Five Years' Single-center Experience of a Modified Approach to Divided Sigmoid Colostomy for Anorectal Malformation.

BACKGROUND: In patients with anorectal malformation (ARM), a divided descending colostomy is associated with high complication rates, including wound infection, dehiscence, and prolapse, and it places a significant burden on caregivers. To decrease the chances of such complications, we modified our approach for colostomy fashioning by keeping an intact skin bridge between the colostomy and mucous fistula. The objective was to compare the rate of complications among patients diagnosed with ARM who underwent a modified divided descending colostomy and classical descending colostomy. METHODS: We included all the patients diagnosed with ARM who underwent a divided colostomy with modified (group A) or classical technique (group B) in the last 5 years. The type of approach used to fashion the stoma was based on the surgeon's preference than on patients' selection criteria. All patients were followed and monitored for postoperative complications. SPSS version 26 was used to analyze the data. RESULTS: A total of 62 patients with ARM underwent the colostomy creation; 27 in group A and 35 in group B. Males were more in both groups and other demographic variables were comparable. The most common associated anomalies were cardiac (58%). The mean duration of surgery was 72.2 ± 18.26 min in group A while 91.25 ± 21.43 min in group B (P = 0.000). The mean hospital stay was 4.28 ± 3.63 days in group A while 7.97 ± 6.12 days in group B (P = 0.007). The overall complication rate was 14.8% in group A and 34.2% in group B (P = 0.082). CONCLUSION: The modified approach to fashioning a divided colostomy is easily reproducible and carries a low risk of postoperative complications. LEVEL OF EVIDENCE: IV.

Hypospadias and anorectal malformation: A difficult combination.

INTRODUCTION: Anorectal malformation (ARM) and hypospadias are both multifactorial and complex diseases, and they present in a spectrum of varieties. However, these pathologies have not been studied jointly in literature. The objective of this study was to look for the association between subtypes of ARM and types of hypospadias. MATERIAL AND METHODS: We conducted a retrospective review of the male patients with ARM, who had been treated at our center. We retrieved information regarding demographic details, ARM sub-type, hypospadias type, and urological problems after the chart review. All data were analyzed using SPSS version 26. RESULTS: A total of 408 patients were included, and 87 patients (20%) had hypospadias and ARM. There was no significant association between the severity of ARM and the severity of hypospadias. Most of the patients having proximal hypospadias belonged to the "simple" ARM group (15/22). The frequency of Vesicoureteric reflux (VUR), hydronephrosis, atrophic kidney, and at least one urological abnormality was significantly higher in patients having hypospadias and showed the strongest relationships with hypospadias. Holding the presence of hypospadias constant, ARM severity was noticeably correlated with all outcomes except solitary kidney. CONCLUSION: We conclude that hypospadias is a common entity among patients with ARM. These patients, having dual pathologies, are at significantly higher risk to develop other urological problems. And they should be considered a special group of patients and need close surveillance for urological issues. LEVEL OF EVIDENCE: III.

Burnout Among Postgraduate Residents Using Copenhagen Burnout Inventory.

BACKGROUND: Generally, the healthcare workers have a stressful job and it includes both physical and mental stress. We conducted this study to determine the burnout among postgraduate residents (PGR's). . METHODS: This cross-sectional study was conducted at The Children's Hospital and The Institute of Child's Health, Lahore over a period of 3 months. A total of 113 PGR's participated in this study. Burnout was measured using Copenhagen Burnout Inventory (CBI). Questionnaire was filled by participants on paper. Results were analyzed through SPSS-26. RESULTS: In this study, most of the participants (n=70) were females. Mean age of the participants was 28.6±2.035 years. More than 50% participants suffer from moderate to severe burnout. Nine percent of participants had high personal and client related burnout. The highest mean score was for personal burnout scale. When burnout scores were categorized according to demographic details, personal burnout was significantly higher among those who considered that they are burnout (p=0.000) and work burnout was significantly higher among those who travelled to the workplace by their cars (p=0.025). Burnout was higher among females, those who have long duration to travel from their homes to the hospital and whose parents were doctors; however, the difference was not significant. The scale showed a good overall internal reliability (Cronbach's alpha=0.697). CONCLUSIONS: This study showed a high rate of burnout among PGR's that needs to be addressed and adequate measures should be taken to reduce it.

Perforated Meckel's diverticulum in neonates: a report of six cases and systematic review of the literature.

Background: Perforation of Meckel Diverticulum (MD) is a rare cause of pneumoperitoneum in neonates. We hereby report six cases of perforation of MD in neonates, with addition of 53 cases from systematic review of the literature. A systematic review was performed using Mesh terms "Neonate, Meckel Diverticulum, Perforation, Pneumoperitoneum." All reports of perforated MD in the English literature were identified. Details of our 6 cases were analyzed in similar fashion. Results: A total of 3027 manuscripts were screened and 59 cases including 6 of our own were identified. The vast majority (78%) were female. Fifty patients (84.7%) presented in the newborn period. Half of the cases (52.5%) had associated anomalies and 13 neonates (22%) required oxygen supplementation including CPAP or ventilatory support before surgery. In 73% of the cases, a resection of gut was undertaken. Histopathological assessment in 44 cases (74.6%) revealed no ectopic gastric mucosa. Three cases demised prior to treatment. The outcome in the vast majority was excellent with 84.7% surviving and discharged well. Conclusion: Perforated MD is an unusual cause of a pneumoperitoneum in the newborns. Diagnosis is established at laparotomy and it rare to find ectopic mucosa histopathologically. The overall outcome is excellent.

Ruptured duplication cyst of transverse colon.

Duplication cysts of gastrointestinal tract are rare congenital abnormalities found in 0.2% of children. We report a rare case of a ruptured duplication cyst of transverse colon in a 7-year-old female child who presented with abdominal pain and mass in the right iliac fossa. We assumed it as an appendicular mass; however, it turned out to be a ruptured duplication cyst of transverse colon. Only two cases of duplication cyst of transverse colon have been reported yet in the literature.

Surgical Field Fire Involving a Premature Neonate.

Surgical field fire is a very rare intraoperative complication and has potentially serious consequences. Cases of surgical field fire have been reported in literature. Usually, surgical field fire involves airway, but it can also occur in surgical field. We, hereby report a case of surgical field fire while operating on a 4-week baby for jejunal atresia. In this case report, we review causes and preventive measures for surgical field fire. Key Words: Surgical field, Fire, Neonate, Prevention, Operation theatre.

Burn out among the paediatric surgeons of Pakistan.

This study was to assess the prevalence of Burnout syndrome among physicians, medical students and other healthcare professionals as they are considered more prone to it. It has been reported to be as high as >85% among surgeons, due to the sensitive and exhaustive nature of their job. The objective was to determine the prevalence of burnout among Paediatric surgeons (PS) of Pakistan. For this cross-sectional study, all PS working in Pakistan were included. In order to assess burnout, Maslach Burnout Inventory (MBI) was used. Burnout was found among 15% of the PS. In this group, it was also found that 17.5% of PS had high Emotional Exhaustion (EE), 12.5% had high Depersonalisation (DEP) and 30% had low Personal and Professional Achievement (PPA). Also 35% of PS were experiencing burnout in at least one domain. The significant protective factors we found in this group was having a non-doctor spouse for low EE (P=0.014), FCPS fellowship degree for low DEP (P=0.011), more than 2 post-graduation degrees for high PPA (P=0.008) and private practice for high PPA (P=0.020). We concluded that a large number of PS are facing burnout, and at the same time, a large proportion of them are at risk of moderate levels burnout from EE, DEP and PPA.

Evaluation of educational environment for postgraduate residents using Post Graduate Hospital Educational Environment Measure.

The objective of this study was to determine the level of educational environment among residents working in our hospital using Post graduate hospital educational environment measure (PHEEM). This cross-sectional study was conducted at services hospital, Lahore. All the Post-graduate residents (PGR's) working at Services hospital, Lahore were asked to fill a proforma having 2 parts: Bio-data and PHEEM. Out of 110 PGR's, 87 completed questionnaires, of which majority labelled education environment into level 3 (71%). Overall mean PHEEM score calculated was 90.49 ±15.44. Maximum score was found for teaching subscale followed by autonomy and social support subscale. Highest mean score was found for neurology (104) department and lowest for anaesthesia (72 ± 9.19). General surgery, internal medicine, paediatric medicine and gynaecology gave mean score of 90, 92, 93 and 89 respectively. There was non-significant difference in terms of PHEEM score when stratified for gender, year of residency and marital status.

Auto-Amputated Ovary Presenting as Abdominal Mass in an Infant.

Among female infants, a mass in the abdomen carries a large number of differential diagnoses. Arelatively uncommon condition is ovarian cyst, which may be encountered among such patients. Even more rare condition is auto-amputation of ovary. We herein, present a case of a female infant who presented as abdominal mass and turned out to be autoamputation of right ovary attached to mesentery of intestine. It was excised successfully and the patient is doing well at 3 years follow-up.

Choledocholithiasis: Treatment Options in a Tertiary Care Setup in Pakistan.

Introduction Among patients with cholelithiasis, choledocholithiasis may also be present in about 18% of cases. They can be treated through various endoscopic, laparoscopic, and open surgical procedures. Objective The objective of this study was to determine the outcome of patients with choledocholithiasis being treated in our setup. Methods This descriptive case series was conducted at Holy Family Hospital, Rawalpindi, Pakistan over two years from January 2015 to December 2016. All patients with choledocholithiasis admitted to Surgical Unit 1 were included in this study. All patients underwent elective endoscopic retrograde cholangiopancreatography (ERCP). In patients with successful ERCP, laparoscopic or open cholecystectomy was performed at a later date. In patients in whom ERCP failed, open surgical clearance of the common bile duct (CBD), along with cholecystectomy, was done. Results A total of 200 cases of choledocholithiasis were admitted during the study period. Most of the participants (73%) in this study were female. Liver function tests were found to be deranged in 88 patients (44%) and normal in 112 patients (56%). At presentation, 3.5% (n=7) had concomitant acute biliary pancreatitis and 8% (n=16) had cholangitis. Successful ERCP followed by cholecystectomy was performed in 88.5% of cases. On the other hand, 11.5% (n=23) patients had failed ERCP due to impacted stones. They underwent open surgical procedures, i.e. 43.48% (n=10) had choledochotomies, 47.82% (n=11) had choledochoduodenostomies and 8.69% (n=2) had hepaticojejunostomies. No postoperative mortality was observed. However, anastomotic leaking occurred in 8.69% cases (n=2). Conclusion A two-staged procedure consisting of ERCP, followed by laparoscopic cholecystectomy, should be the first line of treatment for common bile duct (CBD) stones. In cases where ERCP fails, open surgical procedures still remain a relevant and a definitive option in resource-constrained setups.

Burnout among gynaecological residents in Lahore, Pakistan: A cross-sectional survey.

OBJECTIVE: To determine the prevalence of burnout among gynaecological residents and factors associated with it. METHODS: This cross-sectional study was performed at the University Medical and Dental College, Faisalabad, Pakistan, from March to April 2016, and comprised female medical students. Participants were divided into groups on the basis of their ABO blood groups and on body mass index criteria. Blood groups were determined by simple conventional slide method. Blood pressure was estimated by manual auscultatory technique with a mercury sphygmomanometer. Data was analysed usingSPSS20. RESULTS: Of the 102 participants, 57(55.9%) were satisfied after choosing gynaecology as career. It was found that emotional exhaustion and depersonalisation were significantly higher among residents working in government institutions than private institutions (p<0.05). Those having more than 2 years of post-graduate experience had significantly higher depersonalisation than those with lesser experience (p=0.016). Also, working for 50-60 hours/week and feeling dissatisfied with the specialty were associated with significantly higher emotional exhaustion and depersonalisation (p<0.05). CONCLUSIONS: Burnout was highly prevalent among gynaecological residents.

Comparison of single-dose nalbuphine versus tramadol for postoperative pain management in children: a randomized, controlled trial.

BACKGROUND: Acute postoperative pain control in children is an essential component of postoperative care, particularly in daycare procedures. Giving patients continuous narcotic analgesics can be risky; however, a single dose may be sufficient. METHODS: This study used a prospective, randomized controlled design and was conducted at the Pediatric Surgery Unit, Services Hospital, Lahore. In total, 150 patients who underwent inguinal herniotomy (age range: 1-12 years) were randomly assigned to two groups: group A (nalbuphine) and group B (tramadol). Patients were given a single dose of either nalbuphine (0.2 mg/kg) or tramadol (2 mg/kg) immediately after surgery and pain was measured at 0, 1, 2, 4, and 8 h. RESULTS: The demographic characteristics were similar between the two groups. The mean pain score was lower in group A than in group B at 0 and 1 h (P < 0.05). However, at 4 h and 8 h, the pain scores in group A were still lower, but not significantly. In all, 9 patients (12.0%) required rescue analgesics in group A compared to 16 patients (21.3%) in group B (P = 0.051). The mean time for requirement of rescue analgesics was 6.5 ± 0.5 h in group A and 5.3 ± 1.7 h in group B (P = 0.06). CONCLUSIONS: A single dose of nalbuphine is sufficient, and superior to tramadol, for postoperative pain management in children who have undergone daycare procedures.

Video Assisted Anal Fistula Treatment in a Child with Perianal Fistula.

Perianal fistula formation is a rare complication in children after rectal biopsy. Perianal fistula may become difficult to treat; therefore a lot of surgical options are present. One of these options is video assisted anal fistula treatment (VAAFT). We present a 6-year-old female who developed perianal fistula following rectal biopsy for which VAAFT was done successfully.

Duplication Cyst Presenting as Hydrocoele in a Child.

Enteric duplication cyst can occur anywhere in Gastrointestinal Tract (GIT), from oropharynx to rectum. Their presentation depends upon the portion of GIT involved. The most common site of GIT involved is small intestine, in 50% of cases. Small intestinal duplication cyst usually present with abdominal pain or mass and rarely as intussusception, volvulus or small bowel obstruction. It may also present very rarely as inguinal hernia of which only 2 cases have been reported yet. We report a 3 years child presenting as hydrocoele of the cord which turned to be duplication cyst which is very rare presentation.

Amyand's Hernia with Perforated Appendix in a Neonate.

When vermiform appendix is found in the inguinal hernial sac, the condition is called Amyand's hernia (AH). Appendix in hernial sac can be normal, inflamed or perforated. It can present as complicated hernia or acute scrotum. We present a case of Amyand's hernia in a 25-day-old male who presented with an obstructed hernia having perforated appendix in the hernial sac.

Enteric duplication in children: A case series.

BACKGROUND: Enteric duplication (ED) cysts include a wide variety of cystic lesions, which can involve any part of the gastrointestinal tract (GIT). They can be referred to foregut, midgut, hindgut derived, depending upon the portion of GIT involved. The main purpose of this study was to document the variety of presentation, investigations, and treatment options employed. PATIENTS AND METHODS: This was a retrospective study at Paediatric Surgery Department of Services Hospital, Lahore from August, 2011 to August, 2013. The details of all the patients, including gender, and age, presenting complaint, abdominal examination findings, diagnostic modality, site, type, associated malformations, surgical option, and outcome were analysed. RESULTS: A total of eight patients with histopathological diagnosis of EDs managed were included in the study. Of these eight patients, six were males and two were females, with an average age of 2.4 years. The main diagnostic tool used was ultrasound in almost all patients. The most commonly involved site was ileum in 5 of 8 (62.5%) patients. Two cases had gastric involvement, while one patient had involvement of the descending colon. Six of eight were of tubular type (75%), while remaining 2 (25%) were of cystic type. Excision was possible in all these patients. CONCLUSION: ED can present with a wide spectrum of symptomatology. It can present as mass abdomen, intestinal obstruction or even can mimic as hydrocoele. High index of suspicion is therefore required. Ultimate aim of treatment is excision of cyst with preservation of vascularity of native gut.

Two cases of omental torsion mimicking acute appendicitis.

Acute appendicitis is often simulated by other entities like mesenteric adenitis, worm infestation, Meckel's diverticulitis, urinary tract infection and rarely omental torsion. We report two cases, a 6 year old boy and an 11 year old girl, who presented with symptoms and signs of acute appendicitis but upon exploration turned out to be omental torsion.

Cavernous haemangioma mimicking as clitoral hypertrophy.

Haemangioma is the most common benign neoplasm of infantile age. It is most commonly located in head and neck region, trunk and extremities but very rarely it can be located at clitoris. However, it is very important to differentiate clitoral haemangioma from enlargement of the clitoris secondary to androgen excess. Only four cases of clitoromegaly caused by cavernous haemangioma have been reported in the literature so far. Herein, we report our experience with a 10-year-old girl who presented with clitoromegaly and normal hormonal assay that turned out to be clitoral cavernous haemangioma after histopathological examination of the clitoral mass.

An epigastric heteropagus twin with ruptured giant omphalocele.

We present a case of heteropagus twins attached to the epigastric region. The neonate also had ruptured giant omphalocoele with most of gut and liver lying outside the abdominal cavity. Patient had uneventful surgery for separation of twins and repair of ruptured omphalocoele.