Perforated Meckel’s diverticulum with acute appendicitis in an infant

Meckel’s diverticulum occurs in approximately 2% of the population and is symptomatic in 16% of cases. In children, the most common presentation is intestinal obstruction due to intussusception. The simultaneous occurrence of acute appendicitis and symptomatic Meckel’s diverticulum is rare and when it occurs, it may be associated with non-specific symptoms that present a diagnostic challenge.Keywords: Meckel’s diverticulum, Acute appendiciti

Urethro-cutaneous fistula after hypospadia repair: a single institution study

Urethro-cutaneous fistula (UCF) is one of the most frequently seen complications of hypospadias surgery requiring reoperation; it occurs with an incidence of between 4% and 28%. Risk factors associated with the development of UCF can be classified as preoperative, intraoperative or postoperative. The aim of this study was to determine the association of perioperative risk factors and the development of urethrocutaneous fistula after hypospadias repair. A retrospective review of patients who had undergone hypospadias repair at Kenyatta National Hospital between 2013 and 2017 was conducted. 114 patient records were retrieved. The incidence of UCF was 47%. Risk factors that were significantly associated with UCF are hypospadias type (p=0.028), lack of a protective intermediate layer (p=0.002), and presence of postoperative complications (p=0.001). Age at surgery, suture material, type of repair and use of catheter/stents were not significant factors. Multivariate analysis showed wound infection and meatal stenosis as the most significant factors associated with UCF development.Keywords: Hypospadias, Urethro-cutaneous fistula, Risk factors, Wound infection, Meatal stenosi

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

Repair of giant omphalocele by component separation technique

Giant omphalocele management has always been a challenge because of the large fascial defect and the associated anomalies. We managed successfully a neonate with giant omphalocele and no associated anomalies by delayed repair constituting escharotic therapy initially and later managed the ventral hernia by component separation technique before her preschool years. Her recovery was non-eventful with no recurrence of the hernia on follow up. Keywords: Omphalocele, Component separation technique, Escharotic therap

Report on the 2017 Paediatric Colorectal Conference

No AbstractKeywords: Colorectal Conference, Kenya, Paediatri

Sacrococcygeal teratoma type IV presenting with urine retention in infants

Background: Sacrococcygeal teratoma (SCT) is the commonest tumor in neonatal period. The type IV variant is a concealed presacral tumor which presents a diagnostic challenge as symptoms are only apparent due to the mass effects of the tumor. A common presentation is urine retention. We herein present two cases of patients with type IV tumors who presented with acute urinary retention with the aim of highlighting the challenges in diagnosis of the concealed tumor which apart from its malignant potential has serious obstructive effects on the urinary tract that can lead to irreversible kidney damage. Case presentation: We report two infants a 2 month old female and an 11 month old female who presented with acute urine retention. Both infants had been previously managed in peripheral facilities by urethral catheterization in an attempt to relieve the obstruction which remained persistent. On assessment at our facility both infants were noted to have a pre-sacral mass that was palpable on DRE and confirmed by CT scan. One infant had associated bilateral hydronephrosis from the obstructive effects of the mass on the urinary system. We used a combined abdominal and posterior sacral approach to resect the tumor in both patients with compete resolution of symptoms. Conclusion: SCT type IV presents a diagnostic challenge to the clinician due to its less apparent nature. Patients may present with urologic anomalies due to bladder outlet obstruction and in cases in which diagnosis is delayed, hydronephrosis and renal parenchymal disease may be an associated finding. Clinical assessment in infants presenting with urine retention and constipation of unknown origin should always include a digital rectal examination with particular attention to the posterior rectal wall which can reveal a presacral mass. Keywords: Sacrococcygeal teratoma type IV, Urine retention, Digital rectal examinatio

Variations in branching of the posterior cord of brachial plexus in a Kenyan population

Abstract Background Variations in the branching of posterior cord are important during surgical approaches to the axilla and upper arm, administration of anesthetic blocks, interpreting effects of nervous compressions and in repair of plexus injuries. The patterns of branching show population differences. Data from the African population is scarce. Objective To describe the branching pattern of the posterior cord in a Kenyan population. Materials and methods Seventy-five brachial plexuses from 68 formalin fixed cadavers were explored by gross dissection. Origin and order of branching of the posterior cord was recorded. Representative photographs were then taken using a digital camera (Sony Cybershot R, W200, 7.2 Megapixels). Results Only 8 out of 75 (10.7%) posterior cords showed the classical branching pattern. Forty three (57.3%) lower subscapular, 8(10.3%) thoracodorsal and 8(10.3%) upper subscapular nerves came from the axillary nerve instead of directly from posterior cord. A new finding was that in 4(5.3%) and in 3(4%) the medial cutaneous nerves of the arm and forearm respectively originated from the posterior cord in contrast to their usual origin from the medial cord. Conclusions Majority of posterior cords in studied population display a wide range of variations. Anesthesiologists administering local anesthetic blocks, clinicians interpreting effects of nerve injuries of the upper limb and surgeons operating in the axilla should be aware of these patterns to avoid inadvertent injury. A wider study of the branching pattern of infraclavicular brachial plexus is recommended.</p

Testicular tuberculosis can mimic a testicular tumor

Testicular tuberculosis (TB Orchitis) is a rare condition with a presentation that mimics testicular tumors. We present a rare case of TB orchitis in a 6-month old male infant who presented with a painless, firm left testicular mass that was initially managed as a testicular tumor but later confirmed to be TB orchitis after histological analysis. The aim of this report is to highlight the similarity of presentation between testicular TB and testicular tumors in children which may only be differentiated histologically therefore creating a diagnostic enigma. Keywords: Testicular tumor, Testicular tuberculosis, Histolog