Report of the 10th Biennial conference of Pan African Pediatric Surgical Association, in collaboration with 28th annual meeting of the Egyptian Pediatric Surgical Association

This report highlights the 10th Biennial Conference of Pan African Pediatric Surgical Association (PAPSA), in collaboration with 28th annual meeting of the Egyptian Pediatric Surgical Association (EPSA), held at Semiramis Intercontinental, Cairo, Egypt, 12–14 November 2014, and the three precongress workshops held in Cairo University Children’s Hospital from 9 to 11 November 2014.Keywords: congress, Egyptian Pediatric Surgical Association, Pan African Pediatric Surgical Association, repor

Evolution of management of gastroschisis

Background/purpose The management protocols and outcome of neonates with gastroschisis have improved significantly during the past two decades. The purpose of this study was to evaluate the evolution in management and outcome of gastroschisis in our institution. Materials and methods All patients treated for gastroschisis during the past 12 years were included. These patients were divided into two chronologically distinct groups. Group I included patients who were treated from 1998 to 2005 and group II included patients who were treated from 2005 to 2010. Each group was further subdivided into two subgroups according to the method of closure of the abdominal wall by either primary (group IA and group IIA) or delayed primary closure of the abdominal wall defect after temporary extra-abdominal hosting of the bowel using hand-sewn silastic or plastic sheets (group IB) or a spring-loaded silo (group IIB). Each patient was evaluated with regard to time spent on ventilator, time to initiating enteral feeds, time to discharge from the Neonatal Intensive Care Unit, and any complications. Results There was no difference between the two main groups with regard to the gestational age, sex, mode of delivery, or the percentage of associated congenital anomalies. Primary closure was feasible in 29 patients (18 in group IA and 11 in group IIA). Staged reduction of the herniated bowel and delayed repair were performed in 23 patients (12 in group IB and 11 in group IIB). Reduction of the herniated bowel and delayed staged reduction were performed earlier in group IIB than in group IB. Enteral feeding was earlier in patients who had primary closure either in group IA or group IIA compared with patients treated with delayed closure in either group IB or group IIB. Enteral feeding was relatively earlier in group IIB than in group IB, but the difference was not significant. Conclusion The overall morbidity and mortality showed significant improvement in the management of gastroschisis at our practice. The introduction of springloaded silo has simplified the management of patients born with gastroschisis who cannot be treated with primary reduction. Primary closure continued to have better outcome measures compared with staged closure.Keywords: abdominal wall defect, complications, gastroschisis spring-loaded sil

Y-to-V umbilicoplasty for proboscoid umbilical hernia

Background/purpose Several techniques are proposed for reconstruction of proboscoid umbilical hernia in the pediatric patients. In this work, we reported our experience with Y-to-V umbilicoplasty in the surgical repair of proboscoid umbilical hernia in infants and children.Patients and methods A 3-year prospective study included 15 children presented with proboscoid umbilical hernia. A skin marker was used to draw the lines of skin incisions. ‘Y’ incision was done starting with the vertical limb. The facial defect was repaired. Lateral twin isosceles triangular flaps were excised. A new umbilical valley was reconstructed by one or two subcutaneous stitches of the residual umbilical flap fixing the flap’s summit to the aponeurosis plane. We appreciated the results as excellent, fair or bad according to criteria of the peripheral rim (raised, flattened or depressed) and the central depression (deep, shallow or absent).Results This study included 10 boys and 5 girls. Their ages ranged from 1 to 7 years at the time of surgery. The mean duration of the operation was 45 min and the mean hospitalization stay was 1 day. The early results were excellent in all cases. Follow-up period continued for 6 months and revealed a natural-looking umbilicus with excellent peripheral rim and central depression.Conclusion Y-to-V umbilicoplasty in the surgical repair of proboscoid umbilical hernia in infants and children is simple and easy to design and carried out with excellent aesthetic results

Do we really need a new operation for Hirschsprung's disease?

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/47188/1/383_2004_Article_BF00176145.pd

Current management of Hirschsprung’s disease in Egypt: A survey of members of the Egyptian Pediatric Surgical Association

Background/purpose Significant progress has been made in the management of  Hirschsprung’s disease (HD). The choice of the management plan, surgical  approach, and operative details is still variable among pediatric surgeons. This survey aims to determine the current preferences of Egyptian pediatric surgeons in the management of HD.Materials and methods A survey was circulated individually to the members of the Egyptian Pediatric Surgical Association  (EPSA) during the General Assembly Meeting. An electronic form of the survey was sent by e-mail to all Egyptian consultant  pediatric surgeons registered to EPSA through the ‘EPSA online’ e-mail group. A second round of e-mails was sent 2 weeks later.Results Responses were received from 112 surgeons; seven responses were  excluded (incomplete and duplicate responses), yielding 105 survey charts for  analysis. The 105 responses represent 80.7% of the 130 fully trained pediatric surgeons  currently working in Egypt. A total of 76.2% of responders use both  contrast enema and rectal biopsy for the preoperative diagnosis of HD. Contrast enema alone is used by 13 (12.4%). A further 11.4% combine this with anorectal manometry. Intraoperative frozen section tissue diagnosis is used routinely by only 4.8% of the responders. Surgery is preferred to be  performed during the neonatal period by 21.9% of the responders, from 1 to 3 months (28.6%), or after the third month of life  (49.5%). A definitive one-stage colonic pullthrough is always used by 59%, whereas 7.6% are still using staged operations. The rest of the responders had no specific predilection. The preferred surgical technique for rectosigmoid HD is transanal endorectal pull-through (68.5%), Soave transabdominal endorectal  pull-through (19.0%), laparoscopic-assisted pull-through (9.5%), and Duhamel with GIA staplers (2.9%). The Soave operation is preferred for HD extending to the right side and total colonic HD (45.7%) and redo surgery (37.1%).Conclusion The EPSA survey indicated that most surgeons are moving toward a one-stage pull-through using transanal endorectal pull-through for patients with rectosigmoid HD. There are large variations in preference for the age at  pull-through. There is a need for a routine practice of intraoperative frozen section tissue diagnosis, and popularizing laparoscopic surgery for patients with long segment disease.Keywords: diagnosis, Hirschsprung’s disease, management, surve

Current management of anorectal malformation in Egypt: a survey of members of the Egyptian pediatric surgical association

Background/aim: Anorectal malformation (ARM) represents a wide spectrum of anomalies. Its management includes various strategies. This survey aims at detecting the current preferences of Egyptian pediatric surgeons regarding the management of ARM.Materials and methods: A survey was circulated individually to the members of the Egyptian Pediatric Surgical Association (EPSA) during the general assembly meeting. Another online survey using web-based surveys (Survey Monkey) was also used.Results: Responses were received from 91 surgeons. Nine responses were excluded because of incomplete or duplicate responses, yielding 82 survey charts for analysis. The 82 responses represent 74.5% of the 110 fully-trained pediatric surgeons currently working in Egypt. Sixty-one (74.4 %) of responders used invertogram for preoperative diagnosis of ARM. A further seven (8.5%) combined invertogram with perineal ultrasonography or MRI. The remaining 14 (17.1%) used either perineal ultrasonography or MRI. The age at surgery for high ARM was preferred immediately after birth without colostomy by only five (6.1%) of responders, from 1 to 3 months after initial colostomy by 21 (25.61%), 3?6 months after colostomy by 45 (54.88%), and 6 months after colostomy by 11 (13.41%). The preferable definitive surgical technique for high ARM in male is posterior sagittal anorectoplasty according to 63 (76.82%) surgeons, laparoscopic assisted by 15 (18.3%), and abdminoperineal by four (4.88%) The preferable time for primary repair of rectovestibular fistulas was neonatal period for only nine (10.98%) surgeons, from 1 to 3 months for 20 (24.39%), after the third month for life by 40 (48.78%), whereas 13 (15.85%) did not perform single-stage repair. As regard to outcome of primary versus staged repair for rectovestibular fistula, 64.7% of participants stated that primary repair has similar outcomes compared with staged repair, 19.5% stated that staged repair has lesser complications and better outcome, and 15.8% of participants did not perform singlestage repair.Conclusion: The current EPSA survey indicates that most surgeons still use the invertogram as the principal preoperative diagnostic study. Posterior sagittal anorectoplasty is the preferable definitive surgical technique for high ARM in males. Most surgeons prefer primary repair for rectovestibular fistulas. Laparoscopic approach for the management of high ARM is currently practiced by only a few surgeons.Keywords: ARM, survey, EPS

Reduction glossectomy for macroglossia in children

Background/aim: Although several surgical techniques have been described for reduction glossectomy in children, many general pediatric surgeons are still skeptical about the treatment of patients with macroglossia because of potential surgical complications. The aim of this study was to describe our initial surgical experience with reduction glossectomy in a series of eight patients with macroglossia.Materials and methods: A retrospective file review was carried out for all patients who underwent reduction glossectomy during the period from October 2009 to December 2014. Charts were designed to collect the following data from the patients’ files: age; etiology of macroglossia; and full clinical examination including the functional respiration, deglutition, phonation deficit, and dental occlusion alterations.Results: The records of eight patients were retrieved. Five patients, in whom macroglossia affected the tongue width and length, underwent peripheral glossectomy, whereas two patients, in whom macroglossia affected the tongue in all directions, underwent key-hole glossectomy. In one patient in whom only half the tongue was affected, a central longitudinal strip was excised. Motor and sensory  functions, especially taste sensation, were not affected by resection. Speech articulation errors were corrected in cases that stared speech. One complication occurred in one patient who had undergone a key-hole glossectomy: wound infection, followed by partial wound disruption.Conclusion: Partial glossectomy for macroglossia in children is both feasible and safe. It results in minimal complications. Many clinical problems caused by the pathology improve after surgery repair. The recommended surgical technique should be based on the extent of involvement of the tongue.Keywords: Beckwith–Wiedemann syndrome, macroglossia, reduction glossectom

Urethral mobilization and advancement for distal hypospadias

Background/purpose Despite the existence of numerous techniques for the repair of distal penile hypospadias, none of them is completely satisfactory. Advancing the  urethra without mobilization for repair of glanular hypospadias has the advantage of avoiding a common problem occurring with other techniques: urethrocutaneous fistula. This study aims at evaluation of our experience with this technique for repair of distal hypospadias.Materials and methods A prospective study was conducted on patients with glanular, coronal and subcoronal hypospadias during the period from December 2012 to December 2014. Recurrent cases were excluded. Feasibility of the technique and postoperative complications were recorded.Results A total of 30 boys between 9 months and 7 yearsof age were included in the study. They underwent repair of  glanular (five), coronal (10), and subcoronal (15) hypospadias. The urethra was mobilized to the proximal shaft in almost all cases. Three cases developed postoperative hematoma, which were managed conservatively and resolved spontaneously. Two cases  developed wound infection and were managed with antibiotics and daily dressing until infection resolved. None of the patients had major complications such as dehiscence, urethral stricture, or fistula. Three patients developed meatal stenosis; two of them responded to repeated dilatation twice weekly for 2 weeks; and one needed meatoplasty. In one patient, the most distal of the glans approximation sutures disrupted, leading to a minor detachment in the glans. There was no recurrent chordee. Two patients underwent meatal retraction, wherein the urethra migrated proximally but still within the glans; only one of these patients required a second procedure.Conclusion The urethral mobilization technique seems tobe a good method for the repair of distal hypospadias with or without chordee with satisfactory cosmetic and functional results. The procedure has the advantage of avoiding the need for a second layer of tissue covering during repair. Moreover, there is no chance for the development of urethrocutaneous fistula, a major postoperative complication of other surgical techniques creating a neourethra. Postoperative management is simple and a brief hospital stay is sufficient.Keywords: distal hypospadias, hypospadias repair, urethral mobilizatio

Laparoscopic management of pediatric and adolescent patients with intra-abdominal complications of ventriculoperitoneal shunt

Background/purpose: Ventriculoperitoneal (VP) shunt is the most common operative procedure performed in the treatment of hydrocephalus. The aim of this procedure is to drain CSF from the ventricles to the peritoneal cavity, thus to decrease the intracranial pressure. Numerous complications as a result of this technique are reported in the literature and are most commonly located around the peritoneal end of the shunt tube. The standard approach for management is laparotomy and correction of the complication. This approach, although solves the problem, causes the formation of adhesions, which are also not devoid of consequences. The aim of this study is to present our experience and outline the role of laparoscopy in the management of intraabdominal complications of VP shunt in pediatric and adolescent patients.Patients and Methods: Over a period of 4 years, 14 patients were managed and recruited in this study. All patients were presented with recurrent abdominal signs and symptoms or elevated intracranial pressure. All patients were managed laparoscopically according to the final diagnosis.Results: Fourteen patients (9 men and 5 women) with abdominal complications of VP shunt catheter were managed. Their ages at operation were ranged from 10 months to 15 years. All patients were investigated, diagnosed and managed laporoscopically. The median operative time of the laparoscopic procedure varied according to the diagnosis. It was 120 minutes in pseudocysts, 45 minutes in recurrent congenital inguinal hernias, 100 minutes in adhesive intestinal obstruction and 35 minutes in subcutaneous cyst and 30 minutes in umbilical fistula. Follow up period extended for 24 months after the procedure and all patients had complete resolution of their presenting abdominal or neurological symptoms. The length of the postoperative hospital stay ranged from one day in recurrent congenital hernias up to 4 days in the other procedures. There were no intra- or postoperative complications related to the laparoscopic technique.Conclusion: Laparoscopic is a very useful diagnostic and therapeutic tool in dealing with intra-abdominal complications of VP shunt with high safety and an excellent outcome.Keywords: hydrocephalus, laparoscopic management, ventriculoperitoneal shun

Low-cost laparoscopic appendectomy in pediatric patients

Background/purpose: Laparoscopic appendectomy is widely practiced worldwide and has become one of the commonly performed procedures in pediatric surgery practice. However, the cost effectiveness of the procedure remains a major concern. The present study aimed to evaluate the safety and effectiveness of the operative techniques used to reduce the cost of the procedure.Patients and methods: A prospective study was conducted on patients undergoing laparoscopic appendectomy over a period of 2 years. The techniques used to reduce the cost of laparoscopic appendectomy were as follows: (i) using reusable trocars instead of disposable ones; (ii) using monopolar electrogoagualtion to seal the mesoappendix instead of staplers, LigaSure, or Harmonic scalpels; and (iii) using a handmade loop to secure the base of the appendix instead of using endoloops.Results: This study included 39 boys and 21 girls. The median age was 10 years. The mean duration of the operation was 56.5 min. No intraoperative complications  were encountered. Two cases developed pelvic hematoma and were managed conservatively with success. The mean hospitalization stay was 2 days.Conclusion: Division of the mesoappendix using monopolar electrocautry and closing the base of appendix using handmade endloops during laporoscopic appendectomy appears to be a simple, effective, safe, and cost-efficient technique. Therefore, the use of more costly instruments, such as the endostapler, LigaSure, or Harmonic scalpel, seems unwarranted.Keywords: cost reduction, laparoscopic appendectomy, pediatric ag