Background: Intestinal volvulus (IV) can occur at various sites of the gastrointestinal tract. In Europe, IV in children is most frequently due to malrotation but in Asia Ascaris infestation is a common cause. This report reviews the experience with IV in children in Tunisia; analyzes the aetiologies as well as the clinical presentations and the benefits of the Ladd's procedure in the treatment of the IV. Patients and Methods: The authors retrospectively reviewed the case records of all children with IV from January 2000 to December 2009 at the Tunis Children's Hospital. Results: There were 22 boys and nine girls with an age range of one day to four years. Twenty-five (80%) patients presented during the neonatal period. The most common presentation was bilious vomiting and dehydration. The aetiology was identified in all patients: Anomalies in rotation (n=22), omphalo-mesenteric duct (n=3), internal hernia (n=3), cystic lymphangioma (n=2), caocal volvulus (n=1). The bowel resection rate for gangrene was 16%. All patients with malrotation had Ladd's procedure performed. Five patients (19%) developed wound infections. One patient presented with adhesive small bowel obstruction. There were no recurrences following Ladd's procedure for malrotation. Two neonates (6%) died from overwhelming infections. Intestinal volvulus in our environment differs in aetiology from other reports. The resection rates are not similar, however. Conclusion: Early diagnosis reduced the high morbidity and mortality in our study.

Background : Anorectal malformations (ARM) are associated with congenital anomalies and other risk factors, yielding a poor prognosis, especially in neonatal life. Objectives: This study was performed to identify the congenital anomalies as a factor of poor prognosis (mortality) in such patients. Settings: Department of Pediatric surgery, The Children's Hospital and The Institute of Child Health, Lahore. Design: Prospective observational study, with statistical support. Materials and Methods: The information on the demography, clinical features, investigations, management performed, and outcome was entered in the designed proforma and analysed with the help of statistical software EpiInfo version 3.5.1. Statistical test: Chi-square test was used to determine statistical significance of the results. Results : Of 100 neonates with ARM, 77 were male and 23, female (3.4:1). The mean age at presentation was 3.4 days (range, 12 hrs to 28 days). In 60 patients (60%), the presentation was imperforate anus without a clinically identified fistula. In 28 patients (28%), associated anomalies were present. The common associated anomalies were urogenital (10%), cardiovascular (8%), and gastrointestinal (6%). Down's syndrome was present in 8 (8%) patients. A total of 15 (15%) deaths occurred in this study. In patients having associated congenital anomalies, 11 deaths occurred, whereas, 4 deaths were in patients without associated anomalies (P < 0.5). Conclusion : The mortality is higher in neonates with ARM having associated congenital anomalies.

Context : Elastic stable intramedullary nailing has revolutionised the treatment of fractures in children. Aim : To report our experience with this current technique of management of fractures in children. Methods and Materials : A retrospective study of all children with fractures treated by this method from November 2003 to June 2006 at the Paediatric Surgery Department of Yopougon Teaching Hospital, Abidjan, Côte d'Ivoire. Data were recorded from their medical charts regarding demographics, fracture patterns, associated injuries, morbidity, and outcome. Results : A total of 38 children (14 boys; mean age, 11.7 years; range, 9-15 years) with 41 fractures, sited at femur (n=15), humerus (n=8), tibia and fibula (n=6), forearm (n=7), and radial neck (n=5), associated with other injuries in 7 cases, were enrolled in the study. The mean interval for surgery was 6.8 days. Open reduction was required 5 times (12.1%). The hospital stay was in the range 5-12 days. Minor adverse events were 1 (2.4%) early tibial loss of reduction, 3 (7.3%) skin irritations and 2 (4.8%) transient knee limitations. Complications (17.3%) included 2 axial (4.8%) and 1 rotational (2.4%) femoral malunions below 15°; 3 elbow (7.3%) and 1 knee stiffness (2.4%) in openly reduced cases. Solid consolidation was achieved in all cases, with no disturbance in standard union times. At a mean follow-up period of 16 months (range, 9-28 months), all but 3 patients with opened joints recovered full range of motion, and none showed either limp and gait anomalies or re-fracture after removal of wires. Conclusion : Elastic stable intramedullary nailing in children fractures is easy to perform and has little complications if a proper technique is used.

Background : Abdominal wall defect presents a great challenge when it is large, ruptured, or associated with other anomalies. Objective : To review the challenges and outcome of management of anterior abdominal wall defects (AAWD). Materials and Methods : A retrospective review of omphalocele and gastroschisis managed over 8 years at our institution. Results : Omphalocele (n=49) and gastroschisis (n=7) constituted 2.4% of total admission. The median age was 23.5 hours, with male-female ratio of 1:1.1. Term infants were 91.7% and more than 75% weighed above 2.5 kg. The mean maternal age was 28.5±5.87 years and mean parity was 3.1±2.0, with P values of 0.318 and 0.768, respectively. More than 92.9% of infants were out-born, 46 pregnancies (82.1%) were booked, and 51 (91.1%) had at least one ultrasound scan, but only 1 (1.8%) was diagnosed with gastroschisis. Ruptured omphalocele were 11 (6 major, 5 minor) in number, 3 of which presented with enterocutaneous fistula, and 3 (6.1%) were syndromic omphalocele. Positive blood culture confirmed septicaemia in 21 cases (37.5%). Surgical repair was done in 35 cases (62.5%), 44.6% as emergency, and 17.9% as elective. Non-operative management was done in 21 patients (37.5%) and 5 (8.9%) were discharged against medical advice. Median length of hospital stay was 10 days (mean, 15.98±14.38). Postoperative complication rate was 32.1% and overall mortality was 30.4%, with the highest case fatality among gastroschisis (57.1%) and omphalocele major (32.1%). Conclusions: There were large numbers of out-born infants due to poor prenatal diagnosis in spite of high instances of antenatal ultrasound scan. Many patients presented with complications that resulted in poor outcome.

Background: Urethrocutaneous fistula is the most common complication of hypospadias surgery. The correction of such fistula is associated with a failure rate of 10 to 40%. The step in successful repair of a fistula is separation of the suture lines in the urethra and skin using well vascularized elastic tissue. We report our experience of using the tunica vaginalis flap as a layer between the neourethra and skin suture line in repair of recurrent urethrocutaneous fistula. Patients and Methods: We have used the tunica vaginalis flap for the repair of recurrent urethrocutaneous fistula in 14 children with a mean age of 6.5 years (range 3-14 years). All patients had undergone previous hypospadias repair and at least one previous attempt to close the fistula had failed. Surgery was initiated by injecting a povidone solution via urethral meatus to identify all fistulae. The fistulae were closed primarily and urethral suture line was covered with a flap of tunica vaginalis which was harvested either through a small scrotal incision and mobilized via a subcutaneous tunnel into the penile shaft (8/14) or by the same incision as for fistula closure (6/14). The testis was fixed to the scrotum. A urethral catheter was kept for urinary diversion for 10 days. Results: The repair was successful in all but one patient in whom there was leak from the fistula site. One patient in whom tunica vaginalis fascia was tunnelled into neourethra developed scrotal haematoma which needed drainage. Penile cosmesis was acceptable without any significant postoperative testicular complication in 13/14 patients. Conclusion: Repair of recurrent urethrocutaneous fistula with a tunica vaginalis flap is highly effective regardless of fistula location. This flap is easy to mobilize and provide effective coverage of urethral suture line. Putting a glove drain should be considered into scrotal wound if perfect haemostasis is doubtful.

Background: Although the association of urinary lithiasis and urinary tract malformation is not rare, their management poses challenges. The aim of this study was to evaluate the relationship between urolithiasis and malformations of the urinary system. There were 34 patients (19 males and 15 females) with a mean age of 4.8 years (range, 2 months to 14 years). All patients had urinary lithiasis with a urinary tract malformation. Abdominal pain was the most frequent clinical symptom (38%). Urinary infection was found in 7 patients (21%) and macroscopic haematuria was present in 10 patients (29%). The most frequent urinary tract malformations were megaureter (8 cases), uretero-pelvic junction obstruction (7 cases) and vesico-ureteric reflux (8 cases), but its malformative origin could not be confirmed. Treatment consisted of lithiasis extraction in 32 cases associated with specific treatment of the uropathy in 27 cases. Postoperative outcome was uneventful in all cases. In fact, urinary lithiasis and urinary tract malformation association is not rare. Indeed, 9-34% of urinary lithiasis are noted to be associated with urinary tract malformation. Positive diagnosis relies specifically on kidney ultrasound, intravenous urography, and urethrocystography. Treatment depends on the type of urinary tract malformation, localisation and size of the urinary lithiasis. Conclusion: In conclusion, urinary lithiasis and urinary tract malformation association is a frequent eventuality. Surgical intervention is the usual mode of treatment.

Objectives: To investigate the possible correlation between infantile hypertrophic pyloric stenosis (IHPS) and Helicobacter pylori infection. Materials and Methods: In a case-control study, 20 infants with confirmed IHPS (Group 1) and 30 age-matched healthy infants (Group 2) were enrolled for the assessment of H. pylori infection. Serological testing of anti-H. pylori antibody (IgG) was performed preoperatively on all infants and their mothers. Also, H. pylori stool antigen test (HpSA) was carried out preoperatively on all infants in both groups. Statistical analyses were performed with Chi-square test, Fisher's exact test, Mann-Whitney U test, and Independent-Samples T test. Results: There were 20 patients in group 1 (18 boys, 2 girls) and 30 infants in group 2 (30 boys). The mean age in groups 1 and 2 were 42.40±18.09 days and 44.67±12.65 days, respectively. The numbers of positive HpSA and positive anti-H. pylori antibody both in infants and mothers were comparable between the two groups (P>0.05). The median titres of H. pylori stool antigen were not comparable between the two groups (0.20 ng/dL in group 1 vs 0.57 ng/dL in group 2; P=0.02). Conclusions: H. pylori does not seem to be in a causative linkage with IHPS.

Background: Intussusception is a common abdominal emergency in children which necessitates prompt diagnosis and management. Nonsurgical methods of managing this condition are rapidly gaining popularity with fluoroscopic-guided pneumatic reduction being one of such methods that has been used with great success in many countries. We present our initial experience with fluoroscopic-guided pneumatic reduction of intussusception at Korle Bu Teaching Hospital which is also the first time the technique has been used in Ghana. Materials and Methods: A total of 18 children were enrolled in the study between August 2007 and February 2008 at Korle Bu Teaching Hospital, Accra, Ghana. Patients were given air enema under fluoroscopic-guidance using locally assembled equipment. The intraluminal pressure was monitored with a pressure gauge and was not permitted to go above 120 mmHg. A total of three attempts of 3 min each were allowed. Results: There were 12 males and 6 females. The average age of the patients was 8.3 months (SD= 3 months). Twelve (67%) of the cases were reduced successfully while 6 (33%) failed to reduce. A majority of those that did not reduced had symptoms for at least 2 days. Bowel perforation occurred in three (16.7%) cases. Conclusion: Pneumatic reduction of intussusception is a cost-effective and rapid method of management of intussusception. It however has limitations like high reported rate of bowel perforation and limited ability to identify lead points. The benefits however seem to outweigh these challenges, such as fluoroscopic-guided pneumatic reduction has a very high success rate. Fluoroscopic guided pneumatic reduction should be considered as one of the primary modes of reduction in Ghana and other neighbouring countries that are yet to practice it.

Background: Cataract has emerged as the most important cause of blindness in children worldwide, and has been one of the priorities of VISION 2020, the global initiative to eliminate avoidable blindness by 2020. More than 2500 children are estimated to be blind from cataract in Madagascar. The aim of this study was to investigate the burden and causes of pediatric cataract in a busy eye clinic in Madagascar and measure service delivery. Materials and Methods: This was a retrospective case series of all children aged 15 and below, receiving cataract surgery at the busiest eye clinic in Southern Madagascar. Data on all children operated on at the eye clinic between September 1999 and July 2009 were retrieved from theatre logs and patient charts. Results: One hundred and fourteen eyes of 86 children were operated on during the study period, with congenital cataract being the diagnosis in 53.5% of the children. For the catchment area of 5.8 million inhabitants 2.7% of incident cases of non-traumatic pediatric cataracts had surgery, with a mean CCSR per year for the entire catchment area of 1.1/million population. Conclusions: The Southern part of Madagascar is underserved for pediatric cataract surgical services, hence the need for a childhood blindness program.

Background: Tuberculosis (TB) is a major health problem in resource-constrained countries. Intestinal TB is especially notorious as a number of cases have to be dealt surgically, which too have morbidity and mortality. This study was conducted to identify various presentations of intestinal TB necessitating surgical intervention, their management, complications, and outcome in our hospital. Materials and Methods: This was a retrospective study carried out at the Department of Paediatric Surgery, The Children's Hospital and The Institute of Child Health Lahore, Pakistan, from December 2007 to January 2010. The information about the demography, clinical presentations, investigations, management performed, complications encountered, and outcome of patients with intestinal TB were reviewed. Results: There were a total of 18 patients with intestinal TB who were managed surgically during this period. Five were male and 13 female patients (M : F 1 : 2.6). Mean age of presentation was 8.3 years. Clinical presentations were acute peritonitis in 7 patients, pneumoperitoneum in 5 patients, complete intestinal obstruction in 4 patients, pain in right iliac fossa in 2 patients, and irreducible inguinal hernia in 1 patient. Four patients had concurrent pulmonary TB. Surgical interventions included primary repair of perforation in one, repair of perforation with diversion ileostomy in 8, and merely peritoneal drainage (haemodynamically unstable patients) in 3 patients. The post-operative complications were high output ileostomy in 3, faecal fistula in 1, wound dehiscence in 3, wound infection 5, and prolonged ileus in 1 patient. In three patients stoma was reversed during the same admission. There was one expiry in our study. Conclusion: Acute peritonitis, intestinal obstruction and intestinal perforation are the main clinical presentations requiring surgical interventions. Optimal surgical strategy should be adopted to avoid such pitfalls in the management.

Purpose: To report on a radiological issue and therapeutic aspects encountered in septic hip dislocations in a developing country. Patients and Methods: Nineteen children among whom 11 boys and 8 girls aged on average 5.3-years old presented 7 recent and 12 late hip dislocations. Those dislocations were distributed into in category 1: dislocations without associated lesion; category 2: dislocations associated with minor lesions; category 3: dislocations associated with major lesion. Ten children who presented an elevated erythrocyte sedimentation rate (ESR) received antibiotics. An arthrotomy was performed in children with a recent dislocation. Traction was performed in all children with an average duration of 5 weeks. The results were considered good, intermediate or bad using two parameters: ESR and reduction of dislocation. Results: 2 category 1 dislocations, 6 category 2 dislocations and 11 category 3 dislocations were noted. As concerns the recent dislocations, there were 2 category 1 dislocations and 5 category 2 dislocations. For late dislocations, 1 category 2 and 11 category 3 dislocations were recorded. There were 8 good results and 11 bad results. The good results concerned 7 recent dislocations and one late dislocation. The bad results concerned exclusively late dislocations. Conclusion: In children with septic hip dislocations, the good results concern almost exclusively recent dislocations but arthrotomy and immobilization must be done early.

Background: Management of female phenotype XY disorders poses a series of problems for the treating clinician. Even after a series of investigations and imaging modalities, there are lingering doubts about the exact nature of the disease and the correct management option. Optimal timing and necessity for removal of their testes have been a debated issue by physicians. There is a generally accepted opinion among physicians that the risk of malignancy in androgen insensitivity syndrome (AIS) is considerably lower than with other intersex disorders and occurs at a later age. Objective: The highlight of this presentation is to reinforce the value of laparoscopic gonadectomy in management of AIS in correlation with data suggesting higher risk of malignancy. Patients and Methods: A retrospective review of 11 phenotypic females with XY karyotype was carried out. The patients were evaluated by a diagnostic protocol which included clinical, hormonal, sonographic and cytogenetic examinations. Patients/parents were counselled by the team concerning the different treatment modalities and contrary to the assigned gender, laparoscopy was offered to them. Uneventful bilateral gonadectomy was performed in all the patients and gonads submitted for histopathological examination. Results: A total of 11 patients (mean age, 10.4 ΁ 4.1 years), including six with complete AIS and five with partial AIS (PAIS) were reviewed. In two patients with PAIS (18.1%), histopathology revealed malignancy (bilateral seminoma and gonadoblastoma) and in an additional patient, a benign hamartoma was found. Literature evidence suggests that AIS female phenotype patients retaining their testes through puberty have a 5% chance for developing malignant tumours. Reviewing our results in correlation with literature, we found that PAIS patients may harbour a higher risk of malignancy. Conclusions: In complementation to hormonal tests and cytogenetic techniques, laparoscopic gonadectomy is required to complete the diagnostic work up for AIS as it also adds a final therapeutic approach with low risk and huge benefit. Since laparoscopy is now a well-tolerated and widely accepted gold standard, it should be included in routine management for patients with AIS. Risk of malignancy in PAIS should be investigated in larger cohort of these patients.

Background: Hydrocephalus is a frequent central nervous system disorder in children, and despite its importance, it has not been sufficiently studied in developing countries. Patients and Methods: A prospective and descriptive study on 35 cases of infantile hydrocephalus was carried out in the neurosurgery unit of the Yaounde Central Hospital, from March 2008 to January 2010. Results: The mean age of the patients was 6.69΁1.58 months, and the majority of them were in the 0-6 months age group (71.43%). The most frequent causes were congenital malformations, with stenosis of the aqueduct of Sylvius being the most represented (31.43%). As radiological workup, a CT scan was done in more than half of the cases (57.15%), and ventriculo-peritoneal shunting was the main surgical method of management used (94.29%). Infectious complications were observed in 22.86% of our cases. Conclusion: Hydrocephalus is a frequent disorder in this Cameroonian setting affecting mostly the 0-6months age group. For early diagnosis to be made, the head circumference of neonates should be routinely measured in the labour room and followed-up in all medical visits. To avert complications following surgery, rigorous surgical procedures with effective asepsis and appropriate methods and materials for shunting should be used.

Background: Undescended testes are a common problem, affecting up to 3% of newborn males. The goals of orchiopexy in humans are to provide adequate scrotal fixation, to prevent recurrent torsion of the testis and spermatic cord or ascent of the testis, and to achieve these goals with minimal trauma to the testis. The best method of achieving fixation remains controversial. Purpose: The aim of our study is to evaluate our modified extra Dartos pouch technique in retaining testis in the scrotum. Patients and Methods: A prospective randomized study included 159 patients with 185 orchiopexies age ranging from 5 months to 14 years with the mean age of 49.5 ΁ 33.3 months (4.08 years). They were divided into two groups: Group I for whom the extra Dartos pouch technique was applied were compared to Group II for whom classic sub-Dartos pouch technique was done. Results: Testis was located in the superficial inguinal pouch in 102 cases (64.1%) and intra-canalicular in 57 cases (35.6%). Hernial sac was found in 153 cases (96.2%), postoperative wound infection occurred in 3 cases (1.9%) and hematoma formation in three cases (1.9%); one case reported ascent of the testis and another one had testicular atrophy in the follow-up period which extends now up to 3 years and we are still in follow-up with those cases. Conclusion: Our modified technique for extra Dartos pouch fixation seems to be a fast reliable method for orchiopexy; however, comparative studies and long-term assessment is still needed to establish this method.

Background: Ischemic conditions in the intestine result in deterioration of anastomosis healing process. In this study, our aim was to evaluate the possible effects of intraperitoneal nitroglycerin on the intestinal anastomosis healing and anastomosis burst pressures in rats with ischemia and reperfusion injury (I/R). Materials and Methods: Fifty four Wistar albino rats were divided into six groups. In the first two groups, the rats underwent I/R. In the Group 1, the rats had normal saline (S) and in Group 2, the rats had nitroglycerin (N) injection. In the 3 ^rd and 4 ^th groups, an intestinal anastomosis was made at the 10 cm proximally to the ileocecal valve. In Group 3, S and in Group 4, N were injected. In Group 5, the rats received I/R, intestinal anastomosis and intraperitoneal S injection. I/R, intestinal anastomosis and intraperitoneal N injection were made in Group 6 rats. All nitroglycerin (50 ΅g/kg) injections were made at postoperative days of 0, 1, 2, 3, 4, 5 consecutively. On the sixth day, all rats were killed. In all rats with anastomosis, anastomotic burst pressure (ABP) was measured. Histopathological specimens were collected from all rats and evaluated under light microscopy. Results: Serious tissue damage was only detected in the Group 1 histopathologically (8 rats had grade 4 damage). In Group 2, there was a decrease in tissue damage according to histopathologic examination (5 rats had grade 1 damage). The effect onto the healing was similar in S and N groups. Nitroglycerin was noted to have a positive effect on collagen production. Nitroglycerin increased the ABP levels in rats both with and without I/R (the means are 17.93, 21.10, 14.67, and 17.63 in Groups 3, 4, 5, and 6, respectively). Conclusion: I/R may weaken the strength of intestinal anastomosis. Intraperitoneal application of nitroglycerin may prevent the histopathologic changes within a limited degree. Intraperitoneal nitroglycerin has also positive effects on the healing of intestinal anastomosis of rats with and without I/R. It may increase the fibroblast proliferation and the strength of the anastomosis.

Acute abdomen in a diabetic child may cause diagnostic dilemma. Acalculous emphysematous cholecystitis (EC), although reported among critically ill or diabetic adults, is an uncommon occurrence in the children. It may complicate the presentation due to its varied manifestations; especially when associated with other concomitant intra-abdominal inflammatory pathologies. We encountered a rare concurrence of acute EC complicated with pericholecystic fluid collection and secondary appendicitis causing non-specific acute abdomen in an 11-year-old obese boy with insulin-dependent diabetes mellitus. Laparoscopy proved to be a highly useful tool in the diagnosis and treatment of this surgical dilemma.

Isolated female epispadias without bladder exstrophy is an extremely rare congenital anomaly. The symptoms of female epispadias are primary urinary incontinence and abnormal anatomical features. A 7-year-old girl presented with partial incontinence of urine. On physical examination, bifid clitoris and labia minora were seen. The vagina and hymen were normal. Voiding cystourethrogram showed no reflux. With the diagnosis of isolated female epispadias, single stage reconstruction of the urethra, labia minora and clitoris was performed.

Extensive ureteral loss in early childhood is a rare but dramatic event. We present the case of a 6-month-old girl with a iatrogenic extensive pyelo-ureteral loss and solitary kidney. She successfully underwent left ureteral substitution using the appendix vermiformis. Left ureteral reconstruction using the appendix vermiformis is a feasible procedure even in very small children.

A 3-year-old boy with a right-sided and painful inguinal swelling for the last 2 h was admitted to the emergency department. As there were no apparent peritoneal irritation findings, right-sided incarcerated inguinal hernia was reduced and the patient was scheduled for an elective herniorrhaphy. Perioperatively even though the sac seemed empty, it was opened in order to inspect its content. The adherence of Meckel's diverticulum (MD) to the base of hernial sac was realized and Littre hernia (LH) was diagnosed. The hernia was highly ligated after the wedge resection of the diverticulum and anastomosis. The patient was fed on the second postoperative day and discharged on the third postoperative day. Despite numerous presentations of LH in the adult age group in the literature, there are limited data about the disease in the childhood period. Even though the scarcity of the data, there are some so-called rules for LH in childhood like protruding more common through umbilical hernias, containing heterotopic tissues more frequent than adult age and incarcerating/strangulating more often. The aim of this study is to review the reported LH cases, present a new case and discuss the features of LH in childhood period.

Laparoscopic pyeloplasty is an accepted way of dealing with pelviureteric junction obstruction in children with extrarenal pelvis. However, intrarenal pelvis has been considered a relative contraindication for laparoscopic pyeloplasty. Here, we describe the technique of laparoscopic dismembered pyeloplasty in a child with intrarenal pelvis. The key when one embraces laparoscopic dismembered pyeloplasty is to ensure that outcomes are not compromised. A successful outcome requires a widely patent, well-vascularised anastomosis performed free of tension.

Excessive enlargement of the tongue, macroglossia, is a well-recognised clinical condition which can pose significant social and health problems. We report a case of a neonate who was born with a tongue grossly enlarged to the point of inability to feed and deformation of the jaw. Despite surgical reduction of the tongue to normal size, there was a persistent nonocclusion of the mouth, making sucking impossible. Physiotherapy did not help and our experience with neonatal jaw osteotomy is limited. We wonder if a prenatal aspiration of the tongue cyst could have forestalled this jaw deformation.

Congenital pyloric atresia (CPA) is a very rare malformation with unknown aetiology. It has has numerous complications including gastric perforation, aspiration pneumonia. Gastric perforations in newborns occur by three mechanisms: trauma, ischaemia, or spontaneous. Here, we report a newborn with CPA presenting with gastric serosal tearing without full-cut gastric perforation. The diagnosis was confirmed with the help of plain abdominal radiograph, ultrasound, contrast-study, and at operation. Treatment of CPA is surgery irrespective of the type of atresia. We performed serosa repair and then the solid, cord-like atretic pylorus was excised with accompanying gastroduodenostomy. Our patient had an uneventful course and was discharged at the end of the second postoperative week.

Apple-peel atresia or Type 3 jejuno-ileal atresia (JIA) is an uncommon cause of foetal intestinal obstruction. Bowel obstruction in the foetus is diagnosed on the prenatal ultrasonography only in 50% cases. We report a case in which foetal intestinal obstruction was diagnosed on prenatal ultrasonography. The child showed signs of intestinal obstruction on day one after birth, for which an exploratory laparotomy was performed. Type 3 JIA was found for which resection of atretic segments with jejuno-ascending colon anastomosis was preformed.

Mixed choristomas of the oral cavity are uncommon lesions that show a variety of clinical presentations, histological appearance and growth patterns. Mixed choristoma with cleft palate is a very rare developmental malformation. We report an unusual case of mixed choristoma in posterior tongue and left submandibular region in a 6-month-old male baby who had cleft palate. The patient presented with spontaneous bleeding from mouth and recurrent swelling in submandibular region. The histology of the surgical resected specimens displayed features of heterotopic oral gastrointestinal cyst and glial choristoma. The swelling recurred 1 year after surgery; the histology of the second surgical resected specimen displayed scattered islands glial tissue.

Germ cell tumours (GCTs) commonly involve the ovaries, testes, and other midline structures in children and adolescents and comprised a variety of tumours that have a common histiogenetic origin. The yolk sac tumour (YST) variant is the most common one seen in over 80% of testicular GCTs in children. Other sites of occurrence of these tumours include the mediastinum, prostate, retroperitoneum, and sacrococcygeal region. Penile malignancies account for less than 10% of male malignancies in the elderly, while its occurrence in children is rare. We present the case of a 5-year-old child with YST of the penile shaft and uninvolved testes.

This report describes the clinical course and management of two children with multiple anastomotic complications following primary repair of oesophageal atresia (EA) with distal tracheoesophageal fistula (TEF). These included anastomotic leak and stricture, oesophageal perforation during antegrade dilatation, and finally a recurrent fistula between the oesophagus and the tracheo-bronchial tree. Ultimately, after multiple operative interventions, a successful outcome was achieved in both patients with preservation of the native oesophagus. The anastomotic complications following primary repair of EA with TEF are discussed, with special reference to difficulties in the management of recurrent TEF.

The usual accepted mode of treatment of neonates with necrotizing enterocolitis (NEC) and pneumoperitoneum is surgical. However, in a select group of patients conservative treatment is feasible. Pneumoperitoneum without peritonitis is a rare phenomenon which creates a management problem for the treating surgeon. We present two cases of pneumoperitoneum to discuss the non-surgical management of pneumoperitoneum and describe their outcomes.

Aims: The laparoscopic "Spaghetti Maneuver" consists in holding an organ by its extremity with a grasper and rolling it up around the tool to keep the organ stable and facilitate its traction within a small space. We describe our experience with the "Spaghetti Maneuver" in some minimally invasive procedures. Materials and Methods: We successfully adopted this technique in 13 patients (5F : 8M) aged between 6 and 14 years (average age, 10) on whom we performed 7 appendectomies, 2 ureteral reimplantation and 4 cholecystectomies. In all cases, after the first steps, the appendix, the gallbladder and the ureter were rolled around the grasper and easily isolated; hemostasis was thus induced and the organ was mobilized until removal during cholecystectomy and appendectomy, and before the reimplantation in case of ureteral reimplantation. Results: We found that this technique facilitated significantly the acts of holding, isolating and removing, when necessary, the structures involved, which remained constantly within the visual field of the operator. This allowed a very ergonomic work setting, overcoming the problem of the "blind" zone, which represents a dangerous and invisible area out of the operator's control during laparoscopy. Moreover the isolation maneuvers resulted easier and reduced operating time. Conclusion: We think that this technique is easy to perform and very useful, because it facilitates the dissection of these organs, by harmonizing and stabilizing the force of traction exercised.