The effectiveness of double dorsal dartos flap for urethroplasty coverage in distal hypospadias repair: A single surgeon approach to preventing urethrocutaneous fistula.

PURPOSE: The concept of interposing double dorsal preputial flaps to cover the urethroplasty was introduced in 2005 to reduce the risk of urethrocutaneous fistula (UCF). Our study aims to compare the postoperative outcomes of urethroplasty for distal hypospadias between two groups: one receiving single preputial flap coverage and another receiving double flap coverage. MATERIALS AND METHODS: We conducted a retrospective analysis study of boys with primary distal hypospadias who underwent surgery by the same experienced surgeon, at our department between 2010 and 2021. The study population was divided into two groups: Group A, which underwent urethroplasty coverage with single dorsal preputial flap, and Group B, which underwent coverage with double flap. Postoperative complications were compared between the two groups. RESULTS: We collected 105 cases, comprising 51 in Group A and 54 cases in Group B. The mean age at surgery was 29 months in Group A and 24 months in Group B. Post-operative follow-up period ranged from 6 months to 8 years. Functional and cosmetic outcomes were judged excellent in 88.7%. Only 10 boys experienced complications requiring reoperation. UCF occurred in 5 patients from Group A, while no cases were reported in Group B (p = 0.024). Meatal stenosis was identified in three patients in Group A and in two patients in Group B (p = 1). No other complications, such as glans dehiscence or penile torsion, were noted. CONCLUSION: Double dorsal dartos flap is an effective method for covering the new urethra and can be recommended in the treatment of patients with virgin distal hypospadias.

Peritoneal Hydatid Cysts in Children: A Case Series of Rare Echinococcosis Localization.

Peritoneal hydatid cysts are rare in children even in endemic areas. The primary or secondary origin of this site remains controversial, especially in children. Secondary peritoneal hydatid cysts are mainly the result of spontaneous or traumatic rupture of concomitant liver cysts or the leakage of cystic content during surgery. The purpose of our study is to present the largest case series of peritoneal hydatidosis in children. In addition, we aimed to assess the clinical and paraclinical findings as well as the management of echinococcosis at this location in children. The present case series is a study of ten children with peritoneal hydatid cysts, who underwent surgical intervention between 2013 and 2018 in the Pediatric Surgery Department, University of Monastir (Monastir, Tunisia). The mean age of the children was six years. All children presented abdominal pain, and underwent ultrasonography and contrast-enhanced computed tomography of the abdomen. Two patients had been operated on for lung hydatid cysts six months prior to the study. In two cases, radiologic investigations revealed the presence of an uncomplicated hepatic hydatid cyst located in segments II and IV. All patients underwent surgery, of which four underwent laparoscopy. Post-surgery, all patients received albendazole for three months, and the follow-up period was uneventful. Currently, all patients are in good health. Peritoneal hydatid disease is frequently secondary to the rupture of a primary hepatic cyst. Diagnosis is performed by abdominal ultrasound, computed tomography, and a positive serology result. Open or laparoscopic excision can be combined with medical treatment.

A New Operative Approach for Long-Gap Esophageal Atresia.

Surgical management of long-gap esophageal atresia (LGEA) remains challenging. Yet, there is a consensus among pediatric surgeons to preserve native esophagus. We used a new surgical technique to successfully manage three children diagnosed with LGEA. This technique consists of a combined thoracic and cervical approach to the EA repair using the patient's native esophagus. All patients initially had had gastrostomy and continuous upper pouch suction while awaiting surgery. This new technique has the potential to become the choice method in LGEA management.

Male Gender and Prematurity are Risk Factors for Incarceration in Pediatric Inguinal Hernia: A Study of 922 Children.

OBJECTIVES: The purpose of this study was to document clinical features of inguinal hernia (IH) in the pediatric population. It provides data to evaluate associated risk factors of incarcerated hernia, its recurrence as well as the occurrence of contralateral metachronous hernia. MATERIALS AND METHODS: We report a retrospective analytic study including 922 children presenting with IH and operated from 2010 to 2013 in our pediatric surgery department. RESULTS: We managed 143 girls (16%) and 779 boys (84%). The mean age was 2 years; the right side was predominantly affected (66.8%, n = 616). Incarcerated hernia was documented in 16% of cases with an incidence of 33% in neonates. The incarceration occurrence was 15.5% in males versus 2.09% in females. The surgical repair was done according to Forgue technique. Postoperatively, four cases of hernia recurrence were documented, and contralateral metachronous hernia was reported in 33 children with 7.7% females versus 2.8% males. Forty-five percent of them were infants. The mean follow-up period was 4 years. We think that incarceration can be related to several risk factors such as feminine gender, prematurity, and the initial left side surgical repair of the hernia. CONCLUSION: IH occurs mainly in male infants. Prematurity and male gender were identified as risk factors of incarceration. Contralateral metachronous hernia was reported, especially in female infants and after a left side surgical repair of the hernia.

First molecular evidence of the simultaneous human infection with two species of Echinococcus granulosus sensu lato: Echinococcus granulosus sensu stricto and Echinococcus canadensis.

Cystic echinococcosis is a widespread zoonotic parasitic disease especially in Tunisia which is one of the most endemic countries in the Mediterranean area. The etiological agent, Echinococcus granulosus sensu lato, implies dogs and other canids as definitive hosts and different herbivore species as intermediate hosts. Human contamination occurs during the consumption of parasite eggs passed in the environment through canid feces. Hydatid cysts coming from a child operated for multiple echinococcosis were collected and analyzed in order to genotype and to obtain some epidemiological molecular information. Three targets, ribosomal DNA ITS1 fragment, NADH dehydrogenase subunit 1 (nad1), and mitochondrial cytochrome c oxydase subunit 1 (CO1) genes, were amplified and analyzed by RFLP and sequencing approach. This study presents the first worldwide report in human of a simultaneous infection with Echinococcus granulosus sensu stricto (genotype G1) and Echinococcus canadensis (genotype G6) species. This is also the first report of the presence of E. canadensis in the Tunisian population which argues in favor of a greater importance of this species in human infestation in Tunisia than previously believed.

[Biliary atresia and polysplenia syndrome]. / Atrésie des voise biliaires et syndrome de polysplénie.

Polysplenia syndrome is a rare malformation characterized by the association of multiple rates and other congenital anomalies dominated by cardiac, vascular, intestinal and bile malformations. We report the observation of a patient operated in the neonatal period (3 days) for an upper intestinal obstruction with situs inversus. Surgical exploration noted the presence of multiple rates, a preduodenal vein, a biliary atresia and a duodenal atresia. The surgical procedures performed were a latero-lateral duodeno-duodenostomy and hepatoportoenterostomy of KASAI with simple immediate and delayed outcomes. The follow up was of 23 years. We recall the epidemiological characteristics of this malformative association and we discuss the role played by the prognosis of polysplenia syndrome in the evolution of biliary atresia. The diagnosis and treatment of biliary atresia are always urgent to increase the chances of success of the Kasai, and the chances of prolonged survival with native liver. However, almost all long-term survivors (even anicteric) have biliary cirrhosis, which requires lifelong follow up.

Biliary atresia: experience of a nord africain center.

BACKGROUND: Biliary atresia (BA) is a progressive inflammatory destructive process of the bile ducts occurring in about one of every 20.000 live births. If left untreated, biliary atresia can lead to liver failure. AIM: This is the first study on biliary atresia from Africa. The Aim of our study is to describe the clinical and prognostic aspects of biliary atresia in a Tunisian medical centre, where integrated medico-surgical management of children with liver diseases is lacking and liver transplant is not available. METHODS: Patients who were diagnosed with BA and underwent portoenterostomy between January 1985 and December 2010 at a tertiary regional hospital in Tunisia were included in this analysis. RESULTS: 74 patients were diagnosed with BA. The patients included 34 boys (45.9%) and 40 girls (54.1%). All patients received Kasai operation as the primary treatment and the median patient age at Kasai operation was 60 days (range 3-180 days). The median followup time for the patients was 72 months (range 2 months-23 years 6 months). Out of the 74 patients who received Kasai operation, 49 patients are being followed regularly in the outpatient clinic. Eight patients died immediately after Kasai operation by either hepatocellular decompensation or by cholangitis. Seventeen patients were lost to follow-up. Fifteen out of 49 patients who underwent portoenterostomy for BA are alive at median six years following Kasai intervention. Ten patients out of the 49 who are being followed regularly were Jaundice free. Two patients had portal hypertension. All these patients had survived. Five patients survived with signs of liver failure in four cases. Two of them had received a liver transplant abroad. Survival with the native liver was 6.7 % at 5 years with Kasai operation alone. CONCLUSION: BA still has a very severe prognosis in Tunisia Reducing the age at Kasai operation remains the most important target to reduce the need for LT in infancy and childhood. Centralised care will help to build surgical expertise.

Can the inferior mesenteric artery cause ureteropelvic junction obstruction?

Ureteropelvic junction obstruction (UPJO) is a pathological condition characterized by obstruction of the junction between the renal pelvis and ureter, often resulting in dilatation of the renal collecting system. Aberrant accessory vessels or early branching of the inferior pole vessels are the most common causes of extrinsic UPJO. The inferior mesenteric artery has not been reported as a common cause of UPJO. Here, we report the case of a 7-year-old patient with UPJO and an anomalous inferior mesenteric artery. The patient was initially diagnosed with congenital uropathy during the evaluation for primary enuresis.

Predictive Factors of Pulmonary Hydatid Complications in Children.

BACKGROUND: Pulmonary echinococcosis in children has frequent and severe complications. The aim of our study was to determine predictive factors of pre and postoperative complications of pediatric pulmonary hydatid cyst. METHODS: We conducted a retrospective descriptive and analytic study conducted from January 2010 to December 2018. The study population was divided into two groups to determine predictive factors of pre- and post-operative complications of pediatric pulmonary echinococcosis. Data were analyzed by IBM SPSS 21.0. A p-value of 0.05 was accepted as significant. RESULTS: The study included 106 boys and 94 girls with a median age of 8 years. One hundred and thirty-eight patients (69%) had complicated pulmonary hydatid cyst preoperatively. Univariate analysis identified 12 predictive factors of pre-operative complications: rural origin (p = 0.0001), hydatid contact (p < 0.001), long period between the onset of symptoms and the first medical consultation (p = 0.0001), the autumn and the winter (cold seasons) (p = 0.0001), chest pain (p = 0.0001), hemoptysis (p = 0.023), fever (p = 0.0001), right side (p = 0.01), apical and para hilar location (p = 0.01), superior lobe (p = 0.05), superior right lobe (p = 0.0001), cyst size>5 cm (p = 0.02), positive hydatid serology (p < 0.0001). It identified 2 predictive factors of post-operative complications: giant cyst (p = 0.009) and not performing a capitonnage (p = 0.016). Multivariate analysis showed 4 independent pre-operative predictive factors of complications: rural area (p < 0.0001), fever (p = 0.006), right side (p = 0.02) and positive hydatid serology (p < 0.001). It identified 2 postoperative independent predictive factors of complications: not performing. capitonnage (p = 0.029) and solitary hydatid pulmonary cyst (p = 0.02). CONCLUSION: Pulmonary hydatid cyst management in children needs a thorough appreciation of independent predictive factors of pre and postoperative complications in order to reduce their morbidity.

A case report of urethral prolapse in young girls: Clinical manifestations and surgical management.

BACKGROUND AND IMPORTANCE: Urethral Prolapse (UP), first described by Solinger in 1732, is a rare condition characterized by the circular protrusion of the distal urethral mucosa through the external meatus, forming a hemorrhagic, sensitive vulvar mass. This condition is most commonly observed in prepubertal black females. This case report details the clinical manifestations and surgical management of UP in three young girls. CASES PRESENTATION: Three girls, aged 4, 5, and 6 years, were admitted with symptoms of vaginal blood spotting. Physical examinations revealed moderate bleeding and a red ring of congested, edematous tissue prolapsing through the urethral meatus. Diagnostic procedures confirmed UP, and surgical management was undertaken. The surgical approach involved the complete excision of the prolapsed tissue and mucosal-to-mucosal anastomosis under general anaesthesia. Postoperative follow-up over a mean period of 11 years showed no recurrence or urethral stricture. CLINICAL DISCUSSION: UP is a rare benign condition primarily affecting the female urethra, with several hypothesized etiologies, including weak pelvic floor structures and increased intraabdominal pressure. The typical presentation includes vaginal bleeding and a doughnut-shaped mass around the urethral meatus. Conservative management may be considered for mild cases, but surgical excision is recommended for severe cases, offering a safe and effective solution with low recurrence rates. CONCLUSIONS: UP in children, although rare, should be considered in cases of unexplained vaginal bleeding. Diagnosis is primarily clinical, and surgical resection provides a definitive and cost-effective treatment.

Phenotypic variability and management of patients with mosaic monosomy X and Y chromosome material: a case series.

BACKGROUND: we aim to discuss the origin and the differences of the phenotypic features and the management care of rare form of disorder of sex development due to Mosaic monosomy X and Y chromosome materiel. METHODS: We report our experience with patients harboring mosaic monosomy X and Y chromosome material diagnosed by blood cells karyotypes and cared for in our department from 2005 to 2022. RESULTS: We have included five infants in our study. The current average age was 8 years. In four cases, the diagnosis was still after born and it was at the age of 15 years in one case. Physical examination revealed a variable degree of virilization, ranging from a normal male phallus with unilateral ectopic gonad to ambiguous with a genital tubercle and bilateral not palpable gonads in four cases and normal female external genitalia in patient 5. Karyotype found 45, X/46, XY mosaicism in patient 1 and 2 and 45, X/46, X, der (Y) mosaicism in patient 3, 4 and 5. Three cases were assigned to male gender and two cases were assigned to female. After radiologic and histologic exploration, four patients had been explored by laparoscopy to perform gonadectomy in two cases and Mullerian derivative resection in the other. Urethroplasty was done in two cases of posterior hypospadias. Gender identity was concordant with the sex of assignment at birth in only 3 cases. CONCLUSION: Because of the phenotypic heterogeneity of this sexual disorders and the variability of its management care, then the decision should rely on a multidisciplinary team approach.

Staphylococcus aureus costal osteomyelitis with complicated by pleural effusion in a 7-month-old infant: A misleading clinical presentation.

Osteomyelitis is a rare infectious disease in children, predominantly affecting long bones; however, its clinical presentation can be ambiguous if the location is atypical. Costal osteomyelitis is very rare in children and can mimic other pathologies. We present a case of a seven-month-old infant diagnosed with costal osteomyelitis complicated by rupture of a subperiosteal abscess into the pleura. His clinical condition improved with conservative treatment, which included chest drain insertion and intravenous antibiotic therapy without the need for surgical debridement. Rib osteomyelitis represents a potentially severe condition. Early detection is imperative to prevent the necessity for invasive therapies and mitigate long-term complications.

Gastric perforation in the newborn.

BACKGROUND: Gastric perforation in neonates is an uncommon condition. It could be spontaneous but a contributing cause should be sought. AIM: To review our experience of treating 8 neonates with gastric perforation over the past 20 years. METHODS: We reviewed the records of all newborns admitted to our hospital between 1990 and 2010 with regard to gender, age at admission, contributing factors, associated anomalies, site of perforation, type of operation, and outcome. RESULTS: Of the eight neonates, five were female and three male. The average weight was 2130 g. Four babies were premature. Three infants were ventilated for respiratory difficulty. Five patients had associated anomalies. Perforation occurred in the lesser curvature in 4, at the greater curvature in 3, and at the anterior antrum surface in 1. All patients were treated with gastrorrhaphy. Four neonates required additional gastrostomy. Mortality was 75% (6 infants). CONCLUSION: Active perinatal management, early treatment of primary pathologies, and protection of the stomach against distension in neonates at risk are essential in the management of neonatal gastric perforation.

Intussusception Caused by Heterotopic Pancreas: A Tunisian Case Series of 5 Pediatric Patients.

Heterotopic pancreas (HP) is a rare congenital developmental anomaly of the gastro-intestinal tract, defined as the presence of pancreatic tissue found in ectopic sites. Intussusception caused by isolated HP is extremely rare. Pediatric reports concerning this pathology are case reports. Here, we report cases of secondary intussusception, in which conservative treatment failed and surgery was performed. The aim of this review is to study the epidemiologic and clinical aspects of HP in pediatric patients from our institution. We retrospectively collected patients who were treated in the pediatric surgery department for intussusception caused by HP, from January 1986 to November 2018. We investigated five patients, three boys and two girls, aged 5 months to 2 years. The diagnosis was made incidentally during the operation. HP was found in the jejunum in three cases and in the ileum in two cases. HP was removed. The postoperative course was uneventful. Although rare, HP should be included in the differential diagnosis of gastrointestinal diseases, causing secondary bowel intussusception.

Management of trichobezoar: About 6 cases.

BACKGROUND: Trichobezoar is an uncommon clinical entity in which ingested hair mass accumulates within the digestive tract. It is generally observed in children and young females with psychological disorders. It can either be found as an isolated mass in the stomach or may extend into the intestine. Untreated cases may lead to grave complications. MATERIAL AND METHODS: We retrospectively analyzed the clinical data of six patients treated for trichobezoar in Monastir pediatric surgery department during 16-year-period between 2004 and 2019. Imaging (abdominal computed tomography and upper gastroduodenal opacification) and gastroduodenal endoscopy were tools of diagnosis. RESULTS: Our study involved 6 girls aged 4 to 12. Symptoms were epigastric pain associated with vomiting of recently ingested food in 3 cases and weight loss in one case. Physical examination found a hard epigastric mass in all cases. The trichobezoar was confined to the stomach in 4 cases. An extension into the jejunum was observed in 2 cases. Surgery was indicated in all patients. In two cases, the attempt of endoscopic extraction failed and patients were then operated on. All patients had gastrotomy to extract the whole bezoar even those with jejunal extension. Psychiatric follow-up was indicated in all cases. The six girls have evolved well and did not present any recurrence. CONCLUSION: open surgery still plays a crucial role in Trichobezoard management . After successful treatment, psychiatric consultation is imperative to prevent reccurrence and improve long term prognosis.

Novel biomarkers for the early prediction of pediatric cystic echinococcosis post-surgical outcomes.

OBJECTIVE: This study aims to search for reliable serological biomarkers allowing the early prediction of cystic echinococcosis (CE) post-operative outcomes. METHODS: We applied immunoprecipitation (IP) of Echinococcus granulosus protoscolex antigens with pediatric CE patients' plasma collected at 1-month and 1-year post-surgery, followed by Liquid Chromatography with tandem mass spectrometry (LC-MS/MS). We compared IP proteomic content from relapsed patients within the first-year post-surgery (RCE) to cases with no relapses until 3 post-operative years (NRCE). Selected proteins were recombinantly synthesized and assessed for their prognostic performance by Enzyme-linked immunosorbent assay (ELISA). RESULTS: A total of 305 immunoreactive parasitic proteins were identified, 59 of which were significantly more abundant in RCE than NRCE for both time-points. Four proteins showed the most promising characteristics for predicting CE outcomes: cytoplasmic malate dehydrogenase (Eg-cMDH), citrate synthase (Eg-CS), annexin A6 and severin. ELISA-IgG against the four markers were significantly lower at 1-year post-surgery than 1-month in NRCE, in contrast to RCE that displayed either stable or higher levels. The Eg-cMDH and Eg-CS showed the best prognostic performance, with respective probabilities of being "relapse-free" of 83% and 81%, if a decrease of IgG levels occurred between 1-month and 1-year post-surgery. CONCLUSION: The Eg-cMDH and Eg-CS are promising biomarkers to predict early CE post-surgical outcomes.

Femoral hernia in children: How to avoid misdiagnosis?

BACKGROUND: Femoral hernias are an uncommon groin pathology among pediatric patients. Therefore, they are frequently misdiagnosed. In the present study, we review our experience with this rare surgical entity during the past 25 years. METHODS: The medical records of 19 patients who underwent 22 femoral hernia repairs between January 1994 and December 2019 were retrospectively analysed. RESULTS: Patients' age ranged from 2 to 12 years (mean age was 5. 5 years) with an approximately equal sex ratio (10 girls/9 boys). There were three bilateral cases identified separately. They were discovered and managed at different times. All the children were referred with a groin lump, but the correct pre-operative diagnosis was made in only 13 cases (59%). In the remaining cases, four were identified intraoperatively following negative exploration for a supposed inguinal hernia. The other five were found to have a femoral hernia 1 month to 12 months after ipsilateral inguinal hernia repair. All patients underwent elective surgery. The femoral canal was closed using either Lytle or McVay procedure. Recurrence occurred in only one patient 2 months after initial repair. CONCLUSION: Femoral hernias are often misdiagnosed. Pre-operative diagnosis can be obtained through careful clinical assessment. In equivocal cases, ultrasonography and laparoscopy could be useful. A correct pre-operative diagnosis will lead to suitable treatment, thus avoiding unnecessary reoperations and their related complications.

[Ureterocele associated with simplex ureter in children: clinical and therapeutic features]. / Urétérocèle sur uretère simplex chez l'enfant: aspects cliniques et thérapeutiques.

Ureterocele is a pseudo-cyst dilation of the terminal submucosal ureter. It is a rare malformative uropathy, in particular associated with simplex ureter. We conducted a retrospective study over a period of 10 years. Twelve medical records of patients whose data were collected at the Department of Paediatric Surgery of Monastir between 2006 and 2016 were examined. The average age of patients was 2.7 years (ranging from 7 days to 11 years) with a sex ratio of 1. Patients´ clinical status was dominated by fever due to upper urinary tract infection. Diagnosis was mainly based on renal bladder ultrasound, intravenous urography (IVU) and retrograde urethrography and cystography. Ureterocele was unilateral in 10 cases and bilateral in 2 cases (on a total of 14 cases). It was associated with simplex ureter in all cases and all patients underwent endoscopic surgery. No perioperative adverse event was reported. The postoperative course was uneventful. Clinical and radiological improvements were reported in all cases. Ureterocele associated with simplex ureter is a very rare urinary abnormality. Early diagnosis is essential to avoid upper urinary tract involvement. Endoscopic treatment is a good alternative leading to satisfactory results.

Isolated central sterna clefts: A rare congenital malformation.

Sternal cleft is a rare congenital anomaly which is generally observed at birth. The aetiology remains obscure. Superior clefts are more frequent than inferior ones, and isolated central clefts are extremely rare. Surgery is recommended to protect the heart and other mediastinal contents from trauma and also to improve respiratory dynamics. We present the case of a newborn with isolated central clefts and we will give a review of the literature.

Contribution of laparoscopy in the abdominal tuberculosis diagnosis: retrospective study of about 11 cases.

OBJECTIVE: Abdominal tuberculosis is one of the most frequent extra-pulmonary localizations. Its diagnosis is difficult and may lead to a delayed prescription of specific treatment. This study is aimed at stressing the role of laparoscopy associated with a biopsy in the diagnostic confirmation of abdominal tuberculosis particularly in doubtful cases. METHODS: The diagnostic features of 11 cases hospitalized for abdominal tuberculosis in the Paediatric Surgery Department of Fattouma Bourguiba Hospital in Monastir for a 6-year period (2001-2006), were evaluated retrospectively. The diagnosis of abdominal tuberculosis was substantiated histopathologically by laparoscopy in all cases. The epidemiological and clinical characteristics along with the laboratory, radiological and histological data were studied. RESULTS: Eleven cases of abdominal tuberculosis with a mean age of 5.6 years were diagnosed. It was peritoneal tuberculosis in all cases and associated with intestinal localization in one case. A conversion to laparotomy was practiced in three patients: appendicular plastron in one case, pseudo-tumor aspect of an intestinal loop in another case and because of their pathological aspect appendicectomy and caecum biopsy in the third. The diagnosis was confirmed histologically by biopsies in nine cases and on excision pieces in the other two cases. All patients had an uneventful course with an antituberculosis treatment. CONCLUSION: Abdominal tuberculosis is still frequent in Tunisia. Because of its non-specific clinical presentation and the limited means of investigation, a laparoscopy with biopsy should be practiced as first line diagnostic tool in case of doubtful abdominal tuberculosis. The earlier the diagnosis is established and an adapted antituberculosis treatment is started, the better the prognosis is.