Feasibility of nonoperative treatment of acute appendicitis in children: a prospective cohort study.

Introduction: The management of acute appendicitis is a matter of debate even in contemporary era. Non-operative management is proposed as a valid treatment option for acute appendicitis in children. Methods: A prospective cohort study was conducted from April 2020 to September 2021 at the National Institute of Child Health, Jinnah Sindh Medical University, Karachi, Pakistan, in children aged ≤ 12 years who were suspected of having acute appendicitis. Children with diffuse peritonitis and complex mass on ultrasonography were excluded. All children were kept nil per oral and started on intravenous fluid hydration and antibiotics. Statistical analyses were performed using IBM SPSS version 20. Chi-square test and Fisher's exact test were applied to determine the statistical significance. Results: A total of 190 patients were admitted with a diagnosis of acute appendicitis. Thirty-two children with advanced disease underwent surgery. The remaining 158 patients were managed with nonoperative treatment. In 138 (87.3%) patients, resolution of symptoms occurred. Twenty (12.7%) patients underwent operation during the same admission (non-responders). Thirteen (9.4%) patients had recurrence of symptoms and underwent appendectomy. A total of 33 (20.9%) patients had appendectomy either at the primary admission or after discharge. Non-operative treatment was more likely to be successful in patients with symptoms of ≤ 24 h duration (P = 0.02), total leucocyte count of <12 × 109 cells/L (P = 0.005) and smaller size of the appendix on ultrasound (P = 0.001). Conclusion: Among children with uncomplicated acute appendicitis, a non-operative approach resulted in resolution of symptoms in 87.3% of patients at the initial admission. Failure of non-operative treatment and recurrence of disease after discharge from the hospital occurred in 9.4% of patients after successful initial treatment. Thus, the overall success rate at a mean follow-up of 3 months was about 78%.

Clinical Presentation, Diagnostic Approach, Laparoscopic Evaluation and Treatment of Impalpable Testis.

OBJECTIVE: To find out the clinical presentation, utility of ultrasound for diagnosis, laparoscopic findings and treatment for clinically impalpable testis. STUDY DESIGN: Cross-sectional study. PLACE AND DURATION OF STUDY: Department of Paediatric Surgery, National Institute of Child Health, Jinnah Sindh Medical University Karachi, from September 2019 to April 2020. METHODOLOGY: Patients with clinically impalpable testis were included. Ultrasound of inguinal region was done to locate testis. Presence of testis and its position was confirmed at laparoscopy and surgical procedure done according to the findings. Data was stratified according to the age and Chi-square test and Student t-test were applied to find out statistical significance among different variables in children below and above five years of age. A p <0.05 was taken as significant. RESULTS: Ninety-one patients with 113 testes were included. The median age of the children was 48 months. Sixty-nine (75.8%) patients had unilateral undescended testis and 22 (24.2%) bilateral undescended testes. Fifty-three (58.2%) patients were less than five years of age. On ultrasound, testis was found near deep ring in 23 (25.3%) patients. At laparoscopy, 74 (81.3%) testes were found within the abdominal cavity. In 7 (7.7%) patients, only nubbin of tissue was identified and removed. The first stage of Fowler Stephen procedure was done in the majority of the patients. There was statistically no significant difference following stratification in relation to laterality and position of undescended testis (p = 0.556 and p = 0.846, respectively). However, mean size of the testis was found statistically significant (p = 0.032). CONCLUSIONS: Most of the patients were above five years of age. Ultrasound helped in identifying low-lying intra-abdominal testis in more than 80% of patients. Laparoscopy was helpful in further defining the position of the testis and selection of surgical procedure. KEY WORDS: Undescended testis, Cryptorchidism, Laparoscopy, Orchiopexy.

Analysis of challenges faced and the scientific content of a hybrid pediatric surgical conference arranged during the COVID-19 pandemic.

BACKGROUND: Scientific conferences which are considered as an important event for dissemination of research and related academic activities were badly affected during the COVID-19 pandemic. Virtual format for interaction was used as an alternative method to continue such academic discourse. However, this did not provide the same level of communication and interest as that of in-person meetings. With evolving knowledge about the COVID-19 pandemic especially its transmission, role of vaccine, and observing standard operating procedures (SOPs), fear among healthcare providers is mitigated to some extent. Keeping in mind the importance of scientific conferences in the context of sharing knowledge and its impact on the training of faculty members and postgraduate residents, a hybrid conference was planned by the national association of pediatric surgeons.The purpose of this study was to retrospectively review the challenges faced during the organization of this conference as well as to analyze the pattern of registration, number of abstracts received, the gender of the participants and their status, region of the country they represented, type of presentation made, and scientific subject covered. SPSS version 22 was used for data entry. Descriptive and inferential statistics were used to present data. Chi square test was applied to find out the association between categorical variables and a p value < 0.05 was considered as significant. RESULTS: A total of 170 pediatric surgeons and postgraduate residents participated from all over the country and abroad. Nearly half (47.1%) of the registrants were postgraduate residents. Most of the participants (90%) opted for in-person attendance. The venue was selected with a capacity to house more than double the number of registrants with provision of safe distance. Availability of face masks, gloves, and sanitizers was ensured by the organizers. Packed meal boxes were arranged and served at the venue site in an open place on the terrace. A total of 97 abstracts were accepted for presentation that included 57 (58.8%) long oral podium and 40 (41.2%) poster presentations. Most of the studies (n=48-49.4%) were related to the subject of gastroenterology including pancreatico-hepatobiliary system and spleen. Majority of the presenters were male (p = 0.046) and postgraduate residents (p = 0.001). CONCLUSION: It was possible to organize a hybrid annual medical conference where most of the participants preferred physical presence. A rich scientific program was made to cater the needs for pediatric surgical fraternity. Residents made attractive presentations. It was noted that physical presence during clinical conference produced effective communication and learning.

Effect of Strict Lockdown on Pediatric Surgical Services and Residency Programme during COVID-19 Pandemic.

OBJECTIVE: To document the measures adopted during the COVID-19 pandemic strict lockdown on pediatric surgical services and residents' training at a tertiary care hospital. STUDY DESIGN: Cross-sectional descriptive study. PLACE AND DURATION OF STUDY: Department of Pediatric Surgery, National Institute of Child Health, Jinnah Sindh Medical University, Karachi, from April 2020 to June 2020. METHODOLOGY: Data from the Outpatient Department, Emergency Department, and Operation Theatre records were collected. The number of patients seen in the outpatient department, surgeries performed, index emergency cases dealt with, and the residents' duty roster and teaching methodology were documented. Descriptive statistics were used for reporting. RESULTS: During the strict lockdown period, outpatient services continued; however, elective cases were not operated. A total of 2,930 patients were seen in clinics, and 1,316 surgical procedures were performed. The index cases managed included anorectal malformation (n=35), esophageal atresia with and without tracheoesophageal fistula (n=13), small bowel atresia (n=11), omphalocele (n=6), acute appendicitis (n=35), intestinal obstructions (n=23), intussusceptions (n=18), and intestinal perforations (n=16). On-call days of residents were reduced from every third to the fifth day, and online educational sessions were added. During the pandemic, 13 members of surgical and anaesthesia teams got infected with COVID-19. CONCLUSION: COVID-19 pandemic elective surgical services were restricted; however, emergency cases were managed as per routine. In clinical teaching, virtual technologies were incorporated. Working hours of residents were limited to decrease the exposure to infected persons. Key Words: COVID-19, SARS-CoV-2 pandemic, Healthcare workers, Residency programme.

Early Surgical Management of Appendicular Mass in Pediatric Patients.

OBJECTIVE: To find out the feasibility and safety of early surgery in pediatric patients who presented with appendicular mass. STUDY DESIGN: Analytical observational study.  Place and Duration of Study:  Department of Paediatric Surgery, National Institute of Child Health, Jinnah Sindh Medical University, Karachi, from September 2019 to April 2020. METHODOLOGY: This study was conducted on 60 children, who were diagnosed with appendicular mass. Patients were operated after initial stabilisation and investigations. Variables analysed included demographic characteristics, clinical presentation, intraoperative surgical difficulties and postoperative complications. Data were entered into SPSS version 22. Chi-square test and Fisher Exact test were used for finding statistical significance among variables. A p-value of <0.05 was considered as significant.  Results: There were 41 (68.4%) male and 19 (31.6%) female patients with the mean age of 8.3 + 2.9 year. Mean duration of pain was 3.8 + 1.8 days. In 41 (68.4%) patients, mass was composed of appendix with adherent ileal loops and omentum, while in 19 (31.6%) patients frank pus was also found within the mass. Thirty-four (56.6%) patients had suppurative appendix without gross perforation, while in 26 (43.4%) patients partially sloughed / gangrenous perforated appendix found. Intraoperative difficulties were more in patients with complex mass (p=0.004). Postoperative complications were observed in 14 (23.3%) patients. These were more frequent in female patients (p=0.001), with sloughed, gangrenous perforated appendix (p=0.034) and complex mass (p=0.008). Superficial wound infection was the most common complication noted in 9 (15%) patients. In 5 (8.3%) children, deep seated intra-abdominal collections were found. The mean hospital stay was 3.4 + 1.5 days.   Conclusion: Early surgery in pediatric patients with appendicular mass was found feasible with minimal complications. This obviated the need of prolonged follow-up and interval appendectomy with its inherent risks. Key Words: Appendicular mass, Appendicular lump, Appendectomy, Child.

Reviewers' Responses to Medical Research Articles.

OBJECTIVE: To document the reviewers' responses in terms of reviewers' demographic and professional characteristics, promptness of reply, and duration of reply to the request to review medical research articles for a general biomedical research journal. STUDY DESIGN: Cross-sectional, observational study. PLACE AND DURATION OF STUDY: Department of Publications, College of Physicians and Surgeons Pakistan (CPSP), from October to December 2015. METHODOLOGY: Peer reviewed articles edited by a single staff editor were included. Editorials and correspondence were excluded. Manuscript category, discipline, and the total number of reviewers per manuscript were noted. Responses were divided into no response, regrets, and responded, i.e. provided with the review comments; and further sub-divided into timely response, i.e. within 21 days, or later. Total duration of response was counted in days from the date of dispatch to the date of receiving. Among those who provided a review, reviewers' characteristics were noted as designation, institute affiliation, qualification, and gender. Number and percentages of the studied variables were determined. Chi-square test of proportions was used for comparing the proportions with significance at p<0.05. RESULTS: Reviewers for 50 articles including 28 original articles, 15 case reports, three letters to the editor, two short communications, and two new techniques, were evaluated. A total of 598 reviewers were contacted for those 50 articles; forming an average of 11.96 reviewers contacted and 2.2 responded per manuscript. Four hundred and seventy (78.59%) did not reply at all, 18 (3.01%) regretted, and 110 (18.39%) responded (79/110=71.81% timely, and 31/110=28.18% late). Earliest reply was received in one day and the delayed reply in 87 days. Maximum number of reviewers was 24 for a single original article (internal medicine) and 22 for a case report (cardiology). Significantly, more fellows, professors and females (p=0.004, p=0.002, and p=0.017, respectively) provided timely response. CONCLUSION: An overwhelming majority of the reviewers did not reply at all despite the incentives of CME credits and honorarium, adversely affecting the processing time. Majority of those who replied, were on time. Reasons for those who did not reply need to be explored.

Laparoscopic versus open appendectomy in children: a randomized controlled trial from a developing country.

BACKGROUND: Acute appendicitis is a common surgical emergency. This study was conducted to compare the outcome in terms of duration of surgery, length of hospital stay, and wound infection rate following laparoscopic versus open appendectomy in children with acute appendicitis. METHODS: A prospective randomized controlled trial was conducted. Patients with the diagnosis of acute appendicitis were randomly assigned to Group A: Laparoscopic appendectomy (LA) and Group B: Open appendectomy (OA). Age and sex of patients, signs, and symptoms were noted. Duration of surgery, length of hospital stay (LOS), and postoperative wound infection were recorded. RESULTS: A total of 126 patients were operated, with 63 in each group. Mean age of the patients was 9.7±2.1years in LA group and 9.8±2.3years in OA group. In LA group, inflamed appendix was found in 68% patients, perforated in 17%, gangrenous in 9%, and suppurative in 5%. In OA group, inflamed appendix was found in 60% patients, perforated in 22%, gangrenous in 5%, and suppurative in 13%. The mean duration of operation was 56±24min in LA group and 39±8min in OA group (p<0.0001 in favor of OA group). The mean length of hospital stay was 34±13h in LA group and 40±11h in OA group (p=0.01 in favor of LA group). The results showed no significant association of wound infection between the two groups (p=0.31). CONCLUSION: There was no difference in terms of LOS and rate of wound infection among the groups. However, the laparoscopic procedure was technically demanding. LEVEL OF EVIDENCE: Level I Randomized Controlled Trial.

Comparison of eutectic mixture of local anesthetics cream with dorsal penile nerve block using lignocaine for circumcision in infants.

OBJECTIVE: Circumcision is a commonly performed surgical procedure but choice of anesthesia remained an issue of research and debate. This study was conducted to find out the effectiveness of the eutectic mixture of local anesthetic (EMLA) cream with dorsal penile nerve block (DPNB) using lignocaine, for reduction of pain during circumcision. METHODOLOGY: This was comparative study carried out in Surgical Unit B of National Institute of Child Health Karachi, from May 2008 to October 2008. Patients under six month of age were randomized in to two groups (EMLA and DPNB) of fifty patients each. The effectiveness of pain control was assessed by measuring the baseline heart rate (HR), respiratory rate (RR) and Neonatal infant Pain Scale (NIPS scale) before the start of procedure and measuring of these parameters for each step of circumcision. Independent sample t -test was used to compare means and repeated ANOVA was used to compare means of HR, RR, oxygen (O2) saturations and NIPS. RESULTS: The mean age in both the groups was 2.3 months. There was no statistically significant difference in baseline parameters in both the groups except the respiratory rate, which was significantly raised in DPNB group (33 breaths/min in EMLA and 38 in DPNB P < 0.04). During circumcision there was significant increase in heart rate in DPNB group, especially in step three and step four (p < 0.04). Oxygen saturation dropped in both the groups (baseline saturation 98% up to 91% in step 4). While assessing NIPS scores in both the groups, statistically significant difference was found between NIPS at step two and step four in two groups (p < 0.04). CONCLUSIONS: The overall pain control was equal in both the groups, although NIPS score was higher in DPNB in step two and four of circumcision. There was difference in application and cost. EMLA was easy to apply but has increased cost; while DPNB required expertise.

Omphalomesenteric duct cyst in an omphalocele: a rare association.

Omphalomesenteric duct (OMD) remnants and omphalocele are not infrequently seen in paediatric patients. In most of the cases, OMD remnant in an omphalocele is a Meckel's diverticulum; however rarely there may be other lesions. A one-day old male baby underwent surgery for omphalocele. At exploration a 10 x 12 cm cyst containing gut contents was found as the content of the omphalocele, with proximal and distal ileal loops running in continuity with it. Resection of the cyst with end to end primary gut anastomosis was done. Baby also had complex associated cardiac anomalies and died few days after surgery due to sepsis.

Management of impacted urethral stones in children.

OBJECTIVE: To find out the clinical presentation, site of impaction, management and outcome of children presenting with urinary retention due to urethral stone. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Surgical Unit B of National Institute of Child Health (NICH), Karachi, from April 2009 to January 2010. METHODOLOGY: All the patients under the age of 12 years, who presented with urinary retention due to impacted urethral stones were included. Urinary retention due to other causes like trauma, stricture, pelvic masses etc. were excluded. Diagnosis was made on clinical examination (palpable stone in penile urethra) and with the help of radiology. Surgical procedure was tailored according to the site of impaction in urethra. All stones were sent for chemical analysis and patients were followed in Nephrology OPD (stone clinic) for further work-up. RESULTS: There were a total of 19 patients with mean age of 3.94 ± 2.27 years. All were males. Twelve patients (63.1%) had stones impacted in anterior urethra while 7 (36.9%) were found in posterior urethra. Stones in penile urethra were removed in emergency either by meatotomy (when impacted at urethral meatus, n = 3) or following initial supra-pubic decompression of urinary bladder (using wide bore cannula) by urethrolithotomy (n = 6). Stones in bulbous (n = 3) and posterior urethral (n = 7) locations were pushed back into bladder and later removed on elective list by supra-pubic vesicolithotomy. No patient had proximal urinary tract calculi on further work-up. All patients remained well except one who developed retention of urine after a week of discharge. He had urinary tract infection and was treated with antibiotics. All the stones were of calcium oxalate type. CONCLUSION: Urethral stones must be kept in differential diagnosis in a child who presents with acute urinary retention. Clinical examination can identify causes in significant number of cases. Simple procedures like meatotomy, supra-pubic bladder decompression and urethrolithotomy can relieve the misery in these children.