Background: The aim was to compare gastroschisis (GS) epidemiology, management and outcome in low-income countries (LIC) in Sub-Saharan Africa (SSA) with middle- (MIC) and high-income countries (HIC). Materials and Methods: A 10-question survey was administered at the 2012 Pan-African Paediatric Surgery Association Congress. Results are presented as median (range); differences were analysed using contingency tests. Results: A total of 82 delegates (28 countries [66 institutions]) were divided into LIC (n = 11), MIC (n = 6) and HIC (n = 11). In LIC, there were fewer surgeons and more patients. LIC reported 22 cases (1-184) GS/institution/year, compared to 12 cases (3-23)/institution/year in MICs and 15 cases (1-100)/institution/year in HICs. Antenatal screening was less readily available in LIC. Access to parenteral nutrition and neonatal intensive care in LIC was 36% and 19%, compared to 100% in HIC. Primary closure rates were similar in LIC and HIC at 58% and 54%, respectively; however, the majority of staged closure utilised custom silos in LIC and preformed silos in HIC. In LIC, mortality was reported as >75% by 61% delegates and 50-75% by 33%, compared to <25% by 100% of HIC delegates (P < 0.0001). Conclusions: Gastroschisis is a problem encountered by surgeons in SSA. Mortality is high and resources in many centres inadequate. We propose the implementation of a combined epidemiological research, service delivery training and resource provision programme to help improve our understanding of GS in SSA whilst attempting to improve outcome.

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Background: Posterior urethral valves (PUV) remain the most common cause of bladder outlet obstruction and renal insufficiency in male children. The aim of this study was to evaluate the presentation, management, challenges, and outcome of the disease in a Nigerian tertiary health institution. Patients and Methods: Retrospectively, medical records of male children with a diagnosis of PUVs over a 10 year period (2003-2012) were retrieved. All data in relation to the study objectives were recorded and analyzed. Results: A total of 44 patients was managed for PUV within the period. The mean age of presentation was 3.95 years with 56.8% of the patients presenting after the age of 1 year. Voiding dysfunction noted in 40 (91.0%) patients was the most common mode of presentation. The most common finding on physical examination was a palpable bladder while urinary tract infection noted in 23 (52.3%) patients was the most common complication noted. Abdominal ultrasonography revealed dilated posterior urethra in 16 (36.4%) cases, while micturating cystourethrogram revealed a dilated proximal urethra in all 35 cases in which it was done, diverticulum in 6 and vesicoureteric reflux in 9. The creatinine value at presentation ranged between 0.4 mg/dl and 4.0 mg/dl with a mean of 1.02 ± 0.93 mg/dl. Urethroscopy in 37 patients confirmed type I and type III PUV in 35 and 2 patients, respectively. Valve ablation with a diathermy bugbee electrode provided relief of obstructions in the 37 patients who underwent the procedure without any significant immediate complication. The period of follow-up ranged between 2 weeks and 3 years with a mean of 10.2 months. There was sustained improvement in urine stream, reduction in the mean creatinine concentration and incidence of UTI during follow-up. However, patients with significantly impaired renal function had a poorer outcome. Conclusion: Many patients with PUV presented late within the reviewed period. Valve ablation provided relief of obstruction in most of the cases. There is a need to counsel parents/guardians on the need for long-term follow-up.

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Background: Postoperative complications are related to the surgical procedures, of failures of initial bladder closure and influence the urological, aesthetical and orthopaedic outcomes. Materials and Methods: We reviewed four patients who underwent complex bladder exstrophy-epispadias repair over a period of 14 years. The outcomes of treatment were assessed using, aesthetic, urological and orthopaedic examination data. Orthopaedic complications were explored by a radiography of the pelvis. Results: Out of four patients who underwent bladder exstrophy surgical management, aesthetic, functional outcomes and complications in the short and long follow-up were achieved in three patients. The first patient is a male and had a good penis aspect. He has a normal erection during micturition with a good jet miction. He has a moderate urinary incontinence, which requires diaper. In the erection, his penis-measures 4 cm long and 3 cm as circumference. The second patient was a female. She had an unsightly appearance of the female external genitalia with bipartite clitoris. Urinary continence could not be assessed; she did not have the age of cleanness yet. The third patient had a significant urinary leakage due to the failure of the epispadias repair. He has a limp, a pelvic obliquity, varus and internal rotation of the femoral head. He has an inequality of limbs length. Pelvis radiograph shows the right osteotomy through the ilium bone, the left osteotomy through the hip joint at the acetabular roof. Conclusion: When, the epispadias repair is performed contemporary to initial bladder closure, its success is decisive for urinary continence. In the female, surgical revision is required after the initial bladder closure for an aesthetic appearance to the external genitalia. Innominate osteotomy must be performed with brilliancy amplifier to avoid osteotomy through to the hip joint to prevent inequality in leg length.

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Background: There are various methods for surgical treatment of hernia and hydrocele in children with variable cost-effectiveness, recovery and cosmetic outcomes. This study analyses our experience with mini-incision/invasive herniotomy in children in resource-limited centre. Materials and Methods: Seven hundred and eighty-four n = 784 patients underwent herniotomy via conventional and mini-invasive methods were assigned into Group A and Group B. Three hundred and seventy-six n = 376 (47.95%) in Group A while four hundred and eight n = 408 (52.04%) in Group B. Eight hundred and seventeen (817) herniotomy was performed. Demographic data, hernia/hydrocele sides, volume of surgical suture used, surgery duration, and complications analysed. Results: Right side hernia and/or hydrocele were 464 (59.18%). 287 (36.60%) had left sided while 33 (4.21%) had bilateral hernia and/or hydrocele. There were 14 bilateral hernia repair in Group A and 19 in Group B. The lengths of operation time for unilateral repair ranged from 14 to 54 min in Group A (median, 23 min) and 7-44 min in Group B (median, 15 min) with a mean surgical duration of 15.48 ± 4.16 min in Group B versus 23.41 ± 5.94 min in Group A (P < 0.001) while the range of the lengths of operation time for bilateral repair in Group A was 20-54 min (median, 36) and 12-30 min (median, 21) in Group B with a mean duration of 36.35 ± 9.89 min in Group A versus 20.42 ± 4.83 min in Group B P = 0.00563. 376 sachets of 45 cm suture material were used in Group A versus 137 in Group B. There were total of 87 (23.13%) complications in Group A versus 3 (1.47%) in Group B P = 0.000513. Superficial wound infection and abscess were 9 (2.36%) and 16 (4.25%) in Group A versus none (0) in Group B. Conclusion: Mini-incision/invasive herniotomy in children and adolescents is fast, cost-effective with satisfactory cosmetic outcome and limited complications

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Background: Childhood traumatic brain injury (TBI) has high rate of mortality and morbidity worldwide. There are dearths of reports from developing countries with large paediatric population on trauma; neurosurgery trauma of nonaccidental origin is not an exemption. This study analysed menace of non-accidental TBI in the paediatric population from our center. Materials and Methods: This is a single unit, retrospective study of the epidemiology of non-accidental TBI in children starting from September, 2008 to March, 2014. The management outcomes of the epidemiology of the non-accidental TBI were analysed. Results: Total of 109 children age range from 0 (intra-natal) to 16 years with a mean of 5.8 ± 4.6 years (median, 5 years) were enrolled into the study. 34 (31.2%) were domestic violence, 26 (23.9%) street assaults, 16 (14.7%) were due to animal assaults and mishaps, 17 (15.6%) fall from heights. Seven (6.4%) cases of collapsed buildings were also seen during the period. Four (3.7%) industrial accidents and two (1.8%) were self-inflicted injuries. There were also three (2.8%) cases of iatrogenic TBI out of which two infants (1.8%) sustained TBI from cesarean section procedure while one patient (0.9%) under general anaesthesia felt from the operation bed resulting to severe TBI. Conclusion: Child abuse, unprotected child labour, parental/care-givers negligence are the main cause of nonaccidental TBI. Human right activists and government agents should be incorporated in curtailing the menace.

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Background: To determine the outcome of hypospadias repair in children. Patients and Methods: This was a retrospective study of all patients with hypospadias managed at the University of Abuja Teaching Hospital, Abuja, Nigeria from January 2009 to December 2013. Results: Twenty-four cases of hypospadias had corrective surgery during the 5-year period under review. Seventy-five percent of the patients (n = 18) were seen after the 1 ^st year of life. There were two peaks of ages at corrective repair; 45.8% between age 1 and 3 years and 29.1% between age 5 and 10 years. The average age at time of surgery was 44.9 months. Distal hypospadias were more common (58.4%), followed by glanular (20.8%) and proximal (20.8%) hypospadias. Associated anomalies included chordee, maldescended testicles and inguinal hernia in 20.8%, 4.1% and 8.3% cases, respectively. Operative techniques were single-stage procedures in 79.1% of patients consisting of simple circumcision in two cases (10.5%), Mathieu's peri-meatal based flap in four cases (21%), meatal advancement and glanuloplasty incorporated in three cases (16%) and Snodgrass tubularised incised urethral plate tubularised incised plate in 10 cases (52.5%). The remaining 20.9% (n = 5) had multi-staged procedures. The most common post-operative complications were urethrocutenous fistula in nine patients (33.3%) and metal stenosis in 3 patients (12.5%). Conclusions: Our results show that hypospadia repair is froth with attendant high complications in our setting.

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Background: Congenital abnormalities constitute one of the major causes of infant mortality, particularly in developing countries. The aim of this study was to describe the epidemiology of congenital anomalies in Cote d'Ivoire. Materials and Methods: It was a multicentric study of three academic hospitals and the Heart Institute of Abidjan over 10 years. The epidemiologic Data concerned the Parturients, the annual frequency of congenital abnormalities. Distribution of the congenital abnormalities according to the organs, overall mortality and lethality of congenital abnormalities were evaluated. Results: Over 10 years, 1.632 newborns with 1.725 congenital anomalies were recorded. Frequency was 172.5 congenital anomalies per annum. Parturients were less than 35 years in 33% of cases, multigravida in 20%, multiparous in 18% and had a low socio economic status in 96% of cases. Prenatal diagnosis of congenital anomalies was performed in 1.5%. Congenital anomalies were orthopedic in 34%, neurological in 17%, gastrointestinal in 15%, facial in 11.5%, parietal in 13%, urogenital in 9% and cardiac in 0.5% of cases. The overall mortality rate of congenital anomalies was 52% and gastroschisis was the most lethal disease with 100% mortality. Conclusion: This descriptive study reveals the low socio economic status of Parturients with congenital anomalies and their poor prenatal diagnosis. These factors explain the very high mortality of congenital anomalies due to a delay management in our country in which medical expenses were borne by parents and where technical platforms remain obsoletes for good resuscitation and neonatal surgery.

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A three-year-old child developed a large tracheo-oesophageal fistula secondary to a button battery being lodged in the upper oesophagus for 36 hours. The diagnosis was confirmed with a contrast swallow. Operative access was gained through a combined right cervical incision and complete median sternotomy. Repair of the fistula required a segmental resection of both the trachea and oesophagus followed by primary anastomosis.

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Background: Palpable Undescended Testis (PUT) represents a common paediatric problem in many premature and some mature infants. There are several surgical techniques to correct PUT either through combined inguinal and scrotal incision or single transverse scrotal incision. This study assessed single high transverse scrotal incision for the management of PUT as regards to feasibility, postoperative success and final cosmetic results. Materials and Methods: One hundred twenty patients were managed at the Paediatric Surgery Department of Tanta University Hospital with PUT during the period from March 2010 to March 2014. They were all operated at the age of 6-12 months. We excluded recurrent cases, and cases older than 12 months. Through high transverse scrotal incision, the layers were divided, and the canal entered through the external ring, dissecting the PUT and bringing it through the incision. Hernia sac, if present, was ligated at the neck. Creation of the dartos pouch was then made through the same incision. All infants were followed-up at 1 month, 2 months and 6 months to detect any re-ascended cases, testicular atrophy and the final cosmetic appearance. Results: A total of 140 PUTs were operated upon in 120 patients. PUT was bilateral in 20 patients, right-sided in 65 cases and left-sided in 35 cases. Thirty testes were located at the external ring; the others were located within the inguinal canal. No cases needed a redo operation, and there was no case of postoperative testicular atrophy. Conclusion: Single high transverse incision was sufficient to deal with PUT especially, in young infants (age 6 months) with no need for conversion in most cases to the traditional two incisions technique, and good long term follow-up and a better cosmetic results.

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Intussusception is a very rare cause of intestinal obstruction in neonates. It is of extremely rare occurrence among premature neonates. We present a case of 11-day-old premature neonate who presented with abdominal distension, intolerance to feeds, vomiting, significant bilious aspirate and bleeding per rectum. The initial diagnosis of necrotizing enterocolitis (NEC) led to a delay in the diagnosis. On exploratory laparotomy, it turned out to be a case of ileo-colic intussusception with Meckel's diverticulum as a lead point. This site of intussusception (ileo-colic) and presence of a lead point among premature neonate is of exceedingly rare occurrence and very few such cases have been reported. In this article, the published work about clinical features and management on intussusceptions in premature neonates has been reviewed. The authors intend to highlight the difficulty in distinguishing the NEC and intussusception. Subtle clinical and radiological features which can help in differentiating the two conditions have been emphasized. This can avoid the delay in diagnosis and management which can prove critical. High index of suspicion with timely intervention is the key for optimizing outcome. A diagnosis of intussusception should always be considered in any preterm infant with suspected NEC.

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Background: Ligation of the embryonic gut is an established technique to induce intestinal obstruction and subsequently intestinal atresia in chicken embryos. In this study, we modified this established chicken model of prenatal intestinal obstruction to describe (1) the kinetics of morphological changes, (2) to test if removal of the ligature in ovo is possible in later embryonic development and (3) to describe morphological adaptations following removal of the ligature. Materials and Methods: On embryonic day (ED) 11, small intestines of chick embryos were ligated micro surgically in ovo. In Group 1 (n = 80) gut was harvested proximal and distal to the ligation on ED 12-19. In Group 2 (n = 20) the induced obstruction was released on day 15 and gut was harvested on ED 16-19. Acetyl choline esterase staining was used as to assess resulting morphological changes. Results: A marked intestinal dilatation of the proximal segment can be seen 4 days after the operation (ED 15). The dilatation increased in severity until ED 19 and intestinal atresia could be observed after ED 16. In the dilated proximal segments, signs of disturbed enteric nervous system morphology were obvious. In contrast to this, release of the obstruction on ED 15 in Group 2 resulted in almost normal gut morphology at ED 19. Conclusion: Our model not only allows the description of morphological changes caused by an induced obstruction on ED 11 but also-more important - of morphological signs of adaptation following the release of the obstruction on ED 15.

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Background: The aim was to evaluate the clinical presentation, investigation modalities, operative management, pathology, outcome (morbidity and mortality) and short term follow-up of congenital cystic lesions of the lung. Materials and Methods: This is a retrospective study. Study period was 5 years (December 2008-November 2013) in the Department of paediatric surgery, Nil Ratan Sircar Medical College. Study population: Total number = 10 patients. Age range: 2 days-7 years. (Neonate-4). Male and female ratio = 1:1. Result: Among 10 cases of lung cyst four having congenital lobar emphysema, four having congenital pulmonary airway malformation, one sequestration and one teratoma. All patients have undergone surgical excision in terms of lobectomy or excision of the lesion. Post-operative histopathology confirmed the diagnosis. Recovery was uneventful. Conclusion: Although our experience is limited, operative management of lung cysts seems to be safe with rewarding results. However we are yet to encounter many of the other varieties of the cysts found in the lung, which may be associated with other congenital anomalies and have an impact on prognosis.

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Background: Continent catheterizable conduit (CCC) has made clean intermittent catheterization (CIC) painless and easy. It is applicable in diverse clinical conditions. Nonetheless, convincing the parents for the need of conduit procedure is still difficult. Materials and Methods: A prospective study, included children who underwent CCC procedure from March 2008 to February 2013. The data were assessed for; diagnosis, type of conduit, number of preoperative counselling sessions before acceptance, role of "self-help group" in decision making, parental concern and satisfaction for the procedure. Results: Twenty-nine patients (males; 24, females; 5) underwent CCC procedure for various clinical conditions. The multiple preoperative counselling sessions and creation of "self-help groups" were helped them for decision making. The main concerns among parents were: (1) Impact of procedure on future fertility and sexual life. (2) Patency of native urethral channel. (3) Permanent urinary stoma over the abdomen. Conclusion: CCC procedures are applicable to a wide array of clinical situations with a good outcome. The acceptability of the CCC procedure improves with preoperative counselling of parent/child, initiation of preoperative per urethral CIC and creation of self-help groups.

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Background: The poor outcome for patients with Wilms' tumour (WT) in developing countries has been predicated on late presentation, poverty and low rate of chemotherapeutic access. This study aims to evaluate the effects of an institutionalised approach to improving outcome for patients managed in a tertiary hospital in Nigeria. Materials and Methods: Oncology records of children diagnosed with WT between 2009 and 2013 were analysed for therapy completion and other prognostic parameters. Ensuing data were then compared with those from other centres in Africa. Results: Compared with results from some local and African studies, the therapy completion rate was higher (60%) with a survival rate among this group being between 1 and 4 years. No patient was lost to follow-up because of unavailability or unaffordability of cytotoxic agents. Conclusion: This study shows that an institutionalised approach can help to improve access to anti-cancer drugs, reduce the rate of loss to follow-up and thus improve outcome. There is however need to improve on patient-doctor communication, form support groups and establish a WT registry.

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Background: Scoliosis and limb length discrepancy are the major orthopaedic abnormalities in patients with Silver-Russel syndrome (SRS). In this paper, we describe a series of orthopaedic interventions in an attempt to overcome the progressive pathologic mechanism in a 7-year-old girl who manifested the full phenotypic features of SRS. Materials and Methods: Unilateral hip dislocation, progressive scoliosis and limb length discrepancy have been dealt with through Pemberton osteotomy, spinal fusion and Taylor-Spatial-Frame respectively. Results: In order to correct the axial and the appendicular deformities a sum of seven operations were performed (between the age of 7 years and 13 years). Pemberton osteotomy was performed to treat dislocation of her right hip because of developmental dysplasia of the hip. Spinal fusion (spondylodesis) of segments Th3-L5 was done to correct her scoliosis. And, to overcome the limb length discrepancy of 15-cm we used Taylor-Spatial-Frame with percutaneous distal corticotomy of the femur, and the proximal tibia, as well as the foot, were performed. We were able to minimize the limb length discrepancy to 5 cm. The girl became able to walk with the aid of a below knee orthosis and through lifting the left limb with 5-cm height shoe. Conclusion: Limb lengthening surgery in patients with multiple malformation complex as in SRS is associated with high recurrence risk because of; muscular hypotonia, overtubulation of the long bones, and the poor bone regenerative quality. Our interventions were principally directed towards improving the cosmetic outlook, functions and the biomechanics.

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Gastroschisis is a congenital anomaly characterised by a defect in the anterior abdominal wall through which the intestinal contents freely protrude. Defect is located almost always to right of umbilicus. To our knowledge very few cases of left-sided gastroschisis have occurred and presented in literature. We report case of left-sided gastroschisis with caecal agenesis, short gut, and malrotation of intestine.

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Background: Laparoscopy is not yet routinely employed in many Paediatric Surgical Units in Nigeria despite the advantages it offers. This study describes the preliminary experience with laparoscopic procedures in a single centre. Patients and Methods: A retrospective analysis of all children who had laparoscopic surgery between January 2009 and December 2013 at the Paediatric Surgical Unit of Obafemi Awolowo University Teaching Hospitals Complex Ile-Ife was carried out. Their sociodemographic, preoperative and intraoperative data along with postoperative records were subjected to descriptive analysis. Results: Eleven (44%) diagnostic and 14 (56%) therapeutic procedures were performed on 25 children whose age ranged from 5 months to 15 years (Median: 84 months, Mean: 103 ± 64.1 months), including eight (32%) females and 17 (68%) males. Indications included acute appendicitis in 12 (48%), intra-abdominal masses in six (24%), three (12%) disorders of sexual differentiation, two (8%) ventriculoperitoneal shunt malfunctions and impalpable undescended testes in two (8%) children. The procedures lasted 15-90 minutes (Mean = 54 (±21.6) minutes). Conversion rate was 17% for two patients who had ruptured retrocaecal appendices. No intra operative complications were recorded while three (12%) patients had superficial port site infections post-operatively. All diagnostic (11) and two therapeutic procedures were done as day case surgery. The mean duration of hospital stay was 3.1 (±3.3) days for those who had appendectomies. Conclusion: Laparoscopic surgery in children is safe and feasible in our hospital. We advocate increased use of laparoscopy in paediatric surgical practice in Nigeria and similar developing settings.

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We report a case of a neonate who presented with respiratory distress initially managed for a suspected pneumothorax before being transferred to a tertiary centre where he had a thoracotomy. A large cystic structure was excised later histologically confirmed to be a gastric duplication cyst. We discuss its management.

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We describe herein a case of unilateral pulmonary agenesis (PA) with oesophageal atresia (EA)/tracheoesophageal fistula (TEF) that was diagnosed prenatally and repaired by esophagoesophagostomy with stable postoperative course. The patient was born at 34 weeks gestation, after ultrasonography at 22 weeks gestation showed possible right-sided diaphragmatic eventration or PA and EA was subsequently suspected due to hydramnios. The initial X-ray showed mediastinal shift to the right, and coil up sign of the nasogastric tube, without intracardiac anomaly. Immediately after the diagnosis of EA/TEF and unilateral PA on day 0, the patient was intubated in the operating room, and a gastrostomy tube was placed. After pulmonary status stabilized, at 4 days old, EA/TEF was repaired through a thoracotomy in the right 4 ^th intercostal space. The right main bronchus was noted to continue into the distal oesophagus; this fistula was ligated and divided, and a single-layer esophagoesophagostomy was performed under mild tension with one vertebral gap. The neonate was maintained on mechanical ventilation and gradually weaned to extubation at 7 days old. The postoperative course was uneventful, with the exception of prolonged jaundice that emerged at 3 months old. Laparoscopic cholangiography at that time excluded biliary atresia, and jaundice resolved spontaneously. The patient has not shown any respiratory symptoms or feeding difficulties as of the 12-month follow-up.

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Traumatic right diaphragmatic hernia is rare in children. Its diagnosis can be difficult in the acute phase of trauma because its signs are not specific, especially in a poly trauma context. We report two cases of traumatic right diaphragmatic hernia following a blunt thoraco-abdominal trauma, highlighting some difficulties in establishing an early diagnosis and the need for a high index of suspicion.

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Massive purulent andacute pericarditis in children is a life-threatening disease associated with high mortality. It has been described tocomplicate usuallya bronchopulmonary infectionbut is currently uncommon in the era of antibiotics. Acute and massive purulent pericarditis has been rarely reported in children in association with human immunodeficiency virus (HIV) infection. This is a case of a10-year-old boy who presented with signs of sepsis and cardiac tamponade due to a massive staphylococcal purulent pericarditis complicating an unknown HIV infection.The child underwent pericardiectomy, intensive treatment, and survived this life-threatening disease.

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Classic bladder exstrophy is a rare malformation of the genitourinary tract requiring surgical intervention either one-staged or staged fashion. Premature stent dislodgement is a well-known reported complication. We are reporting an unusual case of migration of ureteric stent to thoracic cavity leading to the pleural effusion and respiratory distress in early post-operative period.

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Epidermoid cyst of the testis is a benign, non-teratomatous tumour. It is often possible to make the diagnosis pre-operatively, combining typical sonographic features with normal biochemical tumour markers. The accurate pre-operative diagnosis will allow for testis-sparing surgery and prevent unnecessary orchiectomy. An 11-year-old boy with testicular epidermoid cyst who presented with pain in testis was presented in this report.

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Late presentation of congenital diaphragmatic hernia is uncommon. It poses considerable diagnostic challenges when it strangulates. The authors report a case of a left posterolateral strangulated congenital diaphragmatic hernia in a 5-year-old child diagnosed at the stage of acute intestinal occlusion with intestinal necrosis and managed successfully. A strangulated congenital diaphragmatic hernia should be suspected in the case of an association of sudden-onset respiratory and digestive manifestations with no sign of trauma or specific pulmonary history. It then requires an antero posterior thoracic X-ray or, even better, a thoracic-abdominal scan to confirm the diagnosis.

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