Evaluation of therapeutic procedures provided in the pediatric surgery unit at alexandria university pediatric hospital

Objectives: Statistical analysis of the pediatric surgery unit at Alex and ria University Children's Hospital [AUCH] retrospective survey from January 2009 to December 2011 and a prospective survey during the year of 2012, AUCH Pediatric Surgery Unit is a tertiary health care facility that serves four provinces [Alex and ria, Behira, Kafr El Sheikh and Marsa Matrouh], AUCH Pediatric Surgery Unit is the first pediatric surgical center established in Egypt by Professor Doctor El Sayed El Akkary in 1973. AUCH Pediatric Surgery Unit receives an average of 7200 cases in the outpatient clinic per year and its schedule has 4 operating list per week and emergency 24 hours a day seven days a week. The most common cause of neonatal admission to the unit during the year 2012 was anorectal malformations found in 68 cases followed by Tracheo-oesophageal fistula [TOF] in 53 cases, almost a case per week, The overall mortality among operated cases done to 1491 case during the year 2012 was 5% with 95% of cases cured and discharged, which is considered an excellent rate of cure and discharge compared to the overall mortality. Study Design: Retrospective survey: from year 2009 till year 2011. Prospective survey: starting from January 2012 till the end of December 2012. Results: Part I: Results of the retrospective survey: A total of 1798 patients were registered in the unit admission records for these three years. Part II: Results of the prospective survey the total number of admissions to the pediatric surgical unit during year 2012 was 1491 patients.Conclusion: 1. Noticeable improvement in registration and recording from 2009- 2012. 2. Electronic recording is an important next step to help medical researching and future study. 3. Electronic records are very important in decision making, fund raising and upgrading of services. 4. Pediatric Surgery Unit in AUCH is a tertiary health care training center due to large volume of cases at national and international levels. 5. Mortality is mainly neonatal, so efforts should be directed to further reduce. Key words: - Statistical analysis, - Demographic characteristics, - Pediatric surgery unit, Alex and ria university children hospital

importance of portal venous gas in neonatal necrotizing enterocolitis; review of 15 cases

To find out if the presence of portal venous gas [PVG] in the abdominal radiography of neonates with necrotizing enterocolitis [NEC] indicates surgical intervention. Retrospective study of cases of NEC managed by the authors over a period of 5 years. Cases with and without PVG were compared Records of 63 neonates with the diagnosis of NEC were obtained. The overall mortality was 20 cases [31.7%]. In both the medically [48 cases] and the surgically [15 cases] treated group. The mortality rates of cases with PVG were not statistically different from those without PVG [33.3% versus 15% ; P value=0.3, for the medical, and 83% versus 66.6% ; P value=0.6, for the surgical]. At surgery, intestinal pan-necrosis was found in 3 cases with PVG [50%] and non in cases without PVG [P=0.04]. Many cases of NEC with PVG could be treated successfully without surgery, with no difference in mortality. However, the presence of this radiological sign in cases requiring surgery, based on other indications, is associated with poor prognosis

Laparoscopy for impalpable testes: is inguinal exploration necessary for hypoplastic gonadal vessels exiting the deep ring?

During laparoscopy for impalpable testes [IT], if the vas and vessels were found exiting the deep ring, many surgeons proceed to inguinal exploration as a routine, regardless the presence or absence of the processus vaginalis [PV] or the adequacy of the vessels. This is to detect an impalpable intra-canalicular testis with possible orchidopexy; if the testis is normal, or excision of a small atrophic testicular remnant; for fear of possible malignant changes later on. It is agreed that in cases of normal testicular vessels the exploration of the inguinal canal should follow. However, with hypoplastic vessels, the need for groin exploration has been questioned. The aim of this study is to assess whether routine inguinal exploration is necessary in all cases of normal vas and hypoplastic vessels passing through the deep inguinal ring during laparoscopy for IT. This is a retrospective study of cases of IT managed by the authors, where during laparoscopy, the vas deferens and the gonadal vessels; were seen passing through the deep inguinal ring. Cases were divided into 4 groups according to the condition of the PV; present [patent or closed] or absent, and the adequacy of the vessels. Findings at inguinal exploration, which was routinely done in all cases, as well as at histo-pathological examination, when done, were compared. The ends of the cord structures were "biopsied" and submitted to histo-pathological study. Cases with hypoplastic vessels were particularly compared in relation to the presence or absence of any testicular tissue on histo-pathological examination. Over a period of 4 years; 27 children had laparoscopy for 36 impalpable testes. Twenty-three cases [64%] had the vas and vessels passing through the deep ring. Eleven cases [48%] had hypoplastic vessels. Five cases [22%] had PV and on inguinal exploration, 3 cases [60%] had atrophic testes, and 2 had small "nubbin" [with calcification and fibrosis on histo-pathology] that were excised. Six cases [26%] had no PV; with 3 having blind ended vas and vessels and 3 having a small "nubbin". No case in the last group showed testicular tissue on histo-pathology. In cases of hypoplastic vessels exiting the deep inguinal ring, it is the presence or absence of PV that should determine the next step. If the PV is present, the possibility of finding an atrophic testicular tissue, which should be excised for fear of malignant changes, is high and inguinal exploration should follow. If the PV is absent, this possibility is not there, and inguinal exploration is unnecessary

Hypospadias repair using the snodgrass technique: the Alexandria experience

The aim of this study was to present single author experience with the technique of tubularized incise plate urethroplasty [Snodgrass operation] in the management of different types of hypospadias. Two hundred eighty seven [287] patients were operated upon between February 1998 and March 2001 in the Pediatric Surgical Center, University of Alexandria. Two hundred twenty one cases had distal hypospadias, 41 cases had proximal penile, 15 of them had skin chordee, and 25 cases had previous tailed repair. The technique used was that originally described by Snodgrass with our modification in the shape of incision. The results showed that the urethral size was equal to or greater than 8 Fr in 275 patients [95.8%]. Fistula occurred in 31 cases 10.8% The final cosmetic result was considered excellent in 81% of cases, satisfactory in 14% and unaccepted in 5%

Conclusion: We believe that the Snodgrass operation can be applied to a wide range of defects from distal to most severe perineal hypospadias. it creates a functional urethra of uniform caliber with a vertical slit-Iike meatus at the tip of the glans. The most common complication of urethral fistula occurs at an acceptably low rate and is much easier to handle than urethral stricture

Towards more humane circumcision: the use of local anaesthesia in circumcision

Circumcision is performed under five techniques for operative and postoperative pain controI. The purpose of this study was to compare between five anaesthetic techniques used during circumcision for the achievement minimal postoperative pain. In a twelve-month prospective study, 450 boys of different age were randomized into five groups. In group I, no analgesia was given, in groups II and III, IocaI infiltration was done by xylocaine or xylocaine marcaine mixture, while groups IV and V received general anaesthesia. In group V, local infiltration by xylocaine marcaine mixture was done in addition to generaI anaesthesia. The groups were compared for operating room time. The time of stay in post anaesthesia care unit [PACU] was significantly shorter in group I, II and III and children in the first group were agitated and need sedation. The percentage of children who needed analgesia in the immediate postoperative period was greater in group I and IV than in group II, III and V; also it recorded the Iowest value in the third group. Severe degree of crying was noticed frequently in group I, II and IV. In group III and IV most of the children [more than 70 %] were calm during the procedure Conclusion: Circumcision without local anaesthesia leads to considerable degree of pain with possible Iong-term effects. Xylocaine + marcaine mixture resulted in best pain relief during and after the procedure with rapid discharge. General anaesthesia alone results in severe pain after recovery. Adding sucrose pacifier during the procedure was very useful. Lastly, it is the right of every newborn boy to have painless circumcision

Spontaneous reduction of intussusception: avoiding unnecessary surgery

The aim of this work was to study cases of spontaneous reduction of intussusception and their implication on the management and outcome. We routinely use ultrasound for diagnosis and hydrostatic reduction of intussusception with saline enema. The study included 16 patients who were admitted to the Pediatric Surgical Center, Faculty of Medicine, University of Alexandria during the period between January 1996 and October 2000 with the diagnosis of intussusception. They fulfilled the study criteria of spontaneous reduction. Details of the clinical picture were compared with the standard cases of intussusception together with correlation with ultrasound features before and after reduction. All cases were examined on admission and diagnosis of intussusception was confirmed by finding the characteristic target sign on ultrasound. During the period of preparation for hydrostatic reduction or during transport from another center, 12 cases showed evidence of spontaneous reduction, which was confirmed by ultrasound and observation. Hydrostatic reduction was attempted in 4 cases. Four cases showed faint target sign on ultrasound after trial of reduction and were considered questionable. Surgical exploration was performed and showed a reduced intussusception. Spontaneous reduction of intussusception is a possible though rare fate of childhood intussusception. It must be borne in mind to avoid unnecessary surgery in this peculiar subset of patients. The pseudotarget sign on ultrasound can be present for a short period after successful reduction of intussusception and is probably due to residual edema. Awareness, short period of observation and repeating sonography examination after 2 hours will avoid confusion in these cases

Factors affecting the functional results after surgical repair of ectopic vestibular anus

It has reported that 1/5000 newborn will have an anorectal malformation. Some 65 to 80% of anorectal anomalies in girls are in the form of imperforate anus with vestibular fistula, a condition commonly known as [ectopic] or [vestibular] anus. are to study the important clinical and technical variables that influence the long-term results of surgical reconstruction for vestibular ectopic anus. This study included 25 females with vestibular ectopic anus. Perineal deformity was found in [20%]. It showed high incidence in relation to rerouting operation [38%], to post operative complications [25%] and to the non use of colostomy. Anal deformity was found in [20%]. It showed higher incidence in patients operated upon before 2years, in relation to re-routing operation, to post operative as well as the absence of colostomy. Anal stenosis showed the same relations but with higher incidence with cutback procedure and with the use of colostomy. Persistence of ano-vestibular communication [20%] and occurrence of anal incontinence [25%], showed higher incidence in relation to re-routing operation, and the occurrence of post operative complications and anal deformity. Anal manometry including RAP, SAP, VSI, and FACL, were performed for 22/25 patients. There was no statistical differences of all the manometric results in relation to various variables except with VSI that showed lower values with post-operative complications and with the non use of colostomy beforehand. The long-term results of treatment of vestibular ectopic anus, especially anal incontinence, deformity and stenosis as well as persistent fistulas are important parameters to be used for assessment of various surgical techniques. Manometric changes are not typically coinciding with the clinical and anatomical appearance. Delaying the surgery to old age did not give significant reduction in the success of surgery in such low anomalies

surgical management of ambiguous genitalia secondary to congenital adrenal hyperplasia Alexandria experience

Congenital adrenal hyperplasia is the most common cause of female pseudohermaphroditism all-over the world. The excessive androgenic intermediates released by the diseased adrenal gland virilize the external female genitalia during the early in-utero life to a variable degree. Medical treatment is mandatory to correct the life-threatening metabolic derangement leading to salt-losing crises and surgical correction of the genitalia is essential for the psychologic and functional integrity of the female patient We operated on 12 girls with CAH to correct their genitalia. The surgical procedure included: [1]. after complete degloving of the hypertrophied phallus, mobilization of the roots of the corpora to their attachment at the pubic arch. The neurovascular bundle is dissected and preserved to keep supply of the glans. The corporal bodies are dissected from their attachment to the pubic bone to their termination at the glans. Adequate hemostasis is performed and the glans is fixed with sutures to the roots of the corpora. [2]. A posterior perineal flap is fashioned by drawing an inverted u incision centered on anal verge and reaching to the posterior limit of urogenital sinus anteriorly. [3]. the skin of the phallus, after degloving, is used for replacing the labia minora after division in the midline. The results of this operative procedure proved very effective with excellent cosmetic appearance of the genitalia and good vaginal patency in all the cases followed-up for three years. Mild vaginal stenosis was encountered only in three girls but none had tight stenosis. In conclusion, our data proved that complete correction in one stage is the treatment of choice. Reduction clitoroplasty is the best procedure for the treatment of phallic enlargement. Posterior perineal flap vaginoplasty is highly successful in preventing later vaginal stenosis. However, regular follow up is recommended for calibration and dilatation of the vagina and adjustment of the doses of steroid to assure good suppression of adrenal androgens in these girls