The outcomes of fundoplication and gastrostomy in neurologically impaired children in a tertiary care hospital in Saudi Arabia.

OBJECTIVES: To evaluate the outcomes of fundoplication and gastrostomy (GT) in neurologically impaired (NI) children. Methods: A retrospective review of medical charts was performed on 178 NI children up to the age of 14 years inclusive, who underwent fundoplication and GT between 1999 and 2014. Results: After fundoplication, the incidence-rate (person-month) of all hospital admissions (0.95 versus 0.13; p less than 0.001), gastroesophageal reflux (GER) - related admissions (0.67 versus 0.09; p less than 0.001), and admissions for seizures (0.21 versus 0.01; p less than0.001 were significantly decreased. Furthermore, all emergency department visits (0.94 versus 0.23; p less than 0.001), GER visits (0.61 versus 0.12; p less than 0.001), seizure visits (0.24 versus 0.01: p less than 0.001) were significantly reduced. The mortality rate after fundoplication was 35%.The risk factors for predicting mortality were being male (odds ratio: 2.2, p=0.027) and being a do not resuscitate (DNR) child (odds ratio: 5.2, p less than 0.001). Majority of the children that died within a year after the procedure were DNR. Conclusions: Fundoplication with GT is effective in reducing hospital admissions and emergency department visits from GER and seizures in NI children. Because of high mortality within a year of fundoplication and GT in DNR children, anti-reflux medications with GT might be an alternative.

Clinicopathological Characteristics of Hirschsprung's Disease With Emphasis on Diagnosis and Management: A Single-Center Study in the Kingdom of Saudi Arabia.

Introduction: Hirschsprung's Disease (HD) is a motor disorder of the gut caused by the failure of neural crest cells to migrate craniocaudally into the bowel during intestinal development, resulting in a functional obstruction. The majority of patients with HD are diagnosed in the neonatal period when they present with symptoms of distal intestinal obstruction. Aim: This study aims to identify the clinic-pathological characteristic of HD patients in our institution in KSA and comparing it with local and international data. Materials and Methods: This retrospective cohort study was conducted in King Abdulaziz Medical City (KAMC), a tertiary care center in Riyadh, Kingdome of Saudi Arabia (KSA). Results: A total of 54 patients (72% male) were diagnosed with HD. Forty-eight patients (89%) were born at term, and 6 were pre-term. Sixty-three percent of the patients presented in the neonatal period. Twenty-two patients (41%) underwent one-stage endorectal pull-through procedure, 23 patients (43%) two-stage endorectal pull-through, and 9 patients (16%) had three-stage endorectal pull-through. Five out of 54 patients had ganglion cells seen on FS but were absent in the permanent section. Therefore, the concordance rate was 90.8%. Conclusion: FS biopsy is a necessary method to determine the level of aganglionosis intraoperatively in HD, but the definitive diagnosis should be with permanent section. Also, the choice of surgical operation type (single-stage or multi-stage pull-through) depends on the patient's clinical condition.

Management of inguinal hernia in premature infants: 10-year experience.

AIM: Debatable issues in the management of inguinal hernia in premature infants remain unresolved. This study reviews our experience in the management of inguinal hernia in premature infants. MATERIALS AND METHODS: Retrospective chart review of premature infants with inguinal hernia from 1999 to 2009. Infants were grouped into 2: Group 1 had repair (HR) just before discharge from the neonatal intensive care unit (NICU) and Group 2 after discharge. RESULTS: Eighty four premature infants were identified. None of 23 infants in Group 1 developed incarcerated hernia while waiting for repair. Of the 61 infants in Group 2, 47 (77%) underwent day surgery repair and 14 were admitted for repair. At repair mean postconceptional age (PCA) in Group1 was 39.5 ± 3.05 weeks. Mean PCA in Group 2 was 66.5 ± 42.73 weeks for day surgery infants and 47.03 ± 8.87 weeks for admitted infants. None of the 84 infants had an episode of postoperative apnea. Five (5.9%) infants presented subsequently with metachronous contralateral hernia and the same number of infants had hernia recurrence. CONCLUSIONS: Delaying HR in premature infants until ready for discharge from the NICU allows for repair closer to term without increasing the risk of incarceration. Because of low occurrence of metachronous hernia contralateral inguinal exploration is not justified. Day surgery HR can be performed in former premature infant if PCA is >47 weeks without increasing postoperative complications.

Bacillus Calmette-Guérin-related cold thigh abscess as an unusual cause of thigh swelling in infants following BCG vaccine administration: a case series.

INTRODUCTION: Thigh swelling in an infant can be a symptom of a simple benign condition or a life-threatening condition. We observed a cluster of thigh swelling episodes in infants in which the cause was Bacillus Calmette-Guérin-related cold thigh abscess. We report this unusual case series to raise awareness about this diagnosis. CASE PRESENTATIONS: We performed a retrospective review of five infants (four boys and one girl) who presented with Bacillus Calmette-Guérin-related left thigh abscess. The swelling was noticed by the parents at a mean period of three months prior to presentation. The ages at presentation were five, five, eight and nine months for the boys, and six months for the girl. All of the patients were healthy Saudi infants, and received the Bacillus Calmette-Guérin vaccine at birth. Clinically, all of the patients were well and did not demonstrate signs of systemic infection. All patients underwent needle aspiration, with subsequent incision and drainage in four of the five cases. The cultures obtained from the abscess fluids were the key to establishing the diagnosis. Only three patients (60%) received antituberculosis drugs. Wound healing lasted for a mean period of approximately seven months. Two-year follow-up was unremarkable for all of our patients. CONCLUSIONS: Technical errors continue to be significant in the development of vaccine-related complications. Bacillus Calmette-Guérin-related cold thigh abscess is an extremely rare entity.

Intestinal ischamemia in a child due to polyarteritis nodosa: a case report.

Polyarteritis nodosa (PAN) is a rare type of childhood vasculitis. We report the case of a 10-year-old boy who was referred to our hospital following an appendicectomy with fever, abdominal pain, vomiting, diarrhoea, weight loss, joint pains and skin rash. Shortly after admission, he developed peritonitis, and an emergency laparotomy revealed ischaemia of the jejunum which required partial resection. Histologic examination of the resected bowel showed features consistent with PAN. He was treated with steroids and cyclophosphamide. Nineteen months later, he is asymptomatic and thriving. PAN should be included in the differential diagnosis if a child with constitutional symptoms also has gastrointestinal complaints or develops an acute abdomen.

Motor vehicle injuries in childhood: a hospital-based study in Saudi Arabia.

Motor vehicles are a major cause of injury-related deaths in children and may also result in temporary or permanent disability. A retrospective analysis of the medical charts of children aged 12 years and younger, who were involved in motor vehicle injuries during a 10-year period, was undertaken. All children who were admitted and treated at King Fahad National Guard Hospital, Riyadh from January 1994 to December 2003 were included in this study. Data analyzed included age, gender, and mechanism of injury, type of injury, management and outcome. Motor vehicle injuries accounted for approximately 42% of all pediatric traumas. There were 664 children, 469 (71%) male and 195 (29%) female and a male: female ratio 2.4:1. Four hundred and seventy two children were injured as pedestrians (71%), 177 as auto passengers (27%), 11 as bicyclists (1.5%), and 4 as motorcyclists (0.5%). Five hundred and sixty two injured children (85%) were between the ages of 1 and 8 years. The most common injuries were to the head and extremities. Thirty-four children (5.1%) died from their injuries, 30 from head trauma. Thirty-five children (5.3%) were discharged home with neurological impairment from head trauma. In this study, the risk factors associated with high volume of motor vehicle injuries in children include, male, 1-8 years, and pedestrian. Head trauma is the most common cause of morbidity and mortality. This study suggests that nationwide programs should target the use of seatbelts and helmets, and dangerous driving practices.

The immediate and long-term outcomes of newborns with congenital diaphragmatic hernia.

In spite of the innovations in the management of newborns with congenital diaphragmatic hernia (CDH) presenting with respiratory distress at birth, mortality and ongoing morbidity still remain high. This is a retrospective analysis of newborns with CDH to determine the immediate and long-term outcomes among survivors. Medical records of newborns with CDH and respiratory distress at birth between January 1993 and March 2002 were reviewed retrospectively. There were 45 newborns, 29 males and 16 females. Eleven newborns (24%) died during the period of preoperative stabilization, 9 from pulmonary hypoplasia and 2 with complex anomalies who were not resuscitated. Surgery was performed in 34 newborns (76%). Three died postoperatively from severe pulmonary hypoplasia and pulmonary hypertension. Eleven newborns (24%) had sepsis from coagulative-negative staphylococci. Thirty-one of 43 newborns (72%) with isolated CDH were discharged home. Twenty-seven of 31 survivors (87%) had adverse long-term outcome and 2 late deaths were from pulmonary complications. Twenty-nine of 43 newborns (67%) with isolated CDH survived. The principal determinant of survival was pulmonary hypoplasia. Eighty-seven percent of survivors have associated morbidity including ongoing pulmonary, nutritional and neuro-developmental problems. Nevertheless preoperative stabilization and delayed surgery have been a satisfactory mode of management.

Cecal duplication cyst: a cause of intestinal obstruction in a newborn infant.

Intestinal obstruction is the most common surgical emergency in newborn infants. We report a case of cecal duplication cyst (CDC) as a cause of intestinal obstruction in a newborn infant. Prenatal ultrasonography (US) had shown an intra-abdominal cyst that was confirmed by the first postnatal US. Water-soluble contrast enema and a repeat US showed an intracecal cyst, however, the diagnosis of CDC was only established at laparotomy. CDC should be considered in the differential diagnosis of intestinal obstruction in an infant with an intra-abdominal cyst on US and a palpable right iliac fossa mass.

CT findings in a child with reflux oesophagitis.

We report the case of a 7-month-old boy who presented with a history of vomiting since birth. A computed tomography study showed circumferential thickening of the lower oesophageal wall with enhancement of the mucosa. After a period of antireflux medication, the patient underwent simultaneous oesophageal dilatation and Nissen fundoplication. He is doing well at 2-year follow up.

Idiopathic intussusception in infancy and childhood.

OBJECTIVE: Idiopathic intussusception is an important cause of abdominal pain, bleeding per rectum and intestinal obstruction in infancy and childhood. This aim of this study was to undertake a retrospective review of all children who presented with idiopathic intussusception over a 17-year period. METHODS: The medical records of children who presented with idiopathic intussusception from January 1984 through December 2000 at King Fahad National Guard Hospital, Riyadh, Kingdom of Saudi Arabia were reviewed. The data obtained included age, sex, clinical presentation, diagnostic investigations, mode of treatment, length of hospital stay and results. RESULTS: Thirty-three children (21 male, 12 female) presented with 37 episodes of intussusception. Their mean age was 8.4 months (range 5 hours to 36 months). The clinical features included rectal bleeding (81%), vomiting (78%), abdominal colic/pain (65%) and abdominal mass (62%). All cases were ileocolic intussusception with no leading point. Barium enema was attempted in 36 cases with success in 20 (56%). Laparotomy was required in 16 cases, manual reduction being successful in 11 (30%) and 6 (16%) had bowel resection. At surgery, after attempted barium reduction, 9 (56%) cases had the intussusception already reduced to the cecum. Seventy percent of the cases presented within 24 hours of onset of symptoms. The 4 recurrences in 3 children had successful enema reduction. There was no mortality but 3 operative cases required late surgery for adhesive intestinal obstruction including one requiring bowel resection. CONCLUSION: Idiopathic intussusception commonly presents as an ileo-colic type but is uncommon in our institution. The clinical features are classical, rectal bleeding being the most common. The majority presented within 24 hours of onset of symptoms and barium enema reduction was successful in 20 out of 36 cases in which it was attempted. Since most intussusceptions were already in the cecum at surgery after failed enema reduction, a repeat or delayed enema reduction could be considered in stable cases. Recurrent intussusception occurred in 3 non-operated cases and adhesive intestinal obstruction in 3 laparotomy cases.

Intramuscular myxoma: a rare neck mass in a child.

Intramuscular myxoma (IM) is a true mesenchymal benign tumour which is rare in both adults and children. In children, it most commonly affects the heart, mandible or maxilla. We report a 5-year-old child with IM presenting as a posterolateral neck mass and review the literature. IM, although very rare, should be included in the differential diagnosis of neck masses in the paediatric age group.

Cryopreserved recombinant tissue plasminogen activator for the restoration of occluded central venous access devices in pediatric oncology patients.

BACKGROUND: Thrombolytic therapy with urokinase 5000 units has been the standard therapy for the restoration of thrombosed central catheters. However, with the decreased availability of urokinase, alternatives needed to be sought. The aim of the study was to determine the efficacy, bioactivity, dwell time and cost of cryopreserved recombinant tissue plasminogen activator (rTPA) in the restoration of occluded central venous access devices. MATERIALS AND METHODS: For children < 10 kg, a dose of 0.5 mg, and for children >10 kg, a dose of 1mg was used. The dwell time was 1-2 hours. RESULTS: Of the 40 courses of rTPA, 39 fully restored central venous line patency (97%). Successful courses were instilled for an average of 1 hour. CONCLUSION: Cryopreserved rTPA appears to be safe and effective in the dose used to restore the patency of occluded central venous access devices in pediatric oncology patients.

Juvenile colorectal polyps in children.

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