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   Table of Contents - Current issue
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October-December 2021
Volume 18 | Issue 4
Page Nos. 179-234

Online since Friday, July 30, 2021

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ORIGINAL ARTICLES  

A wave-like anastomosis, a new technique of anastomosis to prevent stricture after oesophageal atresia repair p. 179
Mohamed Oulad Saiad
DOI:10.4103/ajps.AJPS_123_20  PMID:34341298
Background: Anastomotic stricture still a frequent postoperative complication. Its development is multifactorial, nonetheless by improving some factors we can prevent the stricture. Anastomotic technique is among the factors that can be improved to prevent this complication. Aims and Objectives: Our aim is to report a new technique of anastomosis with a multiple plain suture, wave-like anastomosis and large low traction zone to prevent stricture after esophageal atresia repair. Furthermore this is a self-patient's anatomy dependant technique. Materials and Methods: A retrospective study reported forty nine esophageal atresia survivals without significant difference in weight and gap length. They were divided in two groups A and B with respectively eighteen and thirty one patients. The wave-like anastomosis technique is used in group A but in the group B an end to end anastomosis was used. Results: After a mean follow-up of 3 years no patient of the group A presented with anastomotic stricture and eight patients in the group B presented with stricture (p=0,046) so there was a significant difference between the two groups. Conclusion: This is a technique providing a multiple plain anastomosis, increasing the lumen in the anastomotic site and helping to prevent anastomotic stricture.
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Laparoscopic versus open appendectomy: A retrospective cohort study on the management of acute appendicitis (simple and complicated) in children under 13 years of age p. 182
Esi Botchway, Leszek Marcisz, Hermanus Schoeman, Prince Prah Kofi Botchway, Ernest Matlou Mabitsela, Nyalweni Tshifularo
DOI:10.4103/ajps.AJPS_102_20  PMID:34341299
Introduction: Acute appendicitis is the most common surgical emergency with a lifetime incidence of 7%–8%. There are two operative modalities that are currently used for the management of this condition in the paediatric population. The objective of this cohort study was to review the outcome of the management of paediatric surgical patients presenting with acute appendicitis after either an open appendectomy (OA) or laparoscopic appendectomy (LA) was performed. Methods: This was a 2-year retrospective study conducted from 01 January 2016 until 31 December 2017 on paediatric surgical patients < 13 years of age undergoing appendectomies. Eighty-one (n = 81) files of patients were reviewed, and data analysis was performed on two comparative groups namely the OA group and LA group, with the aid of the SAS system with statistical significance based on P < 0.05. Results: During the study period, 81 children (male: female ratio of 2:1) underwent appendectomies. Nearly 38% (n = 31) of the cases had an OA, with 62% (n = 50) of the cases having an LA. Seven (14%) LA cases were converted to OA. Simple appendicitis accounted for 16% (n = 13) of the patients, with complicated appendicitis accounting for 79% (n = 64) and other pathologies accounting for 5% (n = 4). There were no post-operative complications in the cases of simple appendicitis. Six cases (15.38%) in the LA group versus two cases (5.26%) in the OA group developed intra-abdominal collections, which was statistically significant (P = 0.018). One (2.56%) patient in the LA group versus two patients (7.89%) in the OA group developed intestinal ileus (P = 0.09). Two patients (5.13%) in the LA group versus six patients (15.79%) in the OA group developed surgical-site infection, which was statistically significant (P = 0.013). The mean days of hospital stay was 4.51 days in the LA group versus 5.34 days in the OA group, which was statistically significant (P = 0.016). There were no re-admissions or re-operations in the simple appendicitis group. In the complicated appendicitis cases, five cases (12.82%) were re-admitted in the LA group compared to five cases (13.16%) in the OA group (P = 0.943). Two (5.13%) cases had a re-operation in the LA group compared to one case (2.63%) in the OA group (P = 0.360). Conclusion: Considering that there was an increased incidence of complicated cases and operations being performed by trainees, LA appears feasible at a tertiary-level hospital in a developing country, as shown in this study. Therefore, cases of simple appendicitis can be performed laparoscopically; however with regard to complicated appendicitis, there is no superiority between the two operative modalities in this study, which is consistent with international literature. However, in this study, it can be postulated that the learning curve was a major contributory factor to the increased levels of complications, as all operations were performed by trainees. Therefore, we recommend implementation of adequate simulation practices in laparoscopy in the setting of a developing country to attain the laparoscopic expertise of our international counterparts in order to improve the standard of care.
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Bipolar circumcision: A new technique for an old procedure with quantified cosmetic outcome Highly accessed article p. 187
Naser El-Mefleh, Mahmoud Kaddah, Muhammad Eyad Ba'Ath
DOI:10.4103/ajps.AJPS_108_20  PMID:34341300
Background: Circumcision using bipolar diathermy is well established and used widely. It seems to be superior in terms of post operative complications. The cosmetic outcome of the procedure has never been quantitatively described though. Aims: To describe a modification to performing circumcision with bipolar that involves applying four clamps to the foreskin as it is being amputated with the bipolar so that a consistent length of the mucosal cuff can be obtained with a single almost bloodless cut. Methods: Prospective case series of all patients circumcised using the 4 clamps traction and bipolar cut technique. The cosmetic outcome was assessed in terms of the length of the mucosal cuff in absolute numbers and in proportion to the penile and glanular length. Results: Seventy four patients were recruited with a median age of 3.5 months. No complications were encountered. The average length of the penis was 40 ± 13 mm and the glans 12 ± 3.6 mm. The average length of the mucosal cuff was 8.4 ± 2.9 mm, and the proportion to total penile length was 21.1% ± 4.7% and to glans length 72% ± 24.1%. Conclusion: The four clamp traction method with bipolar circumcision is safe and has a satisfactory cosmetic outcome.
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Predictive factors of post-laparoscopic appendectomy peritoneal collection in children and adolescents with complicated appendicitis p. 190
Mohammad Gharieb Khirallah, Nagi Ebrahim Elsossuky, Mohamed Ghazaly
DOI:10.4103/ajps.AJPS_166_20  PMID:34341301
Introduction: Intra-peritoneal collection (IPC) following laparoscopic appendectomy (LA) of complicated appendicitis in children is a serious complication. This is associated with a longer duration of hospital stay, more costs, and psychological upsets of both children and their parents. The aim of this study is to evaluate different factors that may affect the development of IPC following LA of complicated appendicitis. Patients and Methods: Seventy-five children were admitted with acute complicated appendicitis. All of them had LA between January 2016 and October 2020. The following variables were studied: patients' demographics, clinical findings, laboratory and imaging studies and operative parameters. Patients were divided according to their post-operative course into two groups; Group (A): patients with IPC (n = 19), Group (B): patients without IPC (n = 56). Potential risk factors for the development of post-operative IPC were identified by univariate and multivariate logistic regression analysis. Results: Nineteen cases (25.3%), out of 75 patients, presented with post-operative collection. Forty-seven (62.7%) patients were males, the overall median age was 11 (inter-quartile range [IQR] 10–13). The most significant operative variable was the operative time, which was significantly longer in Group A, 78 min (IQR 75–88) versus 56 (50–66), P = 0.001. The following variables were associated with an elevated incidence of post-operative IPC; age, body mass index, total leucocytic count (TLC), duration of symptoms, pediatric appendicitis score, pre-operative morbidity, being on medications, operative time, suction and irrigation or suction only and drain duration. In the multivariate model, TLC (odds ratios [OR]: 1.358, P 0.006), symptoms duration (OR: 2.051, P 0.012), morbidity (OR: 2.064, P 0.041) and operative time (OR: 2.631, P 0.039) were statistically significant and confirmed as being predictors of IPC post-LA in complicated appendicitis. Conclusion: Post-operative IPC is quite common after LA for complicated appendicitis. Increased TLC, prolonged symptoms duration, associated co-morbidity and operative time could be predictors of its occurrence. Improving general condition, surgical technique and reducing operative time help to reduce its incidence.
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Bringing specialist paediatric surgical care to the doorstep in rural Ghana: A mobile paediatric surgery clinic p. 195
Britta Budde-Schwartzman, Ori Shwarzman, Kokila Lakhoo, Frank Owusu
DOI:10.4103/ajps.AJPS_121_20  PMID:34341302
Background: The contribution of paediatric surgical conditions to the total burden of disease in low- and middle-income countries (LMICs) has recently been highlighted and it is widely agreed that solutions are needed to provide access to safe and affordable surgery for these children. Materials and Methods: We present a simple, cost-effective model that brings paediatric surgery to the doorstep of remote areas and uses the existing health system structure in its entity to fulfil patients' needs. Mobile clinic teams whose members are integrated staff in affiliated mission hospitals reach out daily on a rotational basis to 10 health posts. The team receives continuous paediatric surgery education from a paediatric surgeon to diagnose and treat simple cases. Results: The catchment area of the Gye Nyame Mobile Clinic includes 832,984 inhabitants. From 2008 to 2019, 4362 children visited the mobile clinic with a median age of 4.41 years. Totally 4142 (95.0%) children could be treated in the health post, 150 (3.4%) children were taken to the affiliated missionary hospitals, 55 (1.3%) needed a third-level facility and 15 (0.3%) were taken to the traditional healers by the family. The common paediatric surgical diagnosis on outreach was deep soft-tissue infection/skin lesion for surgical treatment (672/23.8% children), followed by abdominal wall hernia/abdominal wall malformation (586/20.8% children) and gastrointestinal conditions (521/18.5%). Conclusion: This model of paediatric surgery mobile clinic includes capacity-building, task-sharing, outreach and proven 12-year sustainability. We recommend this model for paediatric surgery care in remote areas of LMIC's.
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Byar's flaps in the management of congenital megaprepuce p. 201
Omar Alsamahy, Dalia Gad, Doaa Othman, Mir Fahiem-ul-Hassan
DOI:10.4103/ajps.AJPS_144_20  PMID:34341303
Introduction: Early management of congenital megaprepuce (CMP) is necessary to address recurrent urinary tract infections and parental concerns. Different procedures, mostly using the inner preputial skin to cover the phallus, have been described. However, cosmetic appearance with the inner preputial covering of the penis is suboptimal. Owing to this, we conducted this study using outer preputial skin in the form of Byar's flaps to cover the penile shaft and analysed the results. Patients and Methods: This prospective study included 19 patients with CMP operated by a single surgeon using the Byar's flap technique. Following surgery patients were assessed on the 4th post-operative day, at 3 months and 1-year post-operative for cosmetic and functional outcomes. Parental satisfaction about cosmetic results was evaluated using a subjective score. Data were collected and analysed. Results: Nineteen patients with CMP were studied with a mean age of 6.3 months. Nineteen patients (100%) patients presented with buried penis and preputial ballooning, malodorous infected urine in 15 (78.9%) patients, thin stream of urine in 17 (89.4%) and dysuria in 12 (63%) patients. One of the patients had associated glanular hypospadias and the other two had isolated chordee. There were no significant complications except for one patient who developed meatal stenosis which was later managed by a meatoplasty. All patients had satisfactory cosmetic appearance. Conclusion: CMP is an uncommon but easily identifiable condition. Early surgical correction is recommended to prevent complications. Byar's flap technique yields very good functional and cosmetic results in the management of CMP.
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Paediatric neck masses in Zaria: A review of clinical profile and treatment outcome p. 205
Iliyasu Yunusa Shuaibu, Tunde Talib Sholadoye, Abdulrazak Ajiya, Mohammed Aminu Usman, Halima Oziohu Aliyu
DOI:10.4103/ajps.AJPS_134_20  PMID:34341304
Background: A neck mass is any abnormal lesion in the neck that can be seen, palpated, or identified on imaging. It is one of the most common reasons for presentation to the surgical clinics. Aim: the aim is to analyse the clinical presentation and treatment outcome in children who were diagnosed and managed for neck masses in a tertiary centre in Northwestern Nigeria. Materials and Methods: The records of patients managed for neck masses over 7 years between January 2013 and December 2019 were reviewed. Demographic and clinical data were retrieved and analysed using Statistical Product and Service Solution version 23.0 software (SPSS Inc., Chicago, Illinois, USA). Results: A total of 99 cases were reviewed and there were 52 (52.5%) males and 47 (47.5%) females with male-to-female ratio of 1.1:1, and mean age ± standard deviation of 4.4 ± 3.9 years, the primary complaints of all the patients were neck swellings. The anterior triangle was the most common region involved in 86 (86.9%) patients. The majority of the neck masses were congenital, accounting for 71 (71.8%) patients. Ultrasound scanning was the most commonly requested radiological investigation done in 87 (87.8%) patients. Thyroglossal duct cyst was the most common paediatric neck mass seen in 41 (41.4%) patients. The majority of the patients 68 (68.7%) had an excisional biopsy of the lesion. Surgical site infection was the most common complication noted in 7.1% of the study population. Conclusion: Most of the neck masses were congenital and were managed surgically. Prompt diagnosis with appropriate treatment may result in a good outcome.
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Laparoscopic-assisted transanal pull-through for hirschsprung's children older than 3 years: A case series p. 210
Ahmed Arafa, Wesam Mohamed, Heba Taher, Moutaz Ragab, Mohamed Hamed Abouelfadl
DOI:10.4103/ajps.AJPS_161_20  PMID:34341305
Context: Hirschsprung's disease (HD) is a congenital anomaly affecting the enteric nervous system commonly the rectosigmoid region. Treatment is surgical where the aganglionic segment is resected, and bowel continuity is restored by a coloanal anastomosis. In 1999, Georgeson et al. proposed a new technique of primary laparoscopic-assisted pull-through for HD as a new gold standard. Aim: The aim of the study was to evaluate the outcome of the laparoscopic-aided transanal pull-through procedure for the management of HD in children older than 3 years of age. Methods: This study was conducted on 15 consecutive patients presented to a university hospital, diagnosed as having HD relying on their clinical features, barium enema study and rectal biopsy. In all cases, laparoscopic-assisted transanal pull-through was attempted. The laparoscopic part included transition zone identification, seromuscular biopsy for fresh frozen histopathology and sigmoid and rectal mobilisation as much as possible down the peritoneal reflection. The transanal part included mobilisation of the rectal lower segment by 2–3 cm, resection till the ganglionic segment, and full-thickness two-layer coloanal anastomosis was done. Results: Early complications occurred in eight cases: enterocolitis in four cases and perianal excoriation occurred in four cases. There were no cases of anastomotic leak. Late complications occurred in seven patients: four cases developed stricture at the site of coloanal anastomosis and three cases experienced enterocolitis at 6 and 9 months postoperatively. Conclusion: Laparoscopic-aided transanal pull-through procedure is a safe, feasible modality for the management of HD in children more than 3 years.
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Efficacy of fibrin sealant as waterproof cover in improving outcome in hypospadias surgery p. 215
Neha Sisodiya Shenoy, Charu Tiwari, Suraj Gandhi, Vikrant Kumbhar, Vini Joseph, Syamantak Basu, Apoorva Makan, Hemanshi Shah
DOI:10.4103/ajps.AJPS_132_20  PMID:34341306
Background: This prospective comparative study aims to assess the efficacy of fibrin sealant to improve outcomes in paediatric patients operated for hypospadias. Materials and Methods: Forty consecutive patients with hypospadias were randomised into two groups of twenty patients each. The first group underwent hypospadias repair, technique depending on the type of hypospadias, whereas in the second group, fibrin sealant was used to reinforce the urethroplasty. Assessment was done with respect to the type of hypospadias, type of repair done, operative time, immediate post-operative complications (early ooze and skin flap-related complications), intermediate complications (urethra-cutaneous fistula) and delayed post-operative complications (penile torsion and poor cosmetic outcome) at follow-up. We also compared the overall improvement in outcome among the two groups. Results: First Group: The mean operative time was 1 h and 45 min. Complications were seen in nine patients: Early ooze (n = 2); skin flap-related complications (n = 3); fistula (n = 7); poor cosmetic outcome (n = 7) and penile torsion (n = 4). Second Group (Fibrin Sealant): The mean operative time was 1 h and 30 min. Post-operative complications were observed in five patients: Coronal fistula (n = 3) and poor cosmetic outcome (n = 3). On comparing, the differences in outcomes of ooze, skin flap-related complications and torsion were found to be statistically significant with P < 0.05. The differences in the urethra-cutaneous fistula and cosmetic appearance were not found to be statistically significant. The difference in overall improvement in complications was found to be statistically significant. Conclusion: Fibrin sealant, when applied over the urethroplasty suture line as a waterproof cover, may help to improve the outcome in patients with hypospadias.
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Congenital heart defects in orofacial cleft: A prospective cohort study p. 219
Olufemi A Erinoso, Olutayo James, Ogochukwu J Sokunbi, Olawale O Adamson, Adeola A Adekunle, Olusola F Agbogidi, Ajoke O Ogunlewe, Ekanem N Ekure, Wasiu L Adeyemo, Akinola L Ladeinde, Olugbemiga M Ogunlewe
DOI:10.4103/ajps.AJPS_159_20  PMID:34341307
Background: Congenital heart defects (CHDs) are one of the most common associated anomalies in patients with an orofacial cleft (OFC). However, few studies have shown the association between cleft type and CHDs in our population. This study aimed to assess the prevalence of CHDs in a cohort of OFC patients at a tertiary health facility in Nigeria, as well as assess the risk of CHD by OFC type. Materials and Methods: This was a prospective study design. Patients with an OFC were consecutively enrolled at a single OFC treatment facility. All subjects were assessed by a paediatric cardiologist and had echocardiography done. They were categorised based on the presence of CHDs, as well as the OFC phenotypic type (cleft lip and/or alveolus, cleft lip and palate and cleft palate only). Statistical analysis was done using STATA version 14 (College Station, Texas), and significance was set at P < 0.05. Results: A total of 150 subjects enrolled in the study over a period of 2 years (2018–2020). The median age of subjects was 6 months (interquartile range: 2–24), and 54.7% were female. The prevalence of CHDs in the subjects reviewed was 30.7%. Based on the severity of CHDs, the majority presented with simple defects (95.6%). Overall, the most common presentation was patent foramen ovale (12.7%), followed by septal defects (8.0%). There was no significant association between cleft type and the odds of a CHD. Conclusion: The study reports a relatively high prevalence of CHDs in patients with OFC; however, there was no association between the risk of CHD by cleft type. Although a majority of CHDs may pose a low operative risk, cardiac evaluation is recommended for all cases of OFC to aid the identification of potentially high-risk cases.
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Infantile systemic hyalinosis: Variable grades of severity p. 224
Ali Al Kaissi, Marwa Hilmi, Zulfiya Betadolova, Sami Bouchoucha, Svetlana Trofimova, Mohammad Shboul, Guseyn Rustamov, Wiam Dwera, Katharina Sigl, Vladimir Kenis, Susanne Gerit Kircher
DOI:10.4103/ajps.AJPS_162_20  PMID:34341308
Background: Infantile systemic hyalinosis (ISH) is an autosomal recessively inherited disorder. The classical natural history of the disease is characterised by hypotonia, multiple contractures, skin lesions, osteopenia, joint pain, bone fractures, persistent diarrhoea and growth deficiency. Materials and Methods: Two children manifested the severe type of ISH underwent genotypic confirmation. In order to identify which other family members have inherited the disease. We included siblings and cousins in this study. The baseline tool to study other family subjects was based on the phenotypic characterisations of each child. Results:. Two children with the severe type of ISH showed craniosynostosis (brachycephaly and scaphocephaly) associated with multiple contractures, progressive joint osteolysis ending up with multiple joint dislocations. The full exome sequencing was carried out, revealing a previously reported heterozygous nonsense mutation с.1294С>Т and a novel heterozygous non-synonymous substitution c. 58T>A in ANTRX2 gene. Three children (sibling and cousins) manifested variable clinical manifestations relevant to ISH. Specifically, asymptoamtic skin and skeletal abnormalities of hypoplastic clavicles and 'shepherd's crook' deformity and coxa vara. Conclusion: It is mandatory to perform extensive family pedigree search to detect asymptomatic clinical features in siblings and cousins in families with first degree related marriages. Interestingly, in the mild and the moderate types of ISH, we observed undescribed combination of asymptomatic skin and skeletal abnormalities. This is a comparative study between the severe and the mild/moderate types in a group of children from consanguineous families. Our current study extends the phenotypic characterisations of ISH.
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CASE REPORT Top

Hypothyroidism following sistrunk procedure: Thyroglossal duct cyst or ectopic thyroid? p. 231
Hassan Abdullahi Elechi
DOI:10.4103/ajps.AJPS_147_20  PMID:34341309
Thyroglossal duct cyst is the most common cause of anterior midline neck swelling in children, but ectopic thyroid is an important but rare differential diagnosis. Establishing the orthotopic thyroid gland status is crucial as inadvertent removal of a lone functioning ectopic thyroid tissue in young children could lead to fluttering of growth and development if not identified early. We report the case of a 2 years 10-month-old boy who had Sistrunk's procedure for 'thyroglossal duct cyst': Diagnosed using USS, defaulted follow-up and presented subsequently with growth retardation from hypothyroidism.
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