times per day, 10 patients had perianal excoriation 3months after PT, and 11 patients had post-operative HAEC during 6months of follow-up after PT. Home rectal irrigation in neonates and early in infancy, followed by a delayed and planned SSPT is feasible and effective in patients with HSCR, and could be beneficial to definitive PT. However, for patients with an extended aganglionic segment, older age, or high HAEC score at the time of diagnosis of HSCR, rectal irrigation maybe not suitable. This was a prospective comparative study designed to evaluate the effects of home rectal irrigation for facilitating and enhancing recovery after PT, and was registered at Clinical Trials.gov as NCT02776176.