Assessment of Science Production in the field of pediatric surgery in Iran, Turkey, India and Pakistan

Introduction: Scientific progress is one of the main parts of development in any country. One of the means of assessing it is the number of scientific papers which are published in internationally approved journals. In this article we will compare scientific production in the field of pediatric surgery between Iran and three other Asian countries: Turkey, India and Pakistan during 25 years. Material and methods: Using scientometric methods we analyzed scientific productions in the field of pediatric surgery indexed in bibliographic databases such as PubMed and Scopus during 25 years from 1990-2015 by 4 Asian countries: Iran, Turkey, India and Pakistan.Results: Turkey had the most articles indexed in ISI web of Science with 843 articles, India had 545 articles, Iran had 127 articles and Pakistan had 29 articles in 25 years. Conclusion: Our main intention was to assess the research activity of pediatric surgeons in Iran. And what we found showed that despite similarity in the population and budget among neighboring countries our scientific production is lower

Gastric Tube Interposition for Esophageal Replacement in Children, Is it the best option?

Introduction: Replacement of esophagus can be accomplished using different parts of the gastrointestinal tract, in various positions and in single and multiple stages. The aim of this study is to present the results of gastric tube interposition in children with congenital esophageal anomalies and severe acquired esophageal stricture.Material and Methods: This series describes 22 patients who underwent gastric tube interposition procedures for esophageal replacement at Mofid Children’s Hospital Tehran, Iran between 1996 and 2014. Clinical data including the indication for esophageal replacement, technique and timing of repair, early and late complications, and long-term follow-up were retrospectively gathered from patients’ medical records.Results: Patients consisted of 17 Male and 5 female, aged 8 months to 14 years (mean 47.8 months). Twenty one patients had normal oral feeding and proper weight gain. The mean time of follow up was 9.25 years (9 months to 18 years). One of our cases developed failure to thrive although he had no difficulty in swallowing and was eventually put on supplementary feeding by gastrostomy.There were 3 strictures: one in the neck anastomosis which was treated by dilatation and revision of anastomosis, one in the hiatal level which was because of tight hiatus and was treated by widening of hiatus. The last patient had a stricture at mid-portion of gastric tube, and was treated by dilatation, which resulted in perforation and was treated by stricturoplasty. Three leaks occurred at the neck anastomosis, two healed spontaneously and one resulted in intra thoracic leak and mediastinitis that led to death after 3 months. Another child with lymphocyte adhesion deficiency died due to infected neck wound and severe bleeding from carotid artery 22 days postoperatively, a third death occurred many years after the original operation due to mediastinitis which was the result of dilatation for stricture formation.Conclusions: Although gastric tube replacement in posterior mediastinum seems an ideal replacement because of adequate length which makes it easily reachable to pharynx, good blood supplies, straight and proper size; the management of complicated cases such as mediastinal leaks and strictures is very challenging and rules out this method of esophageal replacement as the best option possible

The role of anti-reflux surgery in the management of respiratory symptoms in gastro-esophageal reflux disease

Introduction: Gastro-esophageal reflux (GER) is common among children of different ages and treatment is necessary since it could turn in to Gastroesophageal Reflux Disease (GERD) and cause complications. In patients that do not respond to medical treatment and patients that have complications such as repeated apnea, pneumonia, stricture caused by esophagitis and failure to thrive, surgical treatment is indicated. In this article the rates of clinical presentations of the disease particularly the respiratory manifestations after operation with the loose Nissen Fundoplication technique are studied.Material and Methods: In this descriptive retrospective study 76 cases of GERD underwent loose Nissen Fundoplication. Clinical presentations and diagnostic methods and the result of surgical treatment were studied.Results: During March 1997 till August 2010, 76 patients were studied. Male to female ratio was 1.6. The mean age of patients was 24.5 months (ranging between 17 days to 18 years).  Fifty nine (78%) patients had respiratory presentations such as RAD (reactive airway disease) and respiratory distress with recurrent pneumonia and apnea. Thirty one (41%) cases had associated anomalies. The most used diagnostic studies were radiography (100%), endoscopy (41%) and PH metry (1.3%). Eleven patients (14.4%) had early or late surgical complications. Respiratory presentations in almost all the patients were controlled postoperatively. The success rate of the operation was 75 (98.6%). There was no operative mortality, but non-operative mortality occurred in one patient (1.3%).Conclusion: LooseNissen Fundoplication technique has a good success rate with a low rate of complications.  Respiratory presentations are the most common presentations of GERD, and in all patients who have respiratory symptoms, GERD workup is necessary, and anti-reflux surgery can control nearly all of these symptoms.                                                                                         

An Assessment of Preoperative and Postoperative Nutritional Status in Children with Cleft Lip and Palate

Background: Children with cleft lip and palate generally suffer from inappropriate and inadequate feeding, resulting in insufficient weight gain leading to malnutrition and poor growth. We aimed to evaluate the nutritional and growth status of cleft lip and palate children before and after reconstructive cleft lip and palate surgery.Methods: All cleft lip and palate children aging from birth up to 36 months who were admitted to a referral Children's Hospital were investigated by a nutritionist. Data were collected using a questionnaire. About 5-6 months after surgery, data regarding their height, weight, feeding status and feeding difficulties were collected by telephone. Statistical analysis was performed using SPSS 18 software. For qualitative variables we used frequency and percentage and for quantitative variables we measured mean and standard deviation. We used Paired Sample T-test for comparing weight differences before and after surgery.Results: In this study, formula was the most common type of feeding before and after surgery. Nasal regurgitation and insufficient sucking was the most common complaint of mother's before surgery, and also nasal regurgitation was reported as the most common difficulty after surgery, probably due to the need for reoperation. Bottle feeding was the most common method of feeding before and after surgery. After surgery only one mother claimed that her child spent more than 30 minutes for feeding. Weight for age of 18 children before surgery was lower than 5th percentile while after surgery this was reduced to 13 children. Also, there were significant differences between mean age before and after surgery which could implicate increase of weight after surgery.Conclusions: Our study demonstrates the results of surgical repair of cleft lip and palate on nutritional status in children.

Comparing midazolam-bupivacaine and neostigmine-bupivacaine for caudal anesthesia in children undergoing herniorrhaphy

Introduction: Neostigmine and midazolam are each added to bupivacaine for the purpose of caudal anesthesia. In this study, we compared neostigmine and midazolam, each coadministered with bupivacaine, in terms of analgesia and side effects during pediatric inguinal hernia operations.Material and Methods: We included 60 children 1–6 years-old, candidates for elective unilateral herniorrhaphy. After general anesthesia induction with inhaled sevoflurane, a caudal block was performed. Patients were randomly allocated to one of two trial groups: midazolam group received bupivacaine 25% 1 ml/kg with midazolam 50µg/kg, and neostigmine group received bupivacaine 25% 1 ml/kg with neostigmine 2 µg/kg through the caudal route. Heart rate, mean arterial pressure, and oxygen saturation were recorded before induction and every five minutes after caudal anesthesia up to 30 minutes. Pain and sedation scores were recorded at two, four, six, 12, and 24 hours after the operation, along with rescue analgesia dosage, vomiting, and respiratory depression.Results: Mean duration of analgesia in the midazolam group was similar to the neostigmine group (18.8±9 vs. 20.4±7.5; P= 0.44).The analgesic dosage required was not significantly lower in the neostigmine group compared to the midazolam group (58.3±121.7 VS .70.8±125.8; P=0.63).The number of patients who needed analgesic agents was similar in both groups (P= 0.76). Nausea (P= <0.05) and vomiting (P=0.01) rates were higher in the neostigmine group.Conclusion: Midazolam (50 µg/kg) compared to neostigmine (2 µg/kg) provided higher sedation along with lower incidence of postoperative nausea and vomiting.

High Dose Botox Injection for Patients with Internal Anal Sphincter Achalasia Persistent to Posterior Internal Anal Sphincter Myectomy

Introduction: one of the most common reported chief complaints in visits to pediatricians is constipation. Although in a majority of cases with no anatomical defect, dietary manipulation, stool softeners, and oral laxatives are successful, some patients fail to respond. Internal Anal Sphincter (IAS) Achalasia is one of the causes of constipation.It results in failure of IAS relaxation and has similar clinical presentation to Hirschsprung’s disease with absence of rectosphincteric inhibitory reflex on anorectal manometry (ARM) and presence of ganglion cells on rectal biopsy. Although posterior internal anal sphincter myectomy (ISM) is considered the standard treatment for IASA, some cases fail to respond and present with intractable constipation which may be associated with soiling. This research aims to assess the role of botox injection for treatment of patients who presented with intractable constipation and have already beentreated by posterior IAS myectomy. Materials and Methods:Internal anal sphincter Botox injection was performed (with a dose of 20 U/Kg) in 14 patients with internal anal sphincter achalasia (IASA); who had presented with intractable constipationafter being treated by posterior internal anal sphincter myectomy. Patients were followed for 2 years after injection. Result: of all 14 patients with persistent constipation (resistant to oral laxatives), 12 patients (85.7%) had regular bowel function for more than 6 months after botox injection therapy (P < 0.05). Of all 14 patients that had needed rectal enema for defecation, no patient needed rectal enema after botox injection therapy (P < 0.05). Of 5 patients with fecal soiling before botox injection therapy (4 had occasionalsoiling, and 1 had soiling every day without social problems) only a single patient experienced transient fecal soiling for 2 weeks after botox injection therapy (P < 0.05). No patient needed another botox injection in 2 years of follow up. Conclusion: IAS Botox injection therapy (BIT) was successfully used to manage IASA patients who had presented with intractable constipation after posterior myectomy. This method significantly reduces the need for laxatives and rectal enema; and improves constipation, fecal soiling and bowel movements at the same time

Results of Onlay Flap Versus Durham Smith in Proximal Hypospadias

Introduction: Urethroplasty was originally used for the repair of hypospadias of the mid and distal portion of the penis but since complications of the two-stage Durham Smith technique such as mega urethra and proximal anastomotic strictures became apparent; the Onlay island flap technique has been increasingly used in more severe cases of hypospadias. The aim of our study was to compare the outcome of these two techniques in the surgical treatment of hypospadias.Material and Methods: In this retrospective study, thirty -three patients underwent surgery for the treatment of hypospadias. The two- stage Durham smith repair was used for 17 cases and the onlay island flap technique was carried out on 16 patients. Data was analyzed using SPSS software version 21 and complication rates of the two procedures were compared.Results: Altogether, frequency of complications was higher in the smith technique than the onlay flap procedure without any significant difference between the two techniques (47% for Smith technique and 19% for onlay repair; P=0.141). Fistula was the most frequent complication in the two techniques (41% for Smith technique and 13% for onlay repair; P=0.117). Meatoplasty was done for meatal stricture in the smith group. Moreover, the smith technique failed completely in one case who then underwent Tabularized Inside-Plate (TIP). There was a case of chordee recurrence in the smith technique; for which a dorsal Nesbit plication was carried out. The mean days of hospitalization was more with the smith technique (7.1 days vs 5.0, P=0.016). In addition, the mean cases which required reoperation was higher in the smith group than the onlay flap (1.0 vs 0.2, P=0.025).Conclusions: The results of this study showed that the onlay flap technique had lower complications and reoperation rates than the two-stage smith technique. In addition, the onlay flap technique has fewer days of hospitalization than the smith technique, resulting in lower costs to the health system and patients

Management and outcomes of hidden penis in children

Introduction: Hidden penis may have different categories: Concealed, trapped, and buried types. The aim of this study was to evaluate the results and outcomes of repaired cases.Material and Methods: A total of 40patients (5months -12years old) underwent surgical repair for different types of hidden penis from April 2010 to December 2015 in our hospital. Multiple surgical procedures were performed for each type. Data were collected and evaluated for number of patient’s, type of anomalies, surgical techniques, outcome and follow-up.Results: All forty cases underwent surgical repair. In all cases of concealed and buried penis penile degloving and penile fixation was used. In all of our cases improved function and good outcome was reported.Conclusions: Patients with hidden penis are in great psychological risks. The aim of hidden penis repair is to restore an aesthetic and functional penis which we are happy that we provided for our patients

Epidemiological Aspects, Clinical Features and Treatment Outcome in Children Suffering Hepatoblastoma

Introduction: Hepatoblastoma (HBL) is the most common primary liver tumor within childhood. Entire tumor resection is basis for ultimate cure for HBL and supports the only pleasant chance of long-standing disease-free survival. Objectives: In the current survey, we attempted to evaluate the long-term survival of children with HBL with surgical resection in a referral children hospital in Iran within the last decade. Materials and Methods:This retrospective descriptive study was conducted on all children who suffered HBL and undergone surgery between 2006 and 2016. Reviewing the recorded hospital files led to a sample of 30 eligible patients. The baseline characteristics of the patients were all collected by reviewing the files. Results:In total, 30 consecutive children (21 male and 9 female) suffering HBL were described. Of those, 40.0% aged less than 12 months and only 6.7% aged higher than 36 months. The most common clinical manifestations were asymptomatic abdominal mass (in 66.7%) followed by fever (in 10.0%) and pain (in 10.0%). In more than half of the patients (53.3%), right lobe involved, while left lobe involved in 16.7%. based on histologicalreport,marginal involvement was found in 75.0% of children, margin intact in 15.0% and margin free feature in 5.0%. Forty percent of children suffered from epithelial subtype of tumor, 20.0% from mixed epithelial and mesenchymal subtypes, and 13.3% from embryonal pattern. In total, 63.3% were scheduled for complete surgical resection followed by chemotherapy. Postoperatively, 40.0% of children remained free of complications, whereas postoperative bleeding occurred in 20.0% and biloma in 40.0%. Overall, 76.9% of patients were completely cured, 7.7% suffered from pulmonary metastasis and 3.9% required liver transplantation. Postoperative death occurred in 11.5%. Conclusions: Considering surgical resection followed by chemotherapy leads to high cure rate, however a notable number of affected children suffer postoperative complication, requiring liver transplantation, pulmonary metastasis, or even non-survived emphasizing a serious review of the treatment protocols.  &nbsp