Omphalocele, Exstrophy of Cloaca, Imperforate Anus, and Spinal Defects Complex: A Case Report.

 Omphalocele, exstrophy of cloaca, imperforate anus, and spinal defects complex is a rare malformation complex that includes omphalocele, cloacal exstrophy, imperforate anus and spinal defects with the incidence of 1 in 200,000 to 400,000 pregnancies and is even rarer in twin gestation. The etiology of this complex is still unclear. Most cases are sporadic. Prenatal screening must be done for diagnosis and appropriate multidisciplinary management of cases. In severe cases, termination of pregnancy is considered. We present a 4-day first twin child with underdeveloped ambiguous genitalia delivered via emergency lower section cesarean section at 32+3 weeks of gestation with giant liver containing omphalocele, cloacal exstrophy, imperforate anus and meningocele with severe pulmonary artery hypertension and non-visualization of right kidney and ureter, absence of uterus, fallopian tubes and right ovary. Separation and repair of the cecum and bladder were done. The ladd procedure was performed. Ileostomy was created and single-stage repair of the abdominal wall was done. Keywords: anorectal malformations; bladder exstrophy; case reports; neural tube defects; umbilicus.

Duplex Collecting System with Ectopic Ureters Opening into Vagina: A Case Report.

Continuous urinary leakage, along with normal deliberate voiding, must suggest diagnosis of ectopic ureter, specifically in girls. Combination of a duplicated collecting system with distal, infra-sphincteric, vaginal insertion of ureter is an uncommon congenital anomaly and rare cause of urinary incontinence. We present a case report of a 7-year-old girl who presented to the urology department with urinary incontinence despite successful toilet training and history of recurrent urinary tract infections. Right duplex collecting system was seen on ultrasound. Magnetic resonance urography revealed a near complete right duplex collecting system with ectopic insertion of ureter into vagina, and aplastic uterus with bilateral normal ovaries suggestive of Mayer-Rokitansky-Kuster-Hauser syndrome. Surgical treatment consisted of "common sheath" reimplantation of ectopic ureters into bladder, with complete resolution of symptoms. This case suggests to us that congenital abnormalities of the genitourinary tract should be considered in case of urinary incontinence and recurrent urinary tract infections.

Length of Stay in the Emergency Department during COVID-19 Pandemic in a Tertiary Care Hospital: A Descriptive Cross-sectional Study.

INTRODUCTION: Emergency Department overcrowding has become worsening problem internationally which may affect patient, emergency department efficiency and quality of care and this may lead to increased risk of in hospital mortality, higher costs, medical errors and longer times to treatment. With this pandemic COVID-19 likely to go on for months, if not a year or longer, the Emergency Department should be prepared for large influx of patients infected with COVID-19. The aim of this study is to find-out the length of stay in emergency department during COVID-19 pandemic at a tertiary care hospital in Nepal. METHODS: This is a descriptive cross-sectional study conducted in the Emergency Department of Kanti Children's Hospital. Ethical clearance was obtained from Institutional review committee Kanti Children's Hospital. Data collection was done from the emergency records from July 23, 2020 to July 29, 2020. The calculated sample size was 211. The data thus obtained was entered in Statistical Package for the Social Science software version 20 and necessary calculations were done. RESULTS: The median length of stay in emergency department was found to be 1.75 hours (Interquartile range 0 to 30 hours). CONCLUSIONS: Definitive management starts in respective wards and Intensive Care Units. During COVID-19, with longer emergency stay, chances of cross-infection increases, and the health workers serving in emergency department will be at risks. So guidelines for shorter emergency stay should be implemented.

A late presenting left-sided congenital diaphragmatic hernia repair complicated by postoperative chylothorax: A case report.

Management of chylothorax after repair of late presenting congenital diaphragmatic hernia is debatable. Conservative management in the form of close monitoring of chylous output with nutritional support appears convincing to surgery.

Prevalence of Tracheoesophageal Anomaly Cases among Neonates Undergoing Surgery in a Tertiary Care Children’s Hospital.

INTRODUCTION: Tracheo-oesophageal anomaly is the abnormal communication between trachea and oesophagus. The most common type of tracheo-oesophageal anomaly is oesophageal atreasia with distal tracheo oesophageal fistula. Tracheo-oesophageal anomaly is a common neonatal problem requiring an urgent surgery. Tracheo-oesophageal anomaly can be diagnosed as an isolated malformation or as part of polymalformative syndrome with possible vertebrae anomalies also known as Vacterl syndrome. The aim of the study is to find out the prevalence of tracheo-oesophageal anomaly cases among neonates undergoing surgery in a tertiary care childrens hospital in Nepal. METHODS: This is a descriptive cross sectional study conducted in a tertiary care children’s hospital in Nepal taking into account the medical records from period of 01 Jan, 2018 to Dec 31, 2019. Study population included the infants undergoing operative procedure in the operation theatre of Kanti Children’s Hospital. The calculated sample size was 306. Data was collected by retrospective chart review technique and listed in performa. Consecutive sampling technique was used. Thus collected data was entered in SPSS version 20 and necessary calculations were done. RESULTS: The prevalence of tracheo-oesophageal anomalies was found out to be 30 (9.8%) at 95% confidence interval. The most common problem, with which infants were brought to Kanti Children’s Hospital, that required urgent neonatal surgical intervention was anorectal malformation constituting 94 (30.72%) of the surgeries followed by intestinal obstruction 76 (24.84%) which included duodenal atresia, jujunal atresia and ileal atresia. CONCLUSIONS: Tracheo-oesophageal anomaly constitutes a major portion of neonatal disease condition requiring surgery in Nepal.

Paediatric Postoperative Intussusception.

Intussusception is one of the common causes of acute abdomen in early childhood, particularly in children younger than two years of age. The majority of cases in children are idiopathic. Pathologic lead points can be identified in only 25 percent of cases. Here. we present a case of 15 months female child with Ileoileal postoperative intussusception with an anastomotic margin as a lead point, following resection anastomosis done for patent vitello intestinal duct. Role of high clinical suspicion, investigations and judgement are highlighted in managing the case. Keywords: Anastomosis; ileoileal; postoperative intussusception; patent vitello-intestinal duct.

Preparing for safety monitoring after rotavirus vaccine introduction - Assessment of baseline epidemiology of intussusception among children <2 years of age in four Asian countries.

Intussusception is the invagination of one segment of the bowel into a distal segment, characterized by symptoms of bloody stool, vomiting, and abdominal pain. Previous studies have found regional differences in incidence but the etiology of most intussusception cases is unknown. Rotavirus vaccines were associated with a slightly of increased risk of intussusception in post-licensure evaluations in high- and middle-income countries, but not in low income African countries. To describe the baseline epidemiology of intussusception in young children prior to rotavirus vaccine implementation, active sentinel hospital surveillance for intussusception in children < 2 years of age was conducted in 4 low income Asian countries (Bangladesh, Nepal, Pakistan and Vietnam). Over a 24-month period, 15 sites enrolled 1,415 intussusception cases, of which 70% were enrolled in Vietnam. Overall, 61% of cases were male and 1% (n = 16) died, ranging from 8% in Pakistan to 0% in Vietnam. The median age of cases enrolled ranged from 6 months in Bangladesh and Pakistan to 12 months in Vietnam. The proportion of cases receiving surgical management was 100% in Bangladesh, 88% in Pakistan, 61% in Nepal, and 1% in Vietnam. The high proportion of males and median age of cases around 6 months of age found in this regional surveillance network are consistent with previous descriptions of the epidemiology of intussusception in these countries and elsewhere. Differences in management and the fatality rate of cases between the countries likely reflect differences in access to healthcare and availability of diagnostic modalities. These baseline data will be useful for post-rotavirus vaccine introduction safety monitoring.

Preparing for rotavirus vaccine introduction - A retrospective assessment of the epidemiology of intussusception in children below 2 years of age in Nepal.

BACKGROUND: Rotavirus is the most common cause of severe diarrhea in Nepali children, accounting for 25-33% of childhood diarrhea hospitalizations. Two rotavirus vaccines recommended for inclusion in national immunization programs have been associated with a low risk of intussusception in post-marketing studies conducted in several countries. Data on the epidemiology of intussusception hospitalizations are lacking in Nepal. Thus, we aimed to describe the epidemiology of intussusception-associated hospitalizations among Nepali children in preparation for rotavirus vaccine introduction. METHODS: A retrospective review of intussusception hospitalizations for a three year period was conducted at two major pediatric hospitals in Kathmandu, Nepal. Possible intussusception cases were identified through admission, discharge, and operation theater logs and ultrasound registers. Cases with a diagnosis of possible intussusception were selected for medical record review and classified as confirmed if they met the Brighton Collaboration level 1 criteria of diagnostic certainty and the child was aged < 24 months. Data on demographics, clinical course, and outcome were abstracted and analyzed. RESULTS: Eight-five confirmed intussusception cases were identified; most (96%) were confirmed at surgery. The number of intussusception cases peaked between ages 4-7 months; no cases occurred in children 0-2 months. Fifty-nine (64%) case-patients were male. The median duration of symptoms before admission was 2 days (range: 0-14). Abdominal pain, bloody stool, and vomiting were the most common clinical features. All cases underwent surgical treatment; there was only one death. CONCLUSIONS: This is the first study to evaluate the epidemiology of intussusception hospitalizations among children aged < 24 months in Nepal. Because the public health impact of rotavirus vaccination could be substantial in Nepal, where childhood diarrhea-related morbidity and mortality are high, this baseline knowledge of intussusception prior to introduction of rotavirus vaccine in the national immunization schedule will provide useful information for post-vaccine introduction safety monitoring.