Comparative study between primary closure and delayed primary closure in potentially contaminated abdominal wound in paediatrics age group

Objective: The purpose of our comparative study is whether the delayed primary skin closure of contaminated and dirty abdominal incision reduces the rate of surgical site infection, and the rate of morbidity as compared with the primary skin closure

Study Design: Experimental / Randomized study

Place and Duration of Study: This study was carried out at National Institute of Child Health Karachi from February 2007 to July 2007

Materials and Methods: A total of 60 patients of pediatric age group were included .They have randomized to have their surgical incision [skin and subcutaneous tissue] either primarily closed or left opened with the pyodine soaked gauze packing and loose stitches applied for delayed primary closure which were tied on 4th post of day of wound closure

A wound was considered infected if pus discharged from the incision site

The main out come measured were the incidence of wound infection and the length of hospital stay

Results: This study revealed that the incidence of wound infection was considerably high in those contaminated wound where primary closure was done in 46.67% 18 out of 60 patients, hence increased morbidity with prolonged hospital stay while in delayed primary closure wound infection was 33.33% 10 out of 60 patients

Conclusion: This study revealed that method of delayed primary closure without skin stitches is better than the primary wound closure technique in contaminated abdominal wounds

Spectrum of medico-legal deaths in metropolis of Karachi: an autopsy based study

Background: The number and variety of medico-Iegal deaths has inflated tremendously in the recent years in relation to acts of terrorism using explosive material and street crimes which often result in tragic death

Objectives: To determine the frequency, causes and manners of medico-legal autopsies at three major mortuaries in Karachi

Methods: A case study, involving the medico legal deaths autopsied at three major mortuaries in Abbasi Shaheed Hospital, Jinnah Postgraduate medical center and Civil Hospital, from March 01, 2008 to February 28, 2009. A detailed autopsy was conducted in each case to determine the cause of death. The bodies were first examined externally followed by dissection of body cavities in accordance with Robert Virchow's technique. The results were collected from the respective institutions on a structured performa and were statistically analyzed using SPSS version 15. The Mean +/- SD was calculated for age

Results: Out of total 2,090 autopsies c0nducted during the period of study, 98.7% of the deaths were found to be due to unnatural causes. Homicides accounted for 54% of the deaths where as 39.3% were accidental deaths. Firearms were the most common cause of deaths [44.6%], followed by road traffic accidents [27.7%]. Male to female ratio was 9:1 with 88.8% of the victims being males. Majority of the victims belonged to age group 19-32 years [47.3%]

Conclusion: Homicides were the most common manner of death [54%], followed by accidents [39.3%]. Frequency in relation to cause of death revealed firearm injuries accounting for 446% deaths followed by road traffic accidents [278%]

Floating death in pericardium

A 12-year-old boy referred from another facility after sustaining stray bullet injury to chest on left side with no exit wound. He remained stable through out although chest intubation was done in referring hospital. In our Emergency Room he remained well therefore shifted to surgical unit. Investigations revealed bullet in pericardial cavity. It was decided to remove the bullet on elective basis. Surgery was deferred at the request of parents. Six months later child was operated. Initially thoracoscopy was performed but it was converted to open thoracotomy as bullet could not be identified. It was then retrieved easily from paricardial cavity. Post operative recovery was uneventful

Video assisted thoracoscopy in children

To determine the outcome of video-assisted thoracoscopic surgery [VATS] in terms of its efficacy, safety and usefulness in children. Case series. Department of Paediatric Surgery Unit B, National Institute of Child Health, Karachi, from May 2006 to December 2006. This study was carried out on patients who were admitted with various intra thoracic pathologies and had video assisted thoracoscopy. Total of 13 patients underwent VATS. There were 6 patients of empyema thoracis who underwent thoracoscopic decortication and done successfully. There were four patients of hydatid disease among which three were converted into open thoracotomy. Two patients were of mediastinal mass and one of bronchopleural fistula. In these patients only biopsy was done which was conclusive in one patient, who was diagnosed as having ganglioneuroma. In other biopsy was inconclusive. Biopsy report was that of tuberculosis in patient with bronchopleural fistula. Video-assisted thoracoscopy is a safe and effective diagnostic and therapeutic procedure in children and this new approach has an important place in pediatric thoracic surgical practice. Thoracoscopic decortication can be treatment of choice for early empyema thoracis. As the learning curve progresses, more and more procedures can be done by VAT

Posterior urethral valves: varied presentations and outcome after preliminary surgical treatment

To find out various modes of presentation and outcome after preliminary surgical treatment of posterior urethral valves in pediatric population. Surgical Unit B National Institute of Child Health, Karachi, during the years 2004-2005. All consecutive patients coming in outpatient / emergency departments, diagnosed as having posterior urethral valves and those who had received initial treatment and came for follow up, were included in the study. All the neonates underwent vesicostomy initially, followed by valve ablation at appropriate age with plan for undiversion at later date. In infants valve ablation was performed if urethral size admitted pediatric cystoscope while older children underwent primary valve ablation. There were total of 22 patients managed during the study period. They included 5 neonates [0-1 month], 11 infants [1-12 months] and 6 older children [1year-12 years]. The main presenting complaint in majority of neonates was inability to pass urine and one had urinary ascites. Infants presented mainly with either difficulty in passing urine [n 5] or dribbling and acute urinary retention in 2 patients each. Majority of older children [n 3] presented with poor urinary stream and dribbling while two had diurnal enuresis and one came with straining at micturition. In all the neonates' vesicostomy was performed. Out of these 3 received valve ablation therapy, followed by undiversion. Two of them improved while 1 had bladder dysfunction. Of the remaining 2 patients with vesicostomy 1 is still waiting for definitive procedure while the other is lost to follow up. Of infant group, 8 were subjected to vesicostomy and valves ablated at later stage whereas 2 received primary valve fulguration therapy. One patient of this group died before any intervention performed. In older age group, 3 received valve ablation as initial treatment while 3 were lost to follow up before any intervention. Outcome assessed clinically, biochemically and radiologically. Out of total 22, four had not received any intervention. Of the remaining 18, treatment completed in 12 patients, 8 of these improved and 4 had residual disease. Two patients expired and 4 were lost to follow up. The overall improvement rate observed at the end of our study was 44%. In 22% patients there were still residual ongoing problems that need to be addressed on long term basis

Intralesional bleomycin injection- A primary therapy for peripheral lymphangiomas

To evaluate the efficacy of intralesional Bleomycin Injection [IBI] as a primary therapy for peripheral lymphangiomas in children. A prospective study was conducted at NICH Karachi from January 2003 to December 2005. Patients with peripheral lymphangiomas were included in the study. Exclusion criteria included previously treated lymphangiomas, infected lesions, intra-thoracic and intra-abdominal lesions. Thirty three patients were included in the study. All were treated with Intralesional Bleomycin Injection [IBI]. After aspiration of fluid from the lesion, 0.5 mg/kg of Bleomycin diluted in saline was administered at different sites into the lesion. Depending upon the size of lesion and age of patient, procedure was performed in operating theatre under local or general anesthesia. Reduction in size was seen in 90% cases [n=29], out of them 30% [n=10] showed near complete disappearance and 63% [n=21] showed good response. Two patients [6%] showed poor response and they underwent surgery. Few patients had minor complications like fever, pain, redness and increase in the size after injection. All these complications were managed conservatively with symptomatic treatment and no patient required hospitalization. IBI is an effective therapy for lymphangiomas, with results comparable to surgical excision. It has the added advantage of avoiding inadvertent injury to vital structures, scarring and other complications of surgery. We recommend it as a primary therapy for all peripheral lymphangiomas

Childhood nephrectomies for benign renal lesions

To conduct an audit of nephrectomies done in children for benign renal pathology. Evidence based study. Place and Duration: National Institute of Child Health, Karachi, during the year 2004-2005. The record of all the paediatric age group patients undergoing unilateral nephrectomy for benign renal diseases over a 2-year period were reviewed for the underlying diagnosis and indication for nephrectomy. Patients of Wilms` tumor subjected to nephrectomy were excluded. In the study nephrectomy was carried out in a total of 12 patients. There were 8 males and 4 females. The age range was 4 to 12 years. Nephrectomy was performed for renal tuberculosis in 5, pelvi-ureteric junction obstruction [PUJO] in 5, congenital hypoplastic kidney in 1 and one for multicystic dysplastic kidney. All the patients following nephrectomy remained well in the immediate post operative period and thereafter. Late presentation and delay in diagnosis of benign lesions of the kidney remained the main culprit in loosing a vital organ in childhood

Complications of inguinal hernia surgery in children

To determine the postoperative complications of elective inguinal hernia surgery in children. Descriptive study. Surgical Unit B, National Institute of Child Health, Karachi, from February 2004 to November 2005. Children with inguinal hernia, admitted electively through surgical outpatient, were included. Patients operated earlier and presenting with complications were excluded. Patients with concomitant diseases, regarded as predisposing factors for hernia development, were also excluded. Physical examination and relevant investigations [hemoglobin level and ultrasound of scrotum] were performed. Inguinal hernia was repaired electively by Rehbein procedure. Patients were followed at day 7, 1 month, 3 months and 9 months to note the postoperative complications of the surgery. Ultrasound was repeated at 6 and 9 months postoperatively for the size of testes. A total of 223 patients with inguinal hernia were included in the study. Age ranged from 8 days to 12 years. There were 188 males with 75 patients under 1 year of age. The longest follow-up was upto 9 months in 133 patients. The complications of scrotal edema occurred in 6 [2.97%], haematoma in 1[0.49%], wound infection in 2 [0.99%] and 5 events of recurrence of hernia in 4 patients. All appeared within 3 months of follow-up. Four recurrent hernia were operated. In all cases intact sac was found. No patient developed decrease in size of testes nor ascent of testes was noted at follow-up. In this series, there were minimal complications observed in relation to inguinal hernia surgery

Correlation the size of undescended testis with its location in various age groups

To assess the correlation of the size of undescended testis with its location in children of various age groups, peroperatively. Cross-sectional study. Surgical Unit B, National Institute of Child Health, Karachi from February 2004 - November 2005. Children presenting with undescended testis at surgical outpatient were recruited. Physical examination and relevant investigations [haemoglobin, ultrasound for location and size of testes] were performed. Patients were divided randomly into three age groups, group I [8 months - 2.5 years], group II [2.6 - 8 years], group III [8.1-13 years]. At orchiopexy location and size of undescended testis were noted. Patients were further sub-divided into groups according to peroperative location of undescended testis, group A [intra-abdominal], group B [intra-canalicular], group C [distal to superficial inguinal ring - pubic]. Where no testis was found, a separate group D was assigned. The size of undescended testis at different locations in various age groups was compared with reference to normal descended testicular size in the respective age group, for statistical significance. ANOVA test was used for intergroup comparison for the size of undescended testis and Student t- test was applied for comparison with reference to normal values of the size of testis. A total of 102 patients with undescended testis were included in the study. The total number of 107 testicular units were assessed. Group I had 28, group II, 41 and group III, 38 testes. There were 24 intra-abdominal, 68 intra-canalicular and 12 pubic in location. In 3 cases, no testis was found at exploration. We found no statistically significant difference amongst groups [p- value=0.090] between the size of the undescended testis at different peroperative locations. The size of undescended testis grew with the age as undescended testis of larger size were found in older age group as compared to younger age group. By applying Student t-test, we did not find statistically significant difference in relation to The size of undescended testis in various age groups in comparison to the reference of mean volume of normally descended testis in the respective age groups. Pre-pubertal size of undescended testis does not differ significantly from that of normal reference value of descended testis in relation to age and location. The ultimate size of the testis can only be assessed after puberty whether it is a normally descended or undescended testis

Surgical management of renal tumors in children

To analyze case records of children with renal tumors. Case series. Surgical Unit B, National Institute of Child Health, Karachi during years 2004-2005. Case records of all patients managed during the study period were reviewed for clinical presentation, investigations and surgical management. National Wilms' Tumor Study. Group [NWTSG] and International Society of Pediatric Oncology [SIOP] protocols were used depending upon stage in cases of Wilms' tumor. Trucut biopsy was done for tissue diagnosis as proposed by UK Children's Cancer Study Group [UKCCSG]. Touch imprints were also made. Surgical procedure was analyzed in terms of ease of dissection, tumor spillage and extent of excision. Twenty-one patients of renal tumors were managed in two years period. Nearly 60% of patients were less than 2 years of age. Majority [n 14] presented with abdominal mass. Few had complaints of abdominal pain. One patient an infant, presented with profuse hematuria. Trucut biopsy was done in 18 cases to have tissue diagnosis. Three patients underwent primary exploration. There were 17 cases of Wilms' tumor and in one case it was suspected on touch imprints. Fourteen patients of Wilms' tumor were given pre operative chemotherapy [SIOP protocol]. Twelve of them were in stage III and IV. Nine out of this have undergone nephrectomy. Marked tumor regression in size of tumor was noted. The tumor also became firm. Only one tumor ruptured during excision. In one tumor with horse-shoe kidney, residual tumor left at margins of dissection. Three patients underwent primary nephrectomy. Two of these were in stage I and one in stage III [NWTSG protocol]. Patient in stage III died in immediate post operative period because of hemorrhage. There was one case each of mesoblastic nephroma, cystic nephroma and rhabdoid tumor. In all these nephrectomy was done following trucut biopsy. Patient with rhabdoid tumor received pre operative chemotherapy. This tumor ruptured during surgery and gross spillage occurred. Wilms' tumor was the most common pediatric renal tumor. Most of the patients were younger than the reported age and presented with advanced stage of disease. SIOP protocol found more appropriate in our group of patients

Neonatal intussusception: a rare entity

Intussusception is a common cause of intestinal obstruction in infancy. It has been reported in pre-matures and during fetal life as well. In full term neonates it is a rare entity. In this case report we describe our experience of management of a six days old male baby. Who turned out to be a case of idiopathic ileoileal intussusception. As the gut was non viable, resection and anastomosis were performed. Post operative recovery were uneventful

Management of simultaneously ingested and aspirated foreign bodies in an infant

This report describes the management of a 7-month-old baby who aspirated one and ingested two paper pins at a time. Bronchoscopic removal was done for aspirated pin and ingested pins were observed for spontaneous passage in stool, which occurred in 48 hours without any untoward incidence

Congenital pyloric atresia: Isolated and associated with aplasia cutis congenita

Two cases of congenital pyloric atresia [CPA] are, hereby, reported. One was suspected on antenatal ultrasound and turned out to be an isolated anomaly. Other patient had a rare association of aplasia cutis congenita with congenital pyloric atresia. The lesions of aplasia cutis congenita were multiple while congenital pyloric atresia was of type II. The patient with an isolated lesion survived following surgery while the other baby died of sepsis in postoperative period

Antibiotic sensitivity pattern in burn wound cultures

To find out the pattern of microbial flora and their sensitivity to antibiotics in burn wounds cultures. Design: Descriptive study. Place and Duration During year 2003, at Burns unit, National Institute of Child Health, Karachi. Subject And Twenty five consecutive patients were included in the study and pattern of most common pathogens was studied with special reference to their antibiotic sensitivity. The bacterial cultures were taken at different intervals during the hospital stay, first on the second day of admission and then subsequently, following every 7-10 days. Antibiotic sensitivity pattern was correlated to the antibiotic the patients were receiving. Our results revealed that the most frequent isolate was pseudomonas [80%] followed by staphylococcus aureus [40%], klebsiella [28%], proteus [16%] and streptococcus [8%]. Time related changes showed that the bacterial isolates were predominantly gram negative rods [70%]. in the first culture taken on the 2nd day of admission and remained high throughout the hospital stay and was up to 90% in the final culture. There is a specific pattern of burn wound microbial colonization, with time related changes in dominant flora. Antibiotic sensitivity profile is helpful to make guidelines for dealing with the burn wound at the outset and for which antibiotic to start with. Following this protocol the morbidity and the resistant flora could be avoided

Hypertrophic pyloric stenosis in a premature. A case report

A four day old baby girl weighing 1.3 kg admitted with respiratory distress. She was delivered by Caesarean section prematurely at 30'h week of gestation due to early rupture of membrane without labor pains. There was no birth asphyxia. She was provided incubator care. As baby was vomiting NG tube was placed. She had non bilious vomiting whenever trial feed given. Surgical opinion was the sought. X ray abdomen showed large gastric shadow with paucity of gas in rest of the abdomen [Figure I]. A diagnosis of malrotation was made. Baby was thus explored. At laparotomy gut was found normally placed with normal caliber of the duodenum. Pylorus was found thickened with dilated stomach. Its appearance was not very classical. Pyloromyotomy was attempted. During the procedure perforation occurred at duodenal end that was closed. Post-operative recovery was uneventful. Baby was put on TPN for 4 days. Trial feed started which was tolerated and then beast feed allowed. She was later discharged

Diagnostic value of clinical profile of patients with foreign body aspiration

Foreign body aspiration is a true emergency with significant morbidity and at times mortality. The aim of this study was to evaluate the clinical profile of the patients suspected of foreign body aspiration so as to know how reliable they were in making decision of bronchoscopy. Design: A prospective study. Place and Duration of Study: At B unit of Paediatric Surgery at National Institute of Child Health, Karachi during the year 1999. Subjects and Forty-two patients, with suspicion of foreign body aspiration, in whom bronchoscopy was performed, were included in this study. Sensitivity and specificity of historical events [history of foreign body aspiration, choking accident], clinical examination and diagnostic tool [x-ray chest] were calculated. There were 26 male and 16 female patients. Ages ranged from 3 1/2 months to 12 years. The most common foreign body removed was betel nut [n-18]. The sensitivity of history of foreign body aspiration was 78% with the specificity of only 16%. The specificity of choking accident was 100% but sensitivity only 55%. Clinical signs were not helpful in arriving at diagnosis. Similarly, x-ray chest was sensitive in 44% of patients only. A history of choking episodes should alert the physician to the possibility of foreign body aspiration. Clinical signs and radiology are not very helpful. High degree of suspicion should be exercised to decrease the morbidity associated with this condition

Chemical analysis of urinary calculi in children

A study of 23 cases of urinary calculi, that were chemically analyzed, showed that most common constituent of the stones removed was oxalate followed by urate. Struvite stones were found infrequently. The lower urinary tract stones occurred more frequently than upper tract calculi and all urates calculi were found in patients less than five years of age. These findings differ from those reported from other developing countries

Removal of impacted blunt esophageal foreign bodies by Foley catheter

A Foley Catheter has been used to remove blunt impacted foreign bodies of the oesophagus. Nine cases were dealt with in the Paediatric Emergency Department of the National Institute of Child Health, Jinnah Postgraduate Medical Centre, Karachi. On X-Ray the foreign bodies coins of different sizes. In 8 out of 9 patients, they were removed successfully by the Foley Catheter. One was removed at oesophagoscopy. The success rate was 88.9%

Pseudopancreatic cyst in children and its management: 5 years experience at National Institute of Child Health JPMC Karachi

During the period 1980-84 seven children between 4 and 12 years of age underwent surgery for Pseudopancreatic cyst at the National Institute of Child Health [NICH]. The cysts were post-traumatic in five children and post-inflammatory in two. Cystogastrostomy in 5 patients and external tube drainage in two patients were successfully carried out and there were no complications. An initial attempt at aspiration in 2 cases resulted in cyst recuurence