Operative management of non-iatrogenic pediatric and adolescence peripheral arterial trauma: An experience from a resource challenged setting.

OBJECTIVES: To evaluates the management and outcome of non-iatrogenic pediatric and adolescence extremity arterial injuries in a resource-challenged setting. METHODS: A retrospective study of the surgical management for non-iatrogenic extremity arterial trauma in pediatric and adolescence during the period from January 2008 to December 2015. This study was performed in two different countries at tertiary referral university and teaching hospitals having a specialized emergency and trauma centers. A thorough study of each patient record was collected from these centers including, the original demographic data and their clinical presentations. Operative data of each patient was also reported. RESULTS: During the 8-year period of the study, 149 pediatric and adolescent extremity arterial trauma patients were treated. They were 93.3% male, and 6.7% female, respectively. The age ranged from 2 to 18 years with a mean of 10.25 ± 4.05 years. Lower extremity arterial trauma was recorded in 51%, while 49% were having upper extremity injuries. Primary repair with end-to-end vascular anastomosis was performed in 51.7%, while an interposition reversed saphenous vein graft was performed in 48.3%. The operative procedures were performed by an experienced vascular surgeon and well-trained pediatric surgeons and general surgeons. Pseudoaneurysms was recorded in 9% of cases. Fasciotomy was performed in 15% of cases. CONCLUSION: Treatment of pediatric and adolescent extremity arterial injuries with primary end-to-end vascular anastomoses or with the use of an interposition reversed saphenous vein graft is a reliable, feasible, and more cost-effectiveness technique with good results. Moreover, it should be adopted for all vascular trauma patients, whenever possible.

Management of Extremity Venous Thrombosis in Neonates and Infants: An Experience From a Resource Challenged Setting.

We aimed to evaluate the outcome of different treatment modalities for extremity venous thrombosis (VT) in neonates and infants, highlighting the current debate on their best tool of management. This retrospective study took place over a 9-year period from January 2009 to December 2017. All treated patients were referred to the vascular and pediatric surgery departments from the neonatal intensive care unit. All patients underwent a thorough history-taking as well as general clinical and local examination of the affected limb. Patients were divided into 2 groups: group I included those who underwent a conservative treated with the sole administration of unfractionated heparin (UFH), whereas group II included those who were treated with UFH plus warfarin. Sixty-three patients were included in this study. They were 36 males and 27 females. Their age ranged from 3 to 302 days. Forty-one (65%) patients had VT in the upper limb, whereas the remaining 22 (35%) had lower extremity VT. The success rate of the nonsurgical treatment was accomplished in 81% of patients. The remaining 19% underwent limb severing, due to established gangrene. The Kaplan-Meier survival method revealed a highly significant increase in both mean and median survival times in those groups treated with heparin and warfarin compared to heparin-only group ( P < .001). Nonoperative treatment with anticoagulation or observation (ie, wait-and-see policy) alone may be an easily applicable, effective, and a safe modality for management of VT in neonates and infants, especially in developing countries with poor or highly challenged resource settings.

Laparoscopy as a Primary Investigatory Tool in Pediatric Abdominal Masses.

BACKGROUND: Management of abdominal masses still pose a major challenge for pediatrician and surgeons with many controversy as regards the best investigatory tools. AIM OF THE WORK: This study was designated to evaluate the role of diagnostic laparoscopy in investigating equivocal pediatric masses that had undergone other imaging modalities. PATIENTS AND METHODS: A combined prospective and retrospective multicenter study over a period of 12 years from January 2005 to December 2016 was undertaken. This study included all children aged from 3 months to 15 years. Those having a documented diagnosis through other imaging modalities such as sonographic and/or computed tomography (CT) guided biopsy were excluded. All patients underwent multiport diagnostic laparoscopy for biopsy of the mass. All specimens were histologically assessed basically using Hematoxylin and Eosin (H and E) staining; some specimens had been immunohistochemically studied. RESULTS: One hundred and thirty-two patients were recruited in the study. They were 69 males and 63 females with a male to female ratio of1.1:1. The age ranged from 3 months up to 15 years with the mean age of 2.7 ± 0.8 years. Out of the total studied group, 54 patients were diagnosed with neuroblastoma (40.9%), while 66 (50%) were having nephroblastoma. The remaining 12 (9.1%) were having non-Hodgkin's abdominal lymphoma. Not all patients showed any complication related to the procedure. The mean follow up period was 3.6 years. Most of the cases (n=121) despite having a different diagnosis, were clinically staged as grade I to grade II (91.7%). Neither intraoperative nor postoperative complications were recorded during this technique. The mean operative time was 72 mins ± 20 in the earliest group; yet, it has declined to be 32 ± 12 minutes in the latest group due to the advancement of the learning curve. CONCLUSION: Laparoscopy is accurate and safe for investigating pediatric solid abdominal masses. It should be used as the sole tool for biopsy of solid abdominal tumors in pediatrics.

Reliability of sonoelastography in predicting pediatric cervical lymph node malignancy.

PURPOSE: Controversy exists as regards the best non-invasive diagnostic tool for pediatric cervical lymphadenopathy. The current work aimed to evaluate the reliability, sensitivity, specificity, and accuracy of sonoelastography in diagnosing benign and/or malignant pediatric cervical lymphadenopathy. METHODS: Prospective study took place over a period of 4 years from January 2013 to December 2016. A total of 177 lymph nodes (LNs) in 128 children with an age ranging from 11 months to 12 years were recruited in this study. Patients were 77 males and 51 females with a ratio of 3:2. All patients underwent a thorough history taking and clinical examination of the neck focusing on the cervical lymph nodes. After that, a B-mode sonography, Color Doppler ultrasound, and Sonoelastography were performed. Elastographic patterns of 1-5 were evaluated, whereas patterns of 3-5 (firm to hard) were suspected to have a malignant nature. Sonographic-guided aspiration cytology took place in 107 lymph nodes and excisional biopsy in 102 lymph nodes, whereas 13 lymph nodes responded adequately to conservative treatment. They proved to be benign reactive hyperplasia. RESULTS: The majority of LNs (87%) were of the malignant type that showed an elastographic pattern of 3-5. The same patterns were observed in only 6 (3.4%) of the benign LNs. Sonoelastography showed a sensitivity of 85.9%, specificity of 100%, PPV of 100%, NPV of 75.96%, and overall accuracy of 90.23% in distinguishing benign from malignant lymph nodes. Using the B-Mode ultrasound, an abnormal hilum was seen in 75%. The accuracy of color Doppler US reached 82.7%. CONCLUSIONS: Sonoelastography may be superior to other US modalities in elucidating different cervical lymph node biopsy helping to distinguish benign from malignant lesions. This may replace the lymph node biopsies in the future. Moreover, its use in the follow-up of patients with cervical malignancies may reduce the number of future biopsies. Further studies with more patients may be needed for a better assessment of results.

Role of clinical judgment and tissue harmonic imaging ultrasonography in diagnosis of paediatric acute appendicitis.

BACKGROUND: Appendicitis is the most common surgical emergency in children; yet, diagnosis of equivocal presentations continues to challenge clinicians. AIM: The objective of this study was to investigate the hypothesis that the use of a modified clinical practice and harmonic ultrasonographic grading scores (MCPGS) may improve the accuracy in diagnosing acute appendicitis in the pediatric population. MAIN OUTCOME MEASURES: Sensitivity, specificity, and accuracy of the modified scoring system. Five hundred and thirty patients presented with suspected diagnosis of acute appendicitis during the period from December 2000 to December 2009 were enrolled in this study. Children's data that have already been published of those who presented with suspected diagnosis of acute appendicitis- to whom a special clinical practice grading scores (CPGS) incorporating clinical judgment and results of gray scale ultrasonography (US) was applied- were reviewed and compared to the data of 265 pediatric patients with equivocal diagnosis of acute appendicitis (AA), to whom a modified clinical practice grading scores (MCPGS) was applied. Statistical analyses were carried out using Z test for comparing 2 sample proportions and student's t-test to compare the quantitative data in both groups. Sensitivity and specificity for the 2 scoring systems were calculated using Epi-Info software. RESULTS: The Number of appendectomies declined from 200 (75.5%) in our previous CPGS to 187 (70.6%) in the MCPGS (P > 0.05).Specificity was significantly higher when applying MCPGS (90.7%) in this study compared to 70.47% in our previous work when CPGS was applied (P < 0.01). Furthermore, the positive predictive value (PPV) was significantly higher (95.72%) than in our previous study (82.88%), (P < 0.01). Overall agreement (accuracy) of MCPGS was 96.98%. Kappa = 0.929 (P < 0.001). Negative predictive power was 100%. And the Overall agreement (accuracy) was 96.98%. CONCLUSIONS: MCPGS tends to help in reduce the numbers of avoidable and unnecessary appendectomies in suspected cases of pediatric acute appendicitis that may help in saving hospital resources.