The value of intra-abdominal pressure monitoring through transvesical route in the choice and outcome of management of congenital abdominal wall defects

Introduction Gastroschisis and omphalocele are most common congenital abdominal wall defects (AWDs). Surgical management aims to reduce the evisceration safely, close the defect with a cosmetically acceptable outcome under guidance of intraoperative monitoring of intra-abdominal pressure (IAP). Intravesical pressure monitoring technique recommended by (WSACS) is the most reliable technique for IAP measurement in neonates.Aim The aim of this study is to assess the value of IAP monitoring via vesical pressure measurement in the choice and outcome of management of congenital AWDs.Patients and methods This is a prospective study of 25 cases that suffered congenital anterior AWDs (gastroschisis and omphalocele) admitted to Mansoura University Children Hospital during the period from October 2013 to October 2015. They were all operated upon guided by IVP monitoring during and after repair. Results In our study, 14 (56%) cases presented with gastroschisis and 11 (44%) presented with exomphalos with a median age of 24 h. Males (56%) were slightly more than females (44%). Congenital anomalies were reported in 16 cases (64%). Primary fascial closure was successful in 15 (60%) cases, whereas Silo repair was done in six (24%) cases and skin closure in only four (16%) cases. During the attempts of closure the mean abdominal perfusion pressure was 40.24 ± 5.59, the mean peak inspiratory pressure was 24 ±6.11 and the mean IAP was 22.60± 6.89. Two cases developed intra-abdominal hypertension after abdominal closure (8%) and only one of them needed decompressive laparotomy (4%). Postoperative complications were reported in 15 (60%) cases and mortality occurred in eight (32%) cases.Conclusion Increased IAP secondary to forceful closure of the abdominal defect is associated with the occurrence of complications. IVP monitoring is feasible during closure of AWDs and a threshold of 20cm H2O is  appropriate to decide between primary and staged approach. Keywords: congenital abdominal wall defect, intravesical pressure, intra-abdominal hypertensio

Cut-edge mucoperiosteal flap for anterior fixation of palatal flap in palatoplasty

Introduction: This study was done at Mansoura University Children Hospital, Egypt from the period of June 2013 to June 2015 on 80 patients with incomplete intramaxillary cleft palate.Patients and methods: After oral layer closure of the cleft palate, anterior fixation of the flap is obtained by raising the anterior cut-edge of mucoperiosteal flap for about 0.5 cm then suturing the flap to the elevated cut-edge with two stitches. We divided the patients into two groups and evaluated the time needed for fixation the palatal flap anddifficulty of fixation and evaluated the incidence of anterior palatal fistula between the two groups.Results: The time used for elevation of the flap and taking the two stitches in group A ranged from 2.5 to 6 min. However, the time used for taking the two stitches without elevation of the flap in group B ranged from 2.8 to 9 min.Conclusion: We found that cut-edge mucoperiosteal flap for anterior fixation of two-flap palatoplasty is a simple step at the end of cleft palate repair procedure which allows easy fixation of the palatal flap with short time and good opposition of the tissue edges, allowing better healing.Keywords: anterior fixation palatal flap, cut-edge, palatoplast

Pneumatic versus hydrostatic reduction in the treatment of intussusception in children

Background: The aim of this study was to compare pneumatic reduction under guidance of fluoroscopy and hydrostatic saline enema reduction under guidance of ultrasound in treatment of intussusception in pediatric patients.Methods: The study included 80 patients with intussusception in the time period from September 2014 to September 2015 who were divided into two groups: group A included 40 patients who underwent US guided hydrostatic reduction and group B included 40 patients who underwent fluoroscopic guided pneumatic reduction.Results: The success rate was significantly higher in the pneumatic group (80%) (P = 0.017) when compared to the hydrostatic group (55%) after 1st trial. However, the outcome was equal in both groups after the 2nd trial with success rate of 82.5%. The time needed for reduction was significantly shorter in the pneumaic group (P =0.001). There was only one case of perforation in hydrostatic group (2.5%).Conclusion: Pneumatic reduction is safe, simple, fast, less messy and as effective as hydrostatic reduction.Keywords: hydrostatic reduction, intussusception, pneumatic reductio

Upper lip myomucosal flap for the repair of anterior oronasal fistula

Anterior oronasal fistula after cleft palatal repair is difficult to correct and it is consider challenging to many surgeons. Many techniques were used to repair this type of fistula without guarantee for success. Upper lip myomucosal flap is an alternative technique for the repair of this type of fistula. This is a retrospective descriptive case series study which included 10 patients diagnosed with anterior oronasal fistula after cleft palatal repair. They presented to Pediatric Surgery Department at the Faculty of Medicine, Mansoura University Children Hospital from the period between November 2013 and August 2014. In this technique, we do harvesting of the flap with measurement of its length and width, then baring the edge of the fistula with trying of its closure with local flaps. After that we suture the flap to the edge of the fistula and then evaluate the success rate. This study included 10 patients with age ranging from 15 to 72 months. The size of the fistula was less than 1 cm in six patients and more than 1 cm in four patients. The flap was used as an additional layer repair in seven patients and as the only layer for the repair in three patients. This technique was found to be successful in 70% of the patients with good healing without any recurrent fistula. We concluded that the use of this technique is feasible; however, its efficacy should be tested in larger number of patients to be considered as an option for the treatment of anterior oronasal fistula.Keywords: oronasal fistula, upper lip myomucosal flap, lip fla

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030