Simulation-based training in the Paediatric Surgery population: A review of current trends and future direction.

In recent years, simulation-based training in surgery has emerged as a viable accompaniment to traditional teaching methods. Multiple studies have highlighted the benefits of simulation-based training in both learning and teaching aspects of surgical training, with a particular emphasis on the honing of technical skills. However, multiple issues still exist in widespread implementation of simulation-based training, especially in the developing countries. Furthermore, the existing literature needs to be expanded upon in both quantity and quality domains to ensure a more evidence-based transition to simulation-based training in surgery. The current review article was planned to take a look at the existing literature on the current state of simulation-based training in paediatric surgery, its potential to revolutionise paediatric surgical training, and to propose solutions to the issues that are delaying wider implementation.

Frequency of Renal Dysfunction and its effects on outcomes after open heart surgery.

OBJECTIVES: In this study we determined the frequency of renal dysfunction and its outcomes in terms of morbidity and mortality in patients who underwent open heart surgery at the Aga Khan University Hospital, Karachi, Pakistan. METHODS: A total of 175 patients aged between 15-80 years having open heart Surgery(OHS) were included. Preoperative and postoperative serum creatinine (SCr) was noted and the glomerular filtration rate (GFR) calculated by Cockcroft-Gault equation. Their hospital course was charted and followed-up for 30-day. RESULTS: The mean age and mean BMI were 58.1±12.6 years and 26.4±4.3 kg/m2 respectively. Females were 18.3%, out of which 51.4% hypertensive, 46.9% diabetics, 45.1% had dyslipidemia, 2.9% had preoperative renal dysfunction and 40% had moderate ejection fraction. On follow up, 30.3% developed postoperative renal dysfunction within 30-days after OHS with mean SCr and GFR as 1.6±0.7 and 56.9±24.5, respectively. In RD group more patients showed positive outcomes i.e. prolonged inotropic requirement (75.5% vs. 18%, p-value <0.005), diuretic infusion usage (47.2% vs. 3.3%, p-value <0.005), dialysis/renal replacement therapy (17% vs. 0%, p-value <0.005), requirement for prolonged ventilation (35.8% vs. 6.6%, p-value <0.005), prolonged ICU and hospital stay (15.4% vs. 1.6%, p-value <0.005 and 41.5% vs. 17.2%, p-value <0.005), sepsis (20.8% vs. 1.6%, p-value <0.005) and death (9.4% vs. 2.5%, p-value 0.05). CONCLUSION: Timely recognition of renal dysfunction, early renal replacement therapy, diuretics or dialysis and proper nutritional and inotropic support to maintain adequate hemostasis shows survival benefits.

Successful recovery in a paediatric patient with polytrauma following multiple gunshot wounds: Case report and review of literature.

Our case report evaluates a 2½ year old boy who presented to emergency care, following multiple gunshot injuries and was managed emergently using a multidisciplinary surgical approach at our center. The patient was unresponsive, had poor perfusion, bilaterally decreased air entry, a distended abdomen, and multiple entry and exit wounds. A multidisciplinary team including Paediatric Surgery, Cardiothoracic Surgery, Paediatric anaesthesiology team and Orthopaedic surgery were taken on board. Following effective immediate management and stabilization, the patient was admitted to the ward under careful observation. He was discharged on post-operative day 28 after a successful recovery and on his 6 month follow-up, the patient had shown significant improvement, with normal bowel and pulmonary function. Rapid intervention along with a multidisciplinary surgical approach helped ensure the success of the treatment. Prior permission from the patient's guardians was acquired before the preparation of this manuscript.

Infantile haemangioendothelioma of the parotid gland: Case report and review of literature.

Haemangioendotheliomas (HAE), although rare but are the most common parotid gland tumours in children. We report a 4-month-old girl who presented with a progressively enlarging right sided facial swelling overlying the angle of the mandible. An Ultrasound of the lesion and a computed tomography (CT) scan of the head and neck was carried out which revealed a large lesion within the right parotid gland. CT scan further demonstrated a direct communication with the right external carotid artery and external jugular vein. Considering the clinical course and radiological findings, there was sufficient evidence to avoid any invasive testing. Due to the self-limiting nature of the disease, patient was managed expectantly.

Amoebic liver abscess: Outcomes of percutaneous needle aspiration vs drain placement in paediatric population.

OBJECTIVE: To compare the effectiveness of percutaneous catheter drain placement with percutaneous needle aspiration in terms of hospital stay, time to resolution of symptoms and cost of intervention performed. Methods: The retrospective cohort study was conducted at Aga Khan University Hospital, Karachi, and comprised data of patients with amoebic liver abscess from, January 2006 to December 2016 which was collected using non-probability purposeful sampling. Primary outcome included length of hospital stay, time to resolution of symptoms and cost of intervention. Secondary outcomes included development of complications, need for re-intervention and abscess resolution. SPSS 22 was used for data analysis. . Results: Of the 62 patients, 36(58%) underwent percutaneous needle aspiration Group A, and 26(42%) were treated with percutaneous catheter drain placement Group B. Both groups were malnourished and anaemic at presentation. Overall, 56(90.3%) patients had single abscess and 44(71%) had it in the right lobe. Mean duration of symptoms was less in Group B compared to Group A (11.2±4.5 versus 16.4±3.2 days). Mean abscess size was 6.13cm ± 9.75cm in Group A and 7.40cm ± 8.40cm in Group B. The mean length of hospital stay Group A was shorter than in Group B (p=0.047) with earlier resolution of symptoms (p=0.027). Conclusion: Both methods were found to be effective in treating amoebic liver abscess in children, but percutaneous needle aspiration was more effective.

Pediatric Ewing Sarcoma of Kidney: A Case Series and Review of Literature.

Introduction: Renal Ewing sarcoma is an aggressive and rare malignancy affecting children and adolescents. Limited data on its management contribute to uncertainties in treatment. Case description: We present two pediatric cases of renal Ewing sarcoma. Both cases emphasize the significance of accurate diagnosis, multimodal treatment, and long-term follow-up in achieving favorable outcomes. Accurate diagnosis of renal Ewing sarcoma is crucial for effective management. Multimodal treatment involving neoadjuvant chemotherapy, surgical resection and staging with lymph node sampling, and chemotherapy continuation has shown promising results in our cases. Long-term follow-up is essential for monitoring disease progression and ensuring optimal outcomes. Practical Implications: There is limited data published about these renal tumors, especially in the pediatric population, and most studies lack long-term follow-up, with uncertain management due to limited data. This data will add to the newer, multimodal approach and form the basis for future meta-analysis to help formulate guidelines for upcoming international meetings. Continued research efforts are necessary to optimize strategies and improve the prognosis for pediatric patients with renal Ewing sarcoma.

Emergency Angioembolization for Life-Threatening Hemorrhage in Wilms Tumor.

Introduction: Renal artery embolization has been used in a palliative fashion for symptomatic relief of hematuria or flank pain in unresectable renal cell carcinoma in adults. There is limited data on the use of embolization for actively bleeding and unresectable tumors in the oncological pediatric population. Case Description: A previously healthy 5-year-old boy with no significant past medical or surgical history presented to the clinic with gradually worsening abdominal distension associated with occasional abdominal pain, gross hematuria, and lethargy for four months. Diagnostic investigations showed an 18-cm left-sided metastatic (pulmonary) renal tumor (Wilms), which was deemed unresectable on imaging. Treatment was planned according to the SIOP-RTSG protocol. However, he became hemodynamically and vitally unstable with acute, sudden distension of the abdomen on the left side after the first cycle of chemotherapy. Imaging showed active bleeding from an inferior branch of the left renal artery. Selective angioembolization was done, and chemotherapy was reinitiated with a patent left main renal artery. Following the fourth cycle of chemotherapy, he developed hemodynamic instability and abdominal pain; imaging revealed the resolution of pulmonary nodules and bleeding from the left renal artery (main); this was again embolized, and the patient was stabilized. The patient was operated on after optimization, and a complete resection of the mass was done with negative margins. On six months follow-up, he is well. Practical Implications: To the best of our knowledge, this is the first case where angioembolization has been done in conjunction with neoadjuvant chemotherapy to downsize a Wilms tumor to achieve favorable outcomes. Continued research efforts are necessary to optimize strategies and improve the prognosis for pediatric patients, and this case is one of the prime examples.

Multidisciplinary management of high-grade pediatric liver injuries.

OBJECTIVE: To present our experience of multidisciplinary management of high-grade pediatric liver injuries. INTRODUCTION: Pediatric high-grade liver injuries pose significant challenge to management due to associated morbidity and mortality. Emergency surgical intervention to control hemorrhage and biliary leak in these patients is usually suboptimal. Conservative management in selected high-grade liver injuries is now becoming standard of care. Management of hemobilia due to pseudoaneurysm formation and traumatic bile leaks requires multidisciplinary management. METHODS: A retrospective review was undertaken for patients presenting with blunt liver injuries at two tertiary care centers in Karachi, Pakistan, from March 2021 to December 2022. Twenty-eight patients were identified, and four patients fulfilled the criteria for grade 4 and above blunt liver injury during this period. RESULTS: One case with grade 4 liver injury developed hemobilia on 7th day of injury. He required two settings of angioembolization but had recurrent leak from pseudoaneurysm. He ultimately needed right hepatic artery ligation. Second patient presented with massive biliary peritonitis 2 days following injury. He was managed initially with tube laparostomy followed by ERCP and stent placement. The third patient developed large hemoperitoneum managed conservatively. One case with grade 5 injury expired during emergency surgery. CONCLUSION: Conservative management of advanced liver injuries can result in significant morbidity and mortality due to high risk of complications. Trauma surgeons need to have multidisciplinary team for management of these patients to gain optimal outcome.

Determination of Normal Anal Position Using the Anal Position Index in Pakistani Neonates.

INTRODUCTION: Anterior displacement of the anus (ADA) is recognized as a common congenital abnormality of the anorectal region and is often associated with constipation. It is diagnosed through a physical examination by measuring the Anal Position Index (API) at birth. METHODS: A cross-sectional study was conducted utilizing non-probability consecutive sampling of all patients presenting with ADA at our institute over a six-month period. The study focused on key variables, including the measurement of scroto-anal and scroto-coccygeal distances in boys and fourchette-anal and fourchette-coccygeal distances in girls. Data collection was carried out using a structured proforma, ensuring prospective data collection from neonates meeting the selection criteria (neonates born at our center and identified by the neonatology team as having a normal anal opening, regardless of their gestational period or birthweight). RESULTS: Our study comprised a cohort of 204 neonates. The Anal Position Index was determined to be 0.36 ± 0.07 for male newborns and 0.24 ± 0.06 for female newborns. Notably, a statistically significant correlation was observed between the API and factors such as gestational age, birth weight, and advancing paternal age. CONCLUSION: The assessment of the API proves highly valuable in identifying indicators of ADA in neonates, facilitating early disease detection, and guiding the prompt management of subsequent functional symptoms, such as constipation, during later stages of life.

Intussusception in an infant as a manifestation of COVID-19.

Gastrointestinal manifestations of COVID-19 are rare and have primarily been limited to diarrhea or vomiting. Intussusception is the most common cause of bowel obstruction in infants, with up to 30% of pediatric intussusception cases having a preceding viral illness. We present the rare case of intussusception in a SARS-CoV-2 positive infant. This is the first documented case of survival in a SARS-CoV-2 positive patient presenting with intussusception as the primary manifestation. As our knowledge of this disease evolves, surgeons need to remain suspicious for possible gastrointestinal manifestations of COVID-19.

Multiple Magnet Ingestion leading to Bowel Perforation: A Relatively Sinister Foreign Body.

Foreign body ingestion is a common reason for seeking emergency care among children. One of the more serious foreign bodies are the ingestion of multiple magnets or concurrent ingestion of a magnet and a metallic foreign body. Conservative management with serial imaging can be misleading in such cases. Multiple magnets tend to have strong attractive forces among them and may encase loops of bowel within them. Once entrapped, pressure necrosis and perforation will ensue, and thus, a low threshold should be adopted for surgical exploration in such cases. We present the case of a two-year-old male who had an accidental, unwitnessed ingestion of multiple magnets and also report the subsequent surgical management and associated morbidity.