Management of Complete Persistent Rectal Prolapse in Children: A Comparative Study Between Mesh Repair Versus Suturing Rectopexy.

BACKGROUND: Rectal prolapse is a relatively common, usually self-limiting illness in children. Peak incidence is between 1 and 3 years. The primary treatment of rectal prolapse is non-operative. Surgical intervention is needed in long-standing intractable cases of rectal prolapse, rectal pain/bleeding/ulceration and prolapse that needs frequent manual or difficult reduction. The aim of this study was to compare the efficacy and outcome of laparoscopic ventral mesh rectopexy versus laparoscopic suture rectopexy in the management of persistent rectal prolapse in children not responding to conservative management and/or recurrent after sclerotherapy or anal encirclement. MATERIALS AND METHODS: Twenty-four cases were randomised into two groups at the ratio of 1:1, Group 1 patients were managed by laparoscopic ventral mesh rectopexy, whereas Group 2 cases were managed by laparoscopic suture rectopexy. Patients with primary surgical conditions such as anorectal malformations, Hirschsprung's disease, rectal polyps or masses and Ectopia Vesicae were excluded from the study. Inclusion criteria were complete rectal prolapse cases with failed medical treatment for at least 6 months and/or recurrent after injection sclerotherapy or anal encirclement. RESULTS: In the mesh rectopexy group, one case had recurrence in the form of partial prolapse 3 weeks postoperatively which improved 2 months postoperatively with conservative management, one case had bleeding per rectum 2 months postoperatively, stool analysis was done revealing parasitic infestation which was treated medically. In the suture rectopexy group, one case had one attack of bleeding per rectum on the 2nd day postoperatively which resolved spontaneously and one case was readmitted on the 5th day postoperatively for non-bilious vomiting which improved by medical treatment. No recurrent cases of complete rectal prolapse were reported in both groups. CONCLUSION: Laparoscopic rectopexy can be an effective modality for the treatment of refractory complete rectal prolapse in children. It is effective, safe and easy. Although the current study has shown that laparoscopic suture rectopexy and mesh rectopexy have nearly the same results, a larger number of patients are needed to compare more deeply between the two groups.

Evaluating the Effect of Low Power Diode Laser 806†nm on the Healing of Unilateral Cleft Lip Scar: An Open-Label Comparative Study.

OBJECTIVE: To investigate the effect of laser bio-modulation irradiation therapy on the scar after surgical correction of unilateral cleft lip. DESIGN: a comparative, open-label study. SETTING: we conducted the study in a university based tertiary hospital that recruited early wound healers of unilateral cleft lip correction. PATIENTS: Eighty patients were divided into two groups: In study's group, patients undergo laser bio-modulation irradiation (n = 60); in the control group, patients were followed-up without intervention (n = 20). INTERVENTION: In the study's group, patients underwent low-power diode Laser with wavelength of 806 nm and power of 100 mw. MAIN OUTCOME: The change in the scar of cleft lip patients, which was assessed by clinical examination and ultrasound. RESULTS: The median pigmentation score was significantly lower in the laser group (median = 1; IQR = 1-2) than the control group (median 2; IQR 1-3), with p-value of <0.001. Likewise, the median height score was significantly lower in the laser group (median = 1; IQR = 1-1) than the control group (median 1.5; IQR 1.5-2), with p-value of 0.001. The median pliability score was significantly lower in the laser group (median = 1; IQR = 1-1) than the control group (median 2.5; IQR 1-3), with p-value of <0.001. Finally, the median vascularity score was significantly lower in the laser group (median = 1; IQR = 1-1) than the control group (median 1.5; IQR 1-2), with p-value of <0.001. CONCLUSION: laser bio-modulation irradiation therapy demonstrates a potential efficacy in managing the hypertrophic scars after surgical repair of unilateral cleft lip.

Minimally invasive surgery in older children with Hirschsprung's disease in a North African Country.

Introduction: Hirschsprung's disease (HSD) is a bowel congenital anomaly affecting mainly the enteric nervous system of the rectosigmoid region. Surgical resection of the aganglionic segment and restoration of bowel continuity via coloanal anastomosis is the main stay of treatment. In 1999, Georgeson et al. introduced a new minimally invasive approach as a standard for the pull-through mechanism. This study aims to evaluate the safety and possibility of the use of a laparoscope in older children with HSD with various techniques for HSD surgery. Methods: This study was performed based on 20 patients diagnosed with HSD. The patients are older children, whose mean age is 3 years. The cases showing enterocolitis or obstruction were excluded from the study. We divided these cases into two groups: Group A, consisting of 10 cases where laparoscopic-aided transanal pull-through was done, and group B, in which the laparoscopic Duhamel procedure was done. Results: We compared between two groups for the first year follow-up period. In Group A, there were two cases of stenosis that respond to regular dilation: one case of enterocolitis and one case of fecal incontinence. In Group B, we had two cases of constipation and three cases of enterocolitis. There was no anastomotic leak in both groups. Conclusion: Minimally invasive surgery is safe in management of HSD in older children in one stage, either by using the Duhamel or transanal Swenson procedure.

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.

Laparoscopic hepaticoduodenostomy for choledochal cysts in children <1 year.

CONTEXT: Choledochal cyst (CHC) is one of the most common causes of surgical jaundice in infants. In 1955, Farello et al. were the first to introduce the laparoscopic approach for treatment of CHC. AIM OF THE STUDY: Minimally invasive approaches to the management of CHC excision have been done in pre-schoolers and above but have not yet been described in toddlers, let alone infants. Herein, we review the results of 10 consecutive children <1 year managed with laparoscopic CHC excision and hepaticoduodenostomy. METHODS: This retrospective study investigated 10 infants who underwent laparoscopic resection of a CHC with creation of a hepaticoduodenostomy. RESULTS: This study was performed on 10 consecutive patients <1 year. Liver fibrosis was found in 4 patients. We had 7 cases with Type 1 CHCs and 3 cases with Type IV A cysts. Total cyst excision was done in all patients, no cases needed blood transfusion and the mean operative time was 200 min. The mean hospital stay was 6 days. Overall, morbidity occurred in 20% of the cases presenting with bouts of cholangitis that resolved without any intervention, once at 6 months, the other at 1-year post-operative. There were neither anastomotic strictures nor biliary fistula formation; magnetic resonance cholangiopancreatography was done to these two cases revealed no stricture and mortality at 30 and 90 days was nil. CONCLUSION: Laparoscopic hepaticoduodenostomy in CHC in children <1 year is safe, with satisfactory short-term results.

Outcome of Tapering Enteroplasty in Managing Jejunoileal Atresia.

Background: Jejunoileal atresia (JIA) represents a common cause of neonatal bowel obstruction. There is a discrepancy between the diameters of the proximal and the distal bowel loops and this is managed with excision or tapering of the dilated proximal bowel loop. We aim primarily to evaluate the outcome of tapering enteroplasty (TE) in managing JIA and secondarily to compare the outcome of TE to non-TE. Materials and Methods: A retrospective analysis of records of all neonatal admissions with JIA from January 2017 to December 2018 at a tertiary university children's hospital. Type and location of atresia, time to full enteral feeds, length of stay (LOS), complications, and outcome were assessed in TE and non-TE groups. Results: Forty-one patients were included in the study; 29 (70.7%) cases had jejunal atresia and 12 (29.3%) had ileal atresia. Seventeen (41.4%) patients had TE. The median days to full feeds was 19; 28 in the TE group versus 16 in the non-TE group (P = 0.022). Four (9.7%) cases needed a re-exploration because of failure to start feeds; all in the non-TE group. The median LOS was 33 days for TE versus 22 days for non-TE (P = 0.101). Twenty-one cases (51.2%) developed a wound infection and showed a significantly longer median LOS of 29.5 versus 19 days (P = 0.019). Mortality was 7 (17.1%). Conclusions: TE did not show a superior outcome when compared to resection of the dilated bowel. It was associated with longer time to reach full enteral nutrition and longer LOS.

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.

Acute abdomen caused by rupture of a torted intra-abdominal testicular mass: Case report.

INTRODUCTION: Cryptorchidism is defined as the absence of one or both testicles from the scrotum, which is considered one of the most common birth defects of male genitalia. Mostly the undescended testes are in the inguinal region, while the intra-abdominal location accounts for only 10 % of the cases. The potential risk of malignant transformation in an undescended testis is approximately 2.5-8 times higher than in scrotal position. Torsion of the cryptorchid testis is a very rare cause of acute abdominal pain with few cases published in literature. CASE PRESENTATION: A 44-year-old male patient presented to the emergency room with acute abdominal pain. General examination revealed relevant tachycardia. Upon abdominal examination there was tenderness and rebound tenderness all over the abdomen, more evident in the lower abdomen. Interestingly, routine examination of the inguino-scrotal region revealed empty right hemi-scrotum despite the patient not being aware. Routine blood tests showed marked anemia Hb: 7.4 g/dl. Urgent pelvi-abdominal U/S showed moderate free intra-abdominal collection in addition to a pelvic mass. CT of the abdomen showed a well-defined heterogenous hypodense mass measuring about 8.5 × 5.5 cm in the pelvis. Urgent exploratory laparotomy was done, and a mass was found to be torted and ruptured. Excision was done and histo-pathological examination revealed testicular mixed germ cell tumor. CONCLUSION: Undescended testis is associated with an increased risk of infertility, testicular cancer and torsion. In any male with undescended testis and intra-abdominal mass; the risk of intra-abdominal testicular tumor should be considered.

Outcome of thoracoscopic repair of type-C esophageal atresia: a single-center experience from North Africa.

Thoracoscopic repair of esophageal atresia is gaining popularity worldwide attributable to availability and advances in minimally invasive instruments. In this report, we presented our experience with thoracoscopic esophageal atresia/tracheoesophageal fistula (EA/TEF) repair in our tertiary care institute. A prospective study on short-gap type-C EA/TEF was conducted at Cairo University Specialized Pediatric Hospital between April 2016 and 2018. Excluded were cases with birth weight < 1500 gm, inability to stabilize physiologic parameters, or major cardiac anomalies. The technique was standardized in all cases and was carried out by operating team concerned with minimally invasive surgery at our facility. Primary outcome evaluated was successful primary anastomosis. Secondary outcomes included operative time, conversion rate, anastomotic leakage, recurrent fistula, postoperative stricture, and time till discharge. Over the inclusion period of this study, 136 cases of EA/TEF were admitted at our surgical NICU. Thoracoscopic repair was attempted in 76 cases. In total, 30 cases were pure atresia/long gap type-C atresia and were excluded from the study. Remaining 46 cases met the inclusion criteria and were enrolled in the study. Mean age at operation was 8.7 days (range 2-32), and mean weight was 2.6 Kg (range 1.8-3.6). Apart from five cases (10.8%) converted to thoracotomy, the mean operative time was 108.3 minutes (range 80-122 minute). A tension-free primary anastomosis was possible in all thoracoscopically managed cases (n = 41) cases. Survival rate was 85.4% (n = 35). Anastomotic leakage occurred in seven patients (17%). Conservative management was successful in two cases, while esophagostomy and gastrostomy were judged necessary in the other for five. Anastomotic stricture developed in five cases (16.6%) of the 30 surviving patients who kept their native esophagus. Despite the fact that good mid-term presented results may be due to patient selection bias, thoracoscopic approach proved to be feasible for management of short-gap EA/TEF. Authors of this report believe that thoracoscopy should gain wider acceptance and pediatric surgeons should strive to adopt this procedure.

Outcome of declined neonatal surgical referrals at Cairo University Specialized Pediatric Hospital.

BACKGROUND: The combination of a high birth rate and limited resources leads to a strain on health services with dire consequences to the patient. This study aimed to track the outcome of declined referrals at the tertiary center in the Cairo University Specialized Pediatric hospital. METHODS: Data were collected prospectively on all declined surgical neonates at the tertiary center. The families were later contacted to document outcomes. Verbal consent was taken. FINDINGS: Over a 12 month period from January 2017 to December 2017, 668 neonatal surgical referrals were received. Of these 278, (41·6%) were declined for lack of available places. The majority were cases of esophageal atresia with tracheoesophageal fistula (35%), followed by bowel obstruction (21%). Thirty-six cases were lost to follow up. Of the remaining 242 cases, 103 (42·5%) died, 63 (26%) were referred to public hospitals, 69 (28·5%) to private hospitals and seven (2·8%) were managed conservatively. CONCLUSIONS: Nearly half of neonatal surgical cases die while waiting for surgical intervention. Cases were shared equally between the public and private sector. The collected data are crucial in planning service provision for neonates requiring surgical treatment. To the best of our knowledge, this is the first study from Egypt and the region to report the number and outcome of surgical neonates who do not get access to expert surgical services. The study outlines the burden of disease faced by a single pediatric surgery unit and documents the various congenital anomalies encountered as well as their outcome when treated elsewhere. STUDY TYPE: Prognosis study. LEVEL OF EVIDENCE: IV.