Circumcision in Hemophilia: A Multicenter Experience.

BACKGROUND: Hemophiliac patients and their families have social pressure to undergo circumcision, despite the potential complications. The objective of this study was to report our experience in the circumcision of hemophilia patients. MATERIALS AND METHODS: We included 35 patients with hemophilia who had circumcision in 3 centers from January 2010 to August 2019. Their age ranged between 0.3 months and 8 years. Hemophilia a was classified as mild (n=3), moderate (n=4), and severe (n=28). Patients received 2 doses of factor VIII concentrate 50µ/kg, 1 hour before the procedure and 12 hours after it. RESULTS: Four neonates were diagnosed with hemophilia after circumcision because of prolonged bleeding. Two patients with severe hemophilia A had bleeding after hospital discharge (6.5%). They received additional factor concentrate, and 1 patient had an extra stitch. Two patients had wound gaping (6.5%), and 1 patient had a wound infection (3.2%). CONCLUSION: Hemophilia is not an absolute contraindication for circumcision. Circumcision of hemophilic children should be performed under appropriate conditions in hemophilia centers. Bleeding is not frequent but could be serious.

Replacement Versus Same-Site Salvage Using Hickman Catheter for Pediatric Stem Cell Transplantation Patients: A Comparative Study.

BACKGROUND: Children undergoing bone marrow transplant need a double-lumen Hickman line. Therefore, changing Port-a-Cath ports to double-lumen Hickman catheter is mandatory. Several methods were described for changing Port-a-Cath ports either through the same-site or a new placement access site. The advantage of one method over the other is still debatable. We conducted this study to compare the safety and effectiveness of replacement versus salvage techniques to change ports to the Hickman lines before bone marrow transplants in pediatric patients. METHODS: We included 85 pediatric patients who underwent stem cell transplants. Their age ranged from 0.2 to 15 years. According to the Hickman reinsertion technique, we classified the patients into 2 groups; the Replacement group (n = 47) and the Same-site salvage group (n = 38). We compared the data before and after Hickman insertion between both groups. Study outcomes were the catheter duration, its complications, and mortality. RESULTS: The mean age of all patients was 4.7 ± 3.9 years, and 65.9% were males. There was no difference in the baseline data between both groups. During Port-a- Cath first insertion; 16.5% of patients suffered complications, with 10.6% had conversion to cut down, 1.2% had a hematoma, and 4.7% had multiple site insertion. We did not report differences between groups in the complications of the first port insertion. The Hickman duration was longer in the replacement group (4 (Q1-Q2: 2-6) vs. 1 (0.5-3) months, P = 0.005). Increased age (odds ratio [OR]: 1.31, P = 0.001) and male gender (OR: 1.19, P = 0.046) were independent predictors of mortality. CONCLUSIONS: Endovascular same-site salvage technique could help preserve vascular access during the tunnel catheter exchange for noninfectious reasons. We recommend the use of the same-site salvage technique in pediatric transplant patients.

Efficacy and Clinical Outcomes of Bleomycin in the Treatment of Lymphangiomas: A Multicenter Experience.

BACKGROUND: Bleomycin sclerotherapy became a popular nonsurgical option for the management of lymphangiomas. However, its efficacy has not been thoroughly evaluated. The purpose of this study was to assess the clinical outcomes and the effectiveness of bleomycin injection for the treatment of lymphangioma. METHODS: This retrospective study was conducted in 4 centers and included 47 infants and children. All patients had bleomycin sclerotherapy between November 2005 and September 2020. Men presented 53.2% of the study sample (n = 25), and the most common site was the head and neck (n = 29, 61.7%). RESULTS: Two injections were required in 11 patients (23.4%), and 7 patients (14.9%) required 3 or more injections. Excellent response was achieved in 63.8% (n = 30), 14 patients (29.8%) had a good response, and 4 had a poor response (8.5%). There was no difference in the response according to the site of the lesion (p = .75). The most frequent complication was recurrence (n = 11, 23.4%), and swelling occurred in 5 patients (10.6%). No patient had facial or phrenic nerve palsy or hoarseness. Two patients had persistent pain, and 2 had an infection (4.3%). CONCLUSION: Intralesional bleomycin injection could be an effective therapy for lymphangiomas. The procedure has a low complication profile, and long-term study is recommended to evaluate the systemic and late bleomycin injection complications.

A comparative study between two techniques of laparoscopic orchiopexy for intra-abdominal testis.

INTRODUCTION: Several techniques have been described for laparoscopic orchidopexy in patients with intra-abdominal testes. We aimed to report our experience with the staged laparoscopic traction orchiopexy (Shehata technique) and to compare it to the Fowler-Stephens orchidopexy (FSLO). METHODS: We conducted a retrospective cohort study at two pediatric surgery departments from 2017 to 2020. Fifty-six patients underwent laparoscopic exploration and the testis was intra-abdominal in 41 of them. Patients with vanished testis or those who underwent open orchidopexy or vessel-intact laparoscopic orchidopexy were excluded. Those who underwent FSLO (n = 18), or Shehata laparoscopic orchidopexy (n = 11) were compared. RESULTS: Preoperative data were comparable between both the groups. FSLO had a significantly shorter first-stage operative time (34.61 ± 6.43 vs. 58 ± 9.39 min, P < 0.001), with no difference in the second stage. There was no difference in the initial position of the testes between both the techniques. The testis dropped from the fixation position in three patients in the Shehata group (27.27%), and consequently, the cord did not increase in length by the second stage, and these testes barely reached the scrotum. At 12 months' follow-up, the testes' size, position, and consistency were comparable between the two groups. CONCLUSION: Staged laparoscopic traction orchidopexy is feasible for the management of intra-abdominal testes, especially in the low-lying testes.

Hickman Central Venous Catheters in Children: Open Versus Percutaneous Technique.

BACKGROUND: The ideal technique for insertion of tunneled central venous catheters (CVCs) in children is still debatable. This study aimed to compare the outcomes of open versus percutaneous technique for the insertion of tunneled CVCs. METHODS: The study included 279 patients who had CVCs insertions from 2010 to 2020. Patients were divided into two groups according to the technique of insertion: group 1 (n = 90) included patients who had the open cutdown method and group 2 (n = 189) included patients who had the percutaneous technique. RESULTS: There was no difference in age and gender distribution between groups (P = 0.152 and 0.102, respectively). Chemotherapy was the most common indication of insertion (77 [85.56%] vs. 165 [87.30%]); in group 1 vs. 2, P = 0.688). The left external jugular was the most common site of insertion in group 1 (n = 66; 73.33%), and the left subclavian was the most common site in group 2 (n = 77; 40.74%). Complications of insertion were nonsignificantly higher in group 2 (P = 0.170). Nine patients in group 2 required conversion to cutdown technique (4.76%). Complications during removal were nonsignificantly higher in group 2 (P = 0.182), and the most common was bleeding (n = 4; 2.12%). The most common indication for catheter removal was the completion of the treatment (36 [40%] vs. 85 [44.97%] in groups 1 and 2, respectively). CONCLUSIONS: Percutaneous and open tunneled central venous catheter insertion are safe in pediatric patients who require long-term venous access. Both techniques have a low complication rate. The choice of each method should be tailored to the condition of each patient.

Efficacy and clinical outcome of the port-a-cath in children: a tertiary care-center experience.

BACKGROUND: Implanted vascular access devices play an essential role in the management of pediatric patients. The objectives of this study were to assess our experience with port-a-cath insertion in pediatric patients, report its complications, and compare open versus percutaneous approaches. METHODS: We performed a retrospective cohort study, including 568 patients who underwent port-a-cath insertion between 2013 and 2019 in our center. We grouped the patients according to the technique of insertion into two groups: group 1 (n = 168) included patients who had the open approach and group 2 (n = 404) included patients who had the percutaneous technique. (p < 0.001). RESULTS: Patients in group 1 were younger (4.10 ± 3.45 years) compared to patients in group 2 (5.47 ± 3.85 years). The main indications of insertion were hematological malignancy 57.74% (n = 328), solid organ malignancy 25.18% (n = 143), pure hematological diseases 5.46% (n = 31), metabolic diseases 2.64% (n = 15), and others for poor vascular access 8.8% (n = 50). The most common site for insertion in group 1 was the left external jugular (n = 136; 82.98%) and the left subclavian in group 2 (n = 203; 50.25%). Two hundred and two patients had a central line before catheter insertion (36.6%). Complications during insertion were comparable between both groups (p = 0.427). The catheter got stuck in 6 patients; all required additional incision and two needed venotomy. The most common reason to remove the catheter was the completion of the treatment (63.69% and 61.14%, in groups 1 and 2, respectively). The duration of the catheter was comparable between the two groups (13.14 ± 14.76 vs. 14.44 ± 14.04 months in group 1 vs.2; p = 0.327). CONCLUSIONS: Open and percutaneous port-a-cath insertions are safe in children with chronic diseases. Port-a-cath improved patients' management, and complications are infrequent. The most common complications are infection and catheter malfunction, which can be managed without catheter removal in some patients.

Resident satisfaction with the pediatric surgery training program.

BACKGROUND: The pediatric surgery residency program is new in Saudi Arabia. As with any new program, residents experience a degree of fear and anxiety about their future in the program. The aim of this study is to examine residents' satisfaction with the program. METHODS: This study included an online survey examining residents' satisfaction. It consisted of demographic, financial, personality, program-specific, and burnout assessment questions. All questions were multiple-choice items. Descriptive statistical data are presented as frequency distributions and percentages. Cross-tabulations and chi-square tests were used at the bivariate level of analysis to compare subgroups and identify factors of satisfaction. Binary logistics regression was used at the multivariate level of analysis to compute the odds ratio of significant variables. RESULTS: Thirty-one out of 32 residents responded to the survey. The multivariate logistic regression showed that current year of residency, current relationship status and personality statistically affected the satisfaction of residents. Senior residents, i.e., residents who had spent four years or more in the program, were 40 times more likely to be satisfied than were residents in their first year; residents who were married were more than eight times more likely to be satisfied than were residents who were single; and residents who were neutral or who agreed that they were very indecisive were 8% less likely to be satisfied than were those who reported being decisive. Gender was statistically significant, such that males were more satisfied than females were. CONCLUSIONS: Although the pediatric surgery residency program is new, this survey has shown that there is generally a high rate of satisfaction. Satisfaction was also observed more in senior residents. Further studies should be conducted in the future when residents graduate from the program.

Risk factors for postoperative hypocalcemia following total thyroidectomy: a retrospective study.

BACKGROUND: and Objectives: Hypocalcemia is a commonly reported complication after thyroid surgery. Many possible risk factors have been identified. The purpose of this study is to analyze various risk factors possibly associated with development of postoperative hypocalcemia after thyroid surgery by dividing the sample population into postoperative hypocalcemia and normal calcium groups. DESIGN: Retrospective. SETTING: Multiple centers in the Makkah region of Saudi Arabia. PATIENTS AND METHODS: Risk factors for postoperative hypocalcemia that were obtained for analysis include patient factors, perioperative blood parameters factors, disease-related factors, and surgical factors. Postoperative hypocalcemia was defined as a reduction of the total calcium level to <8.0 mg/dL. Hypocalcemic and normocalcemic patients were compared by multivariate logistic regression. MAIN OUTCOME MEASURES: Distinguish independent risk factors for postoperative hypocalcemia after thyroidectomy. SAMPLE SIZE: 215 patients. RESULTS: The incidence of hypocalcemia was 52.1% (112 of 215 patients). According to multivariate analysis, statistically significant risk factors for predicting postoperative hypocalcemia included postoperative parathyroid hormone level <10 pg/dL, inadvertent parathyroid gland resection, and neck dissection surgeries. CONCLUSION: The causes of postoperative hypocalcemia are multi-factorial. Because many of these factors are modifiable, they should be identified postoperatively to distinguish high-risk groups and implement early preventive measures. LIMITATIONS: Retrospective with a relatively small size. We encourage additional prospective studies with a larger sample size in multiple regions of the country, which might reveal further significant results.

Percutaneous endoscopic gastrostomy in children: A tertiary center experience.

INTRODUCTION: Percutaneous endoscopic gastrostomy (PEG) is a common procedure in children. The outcomes of PEG could be affected by the associated disease. We aimed to evaluate the outcomes and safety of PEG tube placement in a tertiary care center with special attention to patients with cardiac disease, ventriculoperitoneal (VP) shunt, or peritoneal dialysis (PD) catheter. METHODS: This retrospective study included 113 pediatric patients who had PEG tube insertion from 2011 to 2021. Eighteen patients (15.93%) had cardiac disease, five patients (4.42%) had PD catheters, and three patients (2.65%) had VP shunt. RESULTS: The median age was 3 years (interquartile range: 1-6), and females represented 55% of our patients. The weight ranged from 2.57 to 60 kg, and the most common indication for insertion was neurological disease (n = 56; 49.56%). The median operative time was 30 (20-45) minutes. Pneumonia and vomiting were the most frequent complications (n = 20, 17.7%). Thirty-day mortality occurred in four patients (3.54%) and 1-year mortality in 10 patients (8.85%). Nine patients (7.96%) required fundoplication, and four patients (3.53%) had tube removal and reinsertion. There was no association between weight and postoperative complications (odds ratio: 0.97; P = .48). There were no differences in postoperative complications among patients with cardiac diseases, PD catheters, and VP shunts. No complications were reported in patients with VP shunt. One patient with cardiac disease and one patient with PD catheter required fundoplication. Removal and reinsertion were needed in one patient with a PD catheter. CONCLUSION: PEG is feasible in low-weight infants with a low complication rate. The complication rate is low in patients with VP shunt, PD catheter, and cardiac patients.

Bilateral Wilms' Tumor With Different Responses to Preoperative Chemotherapy.

Wilms' tumor (WT) is a common type of primary renal tumor in the pediatric population that can equally affect both sides. Herein, we describe a case of bilateral Wilms' tumor (BWT) in a three-year-old male with different responses to preoperative chemotherapy in the two kidneys. The left kidney mass responded poorly to chemotherapy than the right kidney, which raised the suspicion of coexisting benign disease or congenital anomaly. However, it was ruled out by preoperative nuclear scan and ultrasound-guided frozen section biopsy taken from the left kidney mass. The report of a frozen section on hematoxylin and eosin (H&E) stain was positive for the small blue cell tumor. The patient was managed successfully with a total nephrectomy of the right kidney and nephron-sparing surgery (NSS) on the left kidney. The postoperative period was uneventful and was managed successfully with radiotherapy. Despite many challenges faced in the management of bilateral Wilms' tumor, surgery is the most preferable mode of therapy with chemotherapy and radiotherapy being effective in certain cases. The patient was followed up till no signs of recurrence or metastasis were observed.

Surgical Outcomes of Pediatric Peritoneal Dialysis Catheter Function in a Referral Center.

Peritoneal dialysis (PD) is used in children with end-stage renal disease (ESRD) for renal replacement therapy. However, it can be associated with the risk of post-surgical complications. The objectives of this study were to report our experience with the placement of PD catheters for 14 years and to assess the incidence of PD malfunction and other PD-related complications, including the effect of adopting minimally invasive techniques for catheter placement. The objectives of this study were to report our experience with placement of PD catheters for 14-year period and to assess the incidence of PD-related complications and the effect of adopting minimally invasive techniques for catheter placement. It is a retrospective cohort study at the department of pediatric surgery and pediatric nephrology, dialysis, and transplant in Jeddah, Saudi Arabia. We reviewed the records of all children who had PD catheter placements between 2005 and 2019. The data included demographics, the surgical technique, the performance of omentectomy, duration of PD catheter, and complication rates. Sixty-five patients had PD catheter insertion during the study period; 16 (24.6%) of them were placed in other institutions then referred to us. Thirty-five patients had no complications. Omentectomy during the first procedure was performed in 53 patients (81.54%). Early dialysate leaking occurred in six patients (9.3%); none were treated with surgical revisions. Four leaks resolved spontaneously, and hemodialysis (HD) was needed in two patients. The median PD catheter duration was 29 months (25th-75th percentiles: 21-41). Sixteen patients required revision (24.62%), and mortality occurred in five patients (7.69%). PD is a safe option in children with ESRD. Open placement with omentectomy in a specialized center could reduce leakage,help to start dialysis early, and decrease the conversion to HD.

Ultrasound guidance for Port-A-Cath insertion in children; a comparative study.

BACKGROUND: Gaining vascular access in children is challenging. Ultrasound-guided central line insertion in adults became the standard of care; however, its role in children is not clear. Our objective was to evaluate the ultrasound-guided Port-A-Cath or totally implanted long-term venous access device insertion in pediatric patients compared to the traditional approach. METHODS: This single-institution retrospective cohort study included 169 children who had port-A-catheters between May 2016 and Oct 2019. The patients were divided into two groups; group A included patients who had Port-A-Cath insertion using the landmark method (n = 117), and Group B included patients who had ultrasound-guided Port-A-Cath insertion (n = 52). Preoperative, operative, and postoperative data were collected and compared between the two groups. The study outcomes were operative time and catheter insertion-related complications. RESULTS: There was no significant difference in age or gender between both groups (P = .33 and .71, respectively). Eleven cases in group A and two cases in group B were converted to cut down technique because of difficulty in inserting the guidewire. There was no difference in the indication of the need for the port-A-Cath between both groups. The mean operative time for group A was 47 min and for group B was 41.7 min (P < .042). Two patients had intraoperative bleeding and hemothorax and required blood transfusion and chest tube insertion in group A. No statistically significant difference was found in the reported complications between the groups. However, the insertion-related complications were higher in group A (P = .053). No procedure-related mortality was reported. CONCLUSIONS: Ultrasound-guided insertion of Port-A-Cath is an effective and safe technique with a reduction of failure rate. It should be considered the standard technique for Port-A-Cath insertion in the pediatric population.

Congenital diaphragmatic hernia in neonates: Open versus thoracoscopic repair.

BACKGROUND: There are no standard criteria to select patients for thoracoscopic repair of congenital diaphragmatic hernia (CDH). The objective of this study was to compare open laparotomy versus thoracoscopic repair of CDH in neonates. PATIENTS AND METHODS: This retrospective study included 41 patients who had repair of CDH from 2011 to 2019. Patients were divided into two groups according to the surgical approach; open laparotomy (n = 30) and thoracoscopic repair (n = 11). Study endpoints were duration of post-operative mechanical ventilation, hospital stay and the return to full enteral feeding. RESULTS: Patients who had thoracoscopic repair were significantly younger (3 [25th- 75th percentiles: 3-3] vs. 4 [3-5] days; P = 0.004). Other pre-operative variables were comparable between both groups. The duration of surgery was significantly longer in the thoracoscopic repair (174 [153-186] vs. 91 (84-99) min; P < 0.001). The use of pre-operative nitrous oxide inhalation was associated with prolonged ventilation (P = 0.004), while the thoracoscopic repair was associated with shorter mechanical ventilation (P = 0.006). Hospital stay is lower in the thoracoscopic approach but did not reach a significant value (P = 0.059). The use of pre-operative nitrous oxide was associated with a prolonged hospital stay (P = 0.002). Younger age (HR: 1.33, P = 0.014) and open approach (HR: 3.56, P = 0.004) were significantly associated with delayed feeding. CONCLUSIONS: The thoracoscopic approach is safe and effective for repairing the CDH. It is associated with shorter mechanical ventilation and rapid return to enteral feeding. Proper patient selection is essential to achieve good outcomes.

Update on transumbilical laparoscopic-assisted surgery in infants and neonates.

BACKGROUND: Because of the restricted space of the peritoneal cavity and the easy mobility of abdominal and pelvic organs in infants and neonates, the boundary of minimally invasive surgery was extended to complete the operation outside the abdomen. The objective of this study was to report our experience with transumbilical laparoscopic-assisted surgery (TULS) in different abdominal pathologies in infants and neonates. PATIENTS AND METHODS: A retrospective study was conducted on 59 patients who underwent TULS from 2014 to 2020. The study outcomes were the conversion to open approach, length of hospital stay and post-operative complications. RESULTS: The most common indications were explorations for intra-abdominal testes (n = 15) and inguinal herniorrhaphy (n = 13). Patients who had surgery for pyloric stenosis were younger (1.03 ± 0.25 months). The average operative time was 45.9 ± 18.39 min. The longest operative time was reported with surgery for liver cysts (94.5 ± 10.6 min). Oral intake was started after 48-56 h in patients who had excision of duplication cysts. The average post-operative hospital stay was 2.6 ± 1.52 days. No major complications were reported. Wound infection occurred in one patient with a duplication cyst. Three patients were converted to open repair (5.1%) and no late complications were reported during the mean follow-up time of 11.2 ± 5.1 months. CONCLUSIONS: The transumbilical approach is a safe alternative method to laparotomy in several abdominal pathologies in infants and neonates. It has a short operative time and hospital stay. The technique is associated with few complications and conversion rates.

A pediatric case of double gallbladder with gallstone.

Double gallbladder is a rare anomaly and an asymptomatic condition. However, it can sometimes present with abdominal pain. Gallbladder pathology requires precise diagnosis and a surgical procedure to relieve its symptoms. Here, we discuss a case of a child suffered from a congenital heart disease who presented with double gallbladder having gallstones. The case was resolved via surgical intervention without postoperative complications.

Comparison of the perspectives of the pediatric surgeons and pediatric urologists in management of cryptorchidism in Saudi Arabia.

OBJECTIVES: To evaluate the variability in perspectives between pediatric surgeons and pediatric urologists in managing cryptorchidism. METHODS: We conducted this survey among pediatric surgeons and pediatric urologists managing cryptorchidism in Saudi Arabia in October 2020. We distributed a questionnaire to 187 consultants using the Google forms platform. We collected data related to the consultant's experience, preoperative management, management of nonpalpable testes, management of palpable undescended testes, management of the cryptorchidism in special situations. RESULTS: The response rate was 77% for pediatric surgeons (n=77) and 46% for pediatric urologists (n=40). The number of cases managed by each specialty per year differed significantly (p=0.02); however, there was no significant difference in their experience (p=0.37). The preferred age for orchidopexy was 6-12 months for both specialties. Pediatric surgeons tend to prescribe preoperative ultrasound more frequently for nonpalpable testes (p=0.05). Laparoscopy was the preferred surgical approach by both specialties. Management of intra-abdominal testes not reaching the contralateral internal ring differed between groups (p<0.001), and it was related to the number of procedures performed annually (p=0.03). Both groups responded differently to the management of unsatisfactory testicular position after orchidopexy (p<0.001). Pediatric surgeons managed it with either observation or re-operative inguinal orchidopexy; however, most pediatric urologists preferred re-operative inguinal orchidopexy. This response was affected by the number of procedures performed annually (p=0.04). CONCLUSION: In Saudi Arabia, practicing pediatric surgeons and pediatric urologists have different perspectives in the management of cryptorchidism. The results of this survey demonstrated the need to establish national guidelines to manage patients with cryptorchidism.

The Outcome of Pediatric Esophageal Strictures Managed with Endoscopic Balloon Dilation in Saudi Arabia.

Background: Esophageal strictures can affect nutrition of infants and children impairing their weight gain. To our knowledge, this is the first article evaluating and comparing between the two methods of dilation in terms of outcome and one of few, if any, to assess both weight and height to evaluate the nutritional outcomes following dilation. To determine the safety, efficacy, and long-term effects of endoscopic dilation in managing pediatric esophageal strictures by assessing the clinical and nutritional outcomes. Methods: A retrospective study of 137 patients with esophageal strictures who underwent either endoscopic balloon dilatation or Savary dilatation, or both. Outcome parameters measured include the number of dilatations, nutritional status, and if symptoms had been relieved. Results: The most frequent cause of esophageal strictures was post-tracheoesophageal fistula repair (n = 51, 37.2%), and the majority were lower third strictures (n = 47, 34.3%). However, 8 cases (5.8%) had failed the dilation procedure. Savary dilatation had the highest number of complications. Overall, success rate was 79.6%. Higher success rate was for cases dilated by endoscopic balloon dilation (EBD) (n = 47, 90.4%). There was a statistically significant correlation between the success rate and the method of dilatation (P = .042). Statistically significant increment of weight was recorded for lower strictures (P = .001). Conclusion: EBD was associated with the highest success rate. Endoscopic dilatations are safe and efficient in managing pediatric esophageal strictures with improvement in both clinical and nutritional outcomes.

Laparoscopic-Assisted Transanal Pull-Through in Hirschsprung Disease: Does Laparoscopic Dissection Minimize Anal Overstretching?

Introduction: Surgical treatment for Hirschsprung disease (HD) has evolved from a staged repair to a primary operation but is still associated with significant complications. Extensive transanal dissection may overstretch the sphincter and cause partial tear; however, laparoscopic dissection can decrease rectal overstretching. Thus, this study aimed to evaluate the outcome of surgical management of HD and the efficacy of laparoscopic-assisted transanal endorectal pull-through in infants and children in our center. Patients and Methods: We reviewed the medical records of 74 patients who underwent surgical repair of HD from 2006 to 2019. However, we excluded 42 patients with HD (patients with stoma [n = 33] and total colonic aganglionosis [n = 9]). The remaining 32 patients were divided into two groups. Group A included patients who had transanal pull-through with laparoscopic assistance only to visualize the transition zone, take a biopsy, and check for twisting or bleeding. Group B included patients who had laparoscopic-assisted transanal pull-through with dissection of the rectum. All patients had Soave repair with an approximate cuff length of 5 cm. Results: Group A included 18 patients, whereas group B included 14 patients. Demographic data were comparable between the two groups with no significant difference in age or gender (P = .12 and .67, respectively). Patients in group A had longer operative time (210 ± 20.75 minutes versus 178 ± 18.92 minutes; P < .001) and hospital stay (6 ± 1.33 days versus 5 ± 1.24 days; P = .033). No significant difference was observed in postoperative complications between both groups (anastomotic site stricture, P = .295; persistent soiling, P = .238). Conclusion: Laparoscopic rectal dissection for managing HD is associated with less operative time and hospital stay. In addition, all procedures required for the repair can be safely performed using laparoscopy.

Congenital lobar emphysema: Thoracotomy versus minimally invasive surgery.

BACKGROUND: Congenital lobar emphysema (CLE) is a rare developmental malformation of the lung but can be associated with high morbidity and mortality. The objective of this study is to review our experience with 45 patients with CLE highlighting clinical features, aspects of diagnosis, and management. METHODS: The medical records of all patients diagnosed with CLE in our center were reviewed. Patients age at the time of diagnosis, sex, clinical presentation, associated anomalies, the lobes affected, treatment modality, and outcome were described. A comparison was made between those who had lobectomy via open thoracotomy and those treated thoracoscopically. RESULTS: From January 2000 to December 2018, a total of 45 infants with CLE were presented to our institution. There were 30 male and 15 female, and the mean age at presentation was 3.35 months. Twenty-five patients presented with respiratory distress. Nine patients presented immediately after birth, and two of them had surgery within the 1st week of life. Twenty patients were presented with repeated chest infections. Left upper lobe was affected in 27 patients, right middle lobe in 13, and right upper lobe in 5 patients. Forty-four patients had a lobectomy, and one was managed conservatively. One patient had a postoperative bronchopleural fistula. Nine patients had a thoracoscopic lobectomy, and two of them were converted to open thoracotomy because of persistent air leak. The operative time and hospital stay were nonsignificantly longer in thoracoscopic lobectomy (P = 0.5 and 0.4, respectively). There was no operative mortality in both groups. CONCLUSIONS: CLE is a rare malformation with variable presentation. Infants presenting with respiratory distress or recurrent chest infection should be evaluated for the possibility of CLE. Lobectomy is the treatment of choice, and rarely, the patients may be managed conservatively. Thoracoscopic lobectomy is a safe procedure with the possibility of air leak and conversion to open lobectomy.

Percutaneous endoscopic gastrostomy in children less than 10 kilograms: A comparative study.

BACKGROUND/AIM: Percutaneous endoscopic gastrostomy tube (PEG) has replaced the standard open surgical gastrostomy for enteral nutrition. However, several complications were reported, especially in children less than 10 kg. Our objective was to report the outcomes of percutaneous endoscopic gastrostomy in children according to their weight. PATIENTS AND METHODS: 163 children had PEG tube insertion in our tertiary referral hospital from January 2007 to March 2019. Patients were divided into two groups according to the weight; group I (less than 10 kg; n = 112) and group II (more than 10 kg; n = 51). Comparisons were made between the two groups for incidence of postoperative complications, the need for reintervention, 30-day, and 1-year mortality. RESULTS: There were 51 males (45.5%) in group I and 27 in group II (52.9%) (P = 0.38). The mean weight at the time of endoscopy was 5.9 ± 1.53 and 17.3 ± 8.23 kg and the mean American Society of Anesthesiologists (ASA) score was 2.6 ± 0.67 and 2.43 ± 0.57 in group I and II, respectively (P = 0.101). The most common associated condition was cerebral palsy (50 (44.6%) and 24 (47.1%) in group I and II, respectively; P = 0.77). The mean operative time was 30.28 ± 11.57 min in group I and 33.62 ± 23.36 min in group II (P = 0.221). Skin complications were the most commonly encountered complications of PEG, and 49% (n = 48) required the removal and replacement of the tube under general anesthesia in group I and 41% (n = 21) in group II (P = 0.84). There was no significant difference in the complication between groups. CONCLUSION: : PEG is a safe technique in children less than 10 kg, and the complications rate is comparable with older children. The use of positive transillumination and small needle for measuring the distance between the skin and the stomach enhances the safety of the procedure. PEG should be considered in children less than 10 kg who need supportive or continuous enteral nutrition for different reasons.