Frequency of urethrocutaneous fistula following snodgrass hypospadias repair in children

To determine the frequency of urethrocutaneous fistula over a period of three months following snodgrass hypospadias repair for the treatment of distal penile hypospadias in children. This descriptive study was conducted in the pediatric surgery unit, Lady Reading Hospital, Peshawar over a period of eight months from June 2009 to February 2010. Patients with distal penilehypospadia without chordee between 2 and 14 years were included and patients were excluded who had previous repair for hypospadias. All those patients fulfilling the inclusion and exclusion criteria whose parents gave informed consent after explanation of the whole protocol were admitted through outpatient department for the said procedure and data was analyzed. A total of 52 patients were included in the study. All patients were in the range of 2 to 10 years and underwent Snodgrass Tubularized Incised Plate [TIP] urethroplasty for hypospadias repair. The overall rate of urethrocutaneous fistula was 9.6% [5 out of 52 patients]. Mean operative time noted in minutes was 57.52 minutes. No major morbidity or mortality was noted in this study. TIP urethroplasty is simple, single stage operation in the management of hypospadias and has good functional and low complication rate

Modified posterior sagittal ano-rectoplasty: a new approach for the management of ano-rectal malformations in children

To introduce a technical modification in Posterior Sagittal Ano-rectoplasty [PSARP], commonly known as Pena's procedure, and to analyse the outcome of such modified procedure in terms of fecal continence and other relevant complications in children with ano-rectal malformations. It was a prospective and descriptive study, conducted at the department of pediatric surgery, Lady Reading Hospital Peshawar from January 2004 to December 2006. Forty patients were studied. All children of either sex with ano-rectal malformation who presented first to our department were included in our study excluding others treated some where else. Relevant investigations were performed in all patients. Diverting colonic or small bowel stoma was created in all patients at presentation to our department. The technique was performed at or after six months of age, depending upon the clinical condition of the patient. After discharge, all patients were examined and monitored in the out-patient department over a period of two years. Out of 40 patients 25[62.5%] were male and 15 [37.5%] were female age range from 6-12 months. On 35 [87.5%]. Isolated PSARP while on 5 [12.5%] patients modified PSARP with abdominal approach were performed. Anal stenosis was found in 3[7.50%] patients, rectal mucosal prolapse in 4[10%], faecal soiling and faecal incontinence in 17[43.58%] and 7[17.05%] patients were respectively. Faecal continence was good, fair and poor in 15[38.46%], 17[43.58%] and 7[17.94%] patients respectively. Our results of the present series suggest that this procedure is a valuable alternative to PSARP for the treatment of anorectal malformations

Dehiscence of laparatomy wounds in children

To assess the various causes or factors leading to dehiscence of incised surgical wounds of the abdomen in children. The record and charts of all patients who developed dehiscence of the abdominal wounds after operation for various diseases were reviewed and data was collected. The age, sex, timing of surgery, reason for surgery, place of primary surgery, operating experience of surgeon, type of suture material, surgical technique, associated medical conditions, nutritional status and the use of per operative antibiotics were the variables which were analyzed. Different causes of wound dehiscence were assessed and analyzed. During the period of 12 months 22 patients developed wound dehiscence. Age ranged from 3 days to 10 years. There were 13 male and 9 female patients. The reason for primary surgery was: intussusceptions in 2 patients; worm obstruction: 2; colostomy for recto vaginal fistula: 3; colostomy closure: 3; posterior saggital anorectoplasty combined with abdominal approach: 1; abdominal injuries [blunt and penetrating]: 5; enteric perforation: 3; mass abdomen: 2 ; band obstruction and subsequent anastomotic leak: 1. Two patients died during the treatment. 17 patients developed complete burst which was repaired while 5 patients were treated conservatively and developed incisional hernia. Wound dehiscence was commonly seen in patients with abdominal wound infection, peritonitis and malnutrition. Control of infection, correction of anemia and malnutrition along with strict adherence to surgical principles plays a vital role in preventing the dreaded complication of abdominal wound dehiscence

Which age, sex and season brings more chances of intussusception for children-an analysis

To know as to which age, sex and season has more cases of intussusception, in children up to the age of 12 years. This prospective study spread over a period of 18 months. A total of 71 patients with surgically diagnosed intussusception were studied. The relevant data, both pre-operative and post-operative, of children who were operated for intestinal obstruction and finally turned out to be suffering from intussusception, was entered in a pre-designed proforma and the information so obtained was analyzed according to objectives of the study. Out of 71 children 55 [77.45%] were male and 16 [22.55%] were female patients. Male to female ratio was 3.4:1. 16[22.53%] were 3 to 7 months old, 55 [77.46%] below 1 year, 16 [22.53%] between 1 to 2 years and 13 [18.30%] above 2 years. 9 [12.67%] were recorded in January, 6 [8.45%] in February, 8 [11.26%] in March, 2 [2.81%] in April, 11 [15.49%] in May, 4 [5.63%] in June, 4 [5.63%] in July, 2 [2.81%] in August, 9 [12.67%] in September, 6 [8.45%] in October, 7 [9.85%] in November, 3 [4.22%] in December., Intussusception is more common in male than female children and again is more common below the age of 2 years and occurs mostly in January-March, May and September to November months of the year, the first 3 months and month of May coinciding with the period when gastroenteritis is endemic and September - November when respiratory tract infections predominate in children

Surgical management of hepatic hydatid cyst in children

To know the effectiveness of removal of hydatid cyst of liver along with pericyst [pericystectomy] as operative treatment, in terms of intra-operative and post-operative complications in the pediatric age group. This study was conducted on paediatric patients with liver hydatid cysts at Department of Paediatric Surgery, Lady Reading Hospital, Peshawar from January 2000 to December 2006. All patients with ultrasound findings for hydatid cyst disease of the liver were included in the study. They were evaluated according to age, clinical presentation, ultrasound and CT scan findings for operative management. After Laparatomy through right transverse incision, half of the contents of the cyst were aspirated, refilled with hypertonic saline solution of the aspirated volume and after waiting for five minutes Pericystectomy was carried out, followed by careful examination and stoppage of any leakage of blood or bile from the residual cavity. In infected cases the cavity was drained. Out of 21 paediatric patients operated for liver hydatid cysts during the study period, 11[52.4%] were girls and 10 [47.6%] were boys, with age ranging from 4 to 15 years. Cystectomy with tube drainage was performed in 20 patients while in one patient de-roofing was performed because of rupture. Hypertonic saline was used as a scoliocidal agent. There was no operative mortality. The mean hospital stay was 6.5+3.8 days. Recurrence after operation was seen in one [4.8%] patient. Hepatic hydatid cysts in children can be treated successfully by peri-cystectomy

Retrospective analysis of clinical presentation of children with diagnosed intussusception

To know the presenting clinical features of intussusception in children up-to the age of twelve years. The study was conducted at the Department of Paediatric Surgery, Post-Graduate Medical Institute, Lady Reading Hospital, Peshawar, over a period of 18 months. A total of 71 patients with diagnosed intussusception were included. The relevant data, both pre-operative and postoperative, of children who were operated for intestinal obstruction and finally turned out to be suffering from intussusception, was fed into a pre-designed proforma and the information so obtained was analyzed according to objectives of the study. The common presenting features were colicky abdominal pain in 70 [98:59%] cases, vomiting in 67 [94.36%] cases, abdominal distension in 67 [94.36%] cases, constipation in 63 [88.73%] cases, bleeding per rectum in 61 [85.91%] cases, palpable mass per abdomen in 56 [78.87%] cases and fever in 18 [25.35%] cases. In 11 [15.49%] cases there was a mass palpable per digital rectal examination and 05 [07.04%] patients had diarrhoea on presentation. Colicky abdominal pain, vomiting, abdominal distention, constipation, bleeding per rectum, palpable mass per abdomen are the commonest presenting clinical features of intussusception in children

Soave procedure versus duhamel procedure for the treatment of hirschsprung's disease

To compare the outcome and cost effectiveness of Soave's and Duhamel's procedures in patients with Hirschsprung's disease in our setup. Patients with clinical suspicion of Hirschsprung's disease were admitted to Paediatric Surgery Unit of PGMI/LRH, Peshawar from July 1998 to July 2003. Diagnosis was confirmed with full thickness rectal biopsy. Colostomy or ileostomy was performed. Stoma was utilized in all patients as a part of the pull-through operation. Staple [GIA 75TLC] was applied in Duhamel procedure with covering ileostomy or colostomy, while no covering stoma was provided in Soave procedure. Postoperative course was monitored and any complication encountered were noted. The results of the two procedures were analysed and compared. Out of 60 patients, 30 patients had Duhamel and 30 patients had Soave procedure. Age ranged form 12 months to 5 years. In Soave procedure, postoperative complications included chronic constipation [33.33%], wound infection [16.66%], anal stenosis [13.33%] and perineal soiling [13.33%]. In Duhamel procedure postoperative complications were wound infection [33.33%], chronic constipation [16.66%] and perineal soiling [13.33%]. Postoperative mortality was 3.3% [1/30] in Duhamel procedure. Hospital Stay was 5-7 days and 7-10 days and cost of the procedure Rs 2500-3000 and Rs 15000-20000 for Soave procedure and Duhamel procedure respectively. Duhamel procedure is more costly and has no better results of surgery than Soave procedure. Hence Soave procedure is more suitable in our set up

Modified posterior sagittal anorectoplasty for the treatment of patients with anorectal malformations

The aim of the study was to assess the results of modification in the posterior sagittal anorectoplasty [PSARP] as devised by Alberto Pena for in patients with anorectal malformations [ARM]. Interventional study. This study was carried out at the Department of Paediatric Surgery, Postgraduate Medical Institute Lady Reading Hospital Peshawar, form January 2003 to December 2004. Forty patients were studied who underwent a modified PSARP. The following technique was adopted. Incision starting from the tip of the coccyx up to the margin of the external anal sphincter muscle complex without cutting it. Levator ani muscle was split preserving the external anal sphincter complex, which was identified by electrical stimulation. Genital or urethral fistula dissected from outside without opening the rectal pouch and divided between the clamps. Fistula was transfixed or repaired with polyglycolic sutures. Rectum was then mobilized to an adequate length. Center of the external anal sphincter complex was identified with a muscle stimulator. Cruciate skin incision was made and cutaneous flaps raised at the proposed anal area. A tunnel was made in the center of the sphincter muscle complex through which the mobilized rectum brought down and stitched with the anal skin to make the neoanus. Rest of the management was similar to the classical PSARP. Patients were followed up in the out patient department and faecal continence was assessed for an average period of 2 years. A total of 40 patients with ARM were studied. There were 25 males and 15 female infants. Age ranged from 6-12 months. Isolated modified PSARP was performed in 35 infants while in 5 patients this procedure was combined with abdominal approach. Post-operative course was uneventful except one death and one burst abdomen. The shape, size and location of the anus were acceptable in all patients. Anal stenosis resulted in 3[7.5%] patients, rectal mucosal prolapse in 4[10%], faecal soiling, and incontinence of faeces in 17[43.58%] and 07[17.05%] patients respectively. Faecal continence was good in 15[38.46%], fair in 17[43.58%] and poor in 07[17.94%] patients respectively. This modification in PSARP allows the surgeon to accurately identify and preserve the anatomic structures that are relevant for faecal continence. Our results of the present series suggest that this procedure is a valuable alternative to classical PSARP for the treatment of anorectal malformations

Two stage management of patients with hirschsprung's disease

To find the outcome of Duhamel procedure in patients with Hirschspnmg's disease.Interventional study. At the Department oj Paediatric Surgery PGMI / Lady Reading Hospital, Peshawar, from January 2003 to December 2004. Twenty patients with Hirschsprung's disease managed over a period of 2 years were included. Diagnosis was established by barium enema and open rectal biopsy. Colostomy was dismantled in all patients and brought down as a pull through gut in a modified Duhamel procedure using a linear cutter [TLC-75].No colostomy cover was provided and the rectum was drained with a big size [30 Fr] flatus tube along with nasogastric suction for 2-3 days. Any complication encountered during the hospital stay was recorded. After discharge patients were followed up in the outpatient department and they were clinically assessed for constipation, diarrhoea, faecal continence etc. There were 15 male and 05 female patients. Age ranged form 12 months to 05 years. All patients had sigmoid colostomy after confirmation with conventional rectal biopsy. There was no mortality in this study. Wound injection occurred in 05 patients. Persistent pyrexia and prolonged hospital stay for more than 10 days was seen in 02 patients. One patient developed incisional hernia while perineal excoriation developed in two patients. Recurrent diarrhoea and perineal soiling jound in 02 and 01 patients respectively. All patients are thriving well with no case presenting with enterocolitis uptil now. There was not a single patient with anal stenosis needing anal dilatation. Two-stage correction of Hirschsprung's disease is a safe procedure in allage groups. It is economical with social advantages to the parents, as the stage of colostomy closure is avoided with elimination ofthe possible complications associated with stoma and its closure. Utilizationojthe stoma to become part ofthe pull through gut gives an additional advantage ofavoiding the need for frozen section biopsy, a facility which is lacking in our set up. From these preliminary data we conclude and suggest that modified Duhamel procedure without covering colostomy is a safe procedure with minimal complications and good results

Usefulness of ultrasound in the diagnosis of infantile hypertrophic pyloric stenosis [IHPS]

The aim of our study was to know the diagnostic accuracy of ultrasonography in infantile hypertrophic pyloric stenosis [IHPS]. Material and This Prospective study of patients with clinical features suggestive of IHPS was carried out from January 2002 to December 2003 [2 years duration], at paediatrics surgery unit of Lady Reading Hospital Peshawar. Patients with clinical suspicion of IHPS were admitted through casualty, OPD and also shifted from other units. After clinical diagnosis of pyloric stenosis, ultrasound scanning was performed in all cases by a single experienced sonographer. All patients underwent surgery and pyloromyotomy was performed in all patients. Patients were followed up for at least 3 months. Twenty patients with clinical suspicion of IHPS were studied. The age ranged from 19 days to 120 days with average of 49 days. Male to female ratio was 19:1. The most common presenting symptom was nonbilious vomiting [100%]. Ultrasound revealed IHPS in all twenty cases. Surgery confirmed the findings of ultrasound scanning, showing 100% sensitivity of ultrasound in diagnosing IHPS. Pyloromyotomy was performed in all cases. There was no complication observed in this study. Ultrasound scanning is a useful tool of investigation and should be done in all suspected cases of IHPS to reduce the diagnostic errors leading to mismanagement

study of effectiveness of local bupivacaine infiltration of the wound in reducing the post-operative parenteral narcotic analgesic requirement

Objective: to see the effectiveness of local perfusion of the wound with bupivacaine .5% following cholecystectomy was studied

Material and Methods: a prospective randomized clinical trail involving 140 patients undergoing cholecystectomy for symptomatic gallstones, using Kocher's incision, was undertaken. Patients were randomized to receive either intermittent intravenous tramadol infusion on demand [parenteral analgesia, PA-group] or wound perfusion with local bupivacaine .5% per-operatively followed by intravenous tramadol infusion, if needed [local analgesia, LA-group]. On hundred and forty patients were recruited in the study, 70 in each group. Patient demographics were comparable in the two groups

Results: there was no statistically significant difference in post-operative pain scores at rest and with movement between the two groups, excepts for pain scores at rest on the first post-operative day [P = 0.03]. The median total amount of tramadol used was significantly greater in PA group i.e. 600 [range 500-1000] mg as compared to the amount used in LA-group i.e. 200 [range 0-400] mg

Conclusion: direct local wound perfusion of bupivacaine 0.5% provides good pain relief after cholecystectomy and reduces the requirements of parenteral narcotic analgesia with no major side effect. In other words, it is a safe and feasible alternative to parenteral opiods

Management of thoracic in juries in children

Objective: the aim of the study was to know the effective way of treatment and to sort out the measures for the prevention of various complications arising from thoracic injuries in children

Material and Methods: this is a prospective study performed on 173 children with thoracic injuries. Birth trauma was not included in this study. All these patients were received in emergency and were admitted to Paediatric surgery unit of Lady Reading Hospital Peshawar during a period of 2 years from January 2000 to December 2001

Results: blunt trauma [121 cases] was the most common cause of chest injuries seen in these children as compared to penetrating injuries [52 cases]. All of them [156 cases] except lung contusion and chest wall injuries were treated with chest tube drainage and under water seal. The clinical condition resulting from these chest injuries confirmed on X-ray chest were haemothorax [99 cases], haemopneumothorax [51 cases] and pneumothorax [6 cases]. Cardiac injuries, great vessel injuries, esophageal injuries, tracheobronchial injuries, stove in and flail chest injuries were not encountered during the course of this study. There is no mortality hm chest intubation in this study. There was no case of emergency thoracotomy however only 2 cases needed elective thoracotomies for complications after treatment with chest intubation

Conclusion: emergency thoracotomy is a lifesaving procedure in all the clinical conditions resulting from thoracic trauma. Isolated chest injuries can be treated effectively by tube drainage of the chest on the affected side, which is safe, less traumatic and associated with least morbidity and no mortality

Erythrocyte glucose-6- phosphate dehydrogenase deficiency: a cause of neonatal jaundice

Objective: to determine the frequency of glucose-6-phosphate dehydrogenase deficiency in the etiology of neonatal jaundice

Material and Methods: this descriptive study was conducted at the Paediatrics Department, Hayatabad Medical Complex, Peshawar from March 2001 to December 2001. All full term newborns with significant jaundice were included, Serum bilirubin level, mother and baby blood group, coomb's test and G6PD enzyme estimation using sigma diagnostic G6Pd reagent were done in all babies

Results: out of 150 icteric newborns, 14% were deficient in G6PD. 90.5% were male and rest were female. No specific precipitating factor for hemolysis was found. The most common age of appearance of jaundice was within the first 48 hours of life. Serum indirect bilirubin level ranged from 9.4 to 40mg%. All G6PD deficient babies receive phototherapy while in 11 babies, exchange transfusion was performed

Conclusion: G6PD deficiency is one of the common causes of neonatal jaundice. Hence, all jaundiced neonates should be screened for G6PD deficiency

Comparison of Magpi and Mathieu repair in distal hypospadias

To compare the outcome of MAGPI and Mathieu Procedures in the treatment of distal penile hypospadias in children. Material and This prospective comparative study was conducted in the Department of Paediatric surgery Lady Reading Hospital, Peshawar from Jan 2002 to Dec 2002. A total of 40 children with distal hypospadias without chordae were selected. They were divided into two groups. Group one consisted of 20 children with glandular, coronal and subcoronal hypospadias without a groove in the glans penis. For this group MAGPI procedure was performed. Group two consisted of 20 children with coronal and subcoronal hypospadias with a groove in the glans penis. This group was managed with Mathieu procedure. of the two procedures were compared. Age of these boys ranged from one to 10 years. 32 children had coronal and subcoronal hypospadias while 8 had glandular hypospadias. Functional and cosmetic were good in Mathieu procedure but the fistula rate was more as compared to MAGPI procedure. Meatal stenosis was more commonly observed in MAGPI procedure. Observed P valve of 0.02 between two procedure is significant statistically. The MAGPI procedure was found to have better as the fistula rate was significantly less in spite of the frequent meatal stenosis

Management of colostomies in infancy

The aim of the study was to assess the complications of colostomies and sort out the measures for the prevention of various complication.This is a prospective study performed on 88 patients in whom colostomies were performed for various problems and were admitted to Paediatric surgery unit of Lady Reading Hospital Peshawar during the year January 2000 to December 2000. Majority of the patients had Anorectal malformation and Hirschsprung's disease. Colostomies performed in neonatal period had a high complication rate and increased rate of mortality. Skin excoriation, colostomy prolapse, colostomy diarrhoea, and failure to thrive were the most common complications encountered. Proper stoma care, education of the parents regarding the stoma care and timely treatment of diarrhoea are important factors in the prevention of various complications of colostomy