Rectovestibular fistula: Which surgical approach is suitable? A randomized controlled trial.

The management of a vestibular fistula is a challenge for pediatric surgeons. We compared four different operative techniques in terms of postoperative complications, continence, and cosmetic appearance. This prospective, randomized, comparative study included female children with rectovestibular fistulae who were selected from patients with Anorectal Malformations (ARMs) treated between January 2016 and July 2020. The patients were randomly divided into four groups based on the operative technique: Trans-Sphincter Anorectoplasty (TSARP), Posterior Sagittal Anorectoplasty (PSARP), Classic Anterior Sagittal Anorectoplasty (ASARP), and modified ASARP. The incidence of vestibular fistulae among all patients with ARMs was 13.4%. The total number of patients with vestibular fistula was 112, including eighty-four (75%) with rectovestibular fistulae and twenty-eight (25%) with anovestibular fistulae. Associated congenital anomalies were found in nineteen (22.6%) patients. The percentage of parents satisfied with the cosmetic appearance and continence of their children was the highest after TSARP. PSARP had the lowest incidence regarding vaginal wall injuries. TSARP is the best operative technique for handling rectovestibular fistulae and is suitable for infants and children. In the TSARP technique, the external sphincter muscle can be preserved following complete dissection of the rectum without the need for a midline skin incision. A midline skin incision is required in the modified ASARP technique.

Association of Hirschsprung's disease with anorectal malformations: the early alarming signs for diagnosis and comorbidity related to this association.

BACKGROUND AND AIM: The association of Hirschsprung's disease (HD) and anorectal malformation (ARM) is rare. The aim of this study is to highlight the frequency of this rare association and comorbidity that may be related to this association. PATIENTS AND METHODS: Eleven cases out of four hundred forty six cases (2.5%) with ARM found to have HD association presented to Assiut University Children Hospital. All cases were diagnosed by complete clinical, radiological assessment and histopathological examination before correction. The evaluating parameters for those patients were the early warning signs for diagnosis, any unnecessary procedures done and any associated morbidity related to misdiagnosis of this association. RESULTS: Age at presentation of these eleven cases ranged from 2 days to 10 years. The diagnosis started early during neonatal period only in four cases either by change of bowel caliber or nonfunctioning stoma. In the remaining seven cases the diagnosis was delayed because of unsuspected association. Fecal fistula after closure of stoma and wound dehiscence followed by incisional hernia is evident associated comorbidity. CONCLUSIONS: The incidence of HD in ARM population seems to be more common than its incidence in the general pediatric population. Caliber change of the bowel during the first operation or nonfunctioning stoma is early alarming sign for diagnoses of such association and should direct the attention for stomal biopsy.

Topical treatment of major omphalocoele: Acacia nilotica versus povidone-iodine: A randomised controlled study.

BACKGROUND: Conservative management for major omphalocoele with topical agents as escharotics therapy is well established in practice. Different agents have been used in the past, including mercurochrome and alcohol, proved later to be unsafe. The aim of this study is to evaluate the efficacy and safety of the application of Acacia nilotica paste compared to povidone-iodine solution as a primary non-surgical treatment of major omphalocoele. PATIENTS AND METHODS: A double-blind, randomised study was conducted on 24 cases of major omphalocoele where they were randomly divided into two equal groups; Group A treated with topical application of A. nilotica paste and Group B treated with topical application of povidone-iodine solution. Cases with gastroschisis, ruptured major omphalocoele or minor omphalocoele were excluded from the study. The evaluating parameters were size of the fascial defect in cm, period of mechanical ventilation if needed, time required for full oral feeding tolerance, duration of hospital stay and any short- or long-term complications. RESULTS: There was no statistical significant difference between both groups regarding their gestational or post-natal age, weight and the mean umbilical port defect. Patients from Group A tolerated full oral feeding earlier and had shorter total hospital stay duration than those from Group B, but without a statistical significant difference (P = 0.347 and 0.242, respectively). The overall mortality rate was 33.3% without a statistical significant difference between both groups (P = 0.667). CONCLUSIONS: Application of A. nilotica is a safe and effective treatment of major omphalocoele as it was associated with rapid full enteral feeding tolerance, short duration of hospital stay and low mortality rate.

Button hole hernioplasty: A new technique for treatment of umblical hernia in cirrhotic patients. A prospective follow up study.

BACKGROUND: Surgical treatment of umbilical hernia in cirrhotic patients is still an interesting topic in many studies to achieve the best method of treatment. These patients are liable to many surgical and medical risks. AIMS: to evaluate the surgical outcome as well as the postoperative course of Button hole hernioplasty as a simple, safe, and effective new technique for hernia repair in cirrhotic patients. METHODS: Forty cirrhotic patients with uncomplicated umbilical hernia were included in this study through collaboration between Departments of General Surgery and Tropical Medicine and Gastroenterology, Assiut University Hospital, Assiut, during one year period. Patients were categorized according to the severity of liver cirrhosis into three groups (A, B, and C). Patients were subjected to an elective hernioplasty after adjustment of the disturbed medical and biochemical factors. RESULTS: There was a significant difference in operative time, hospital stay, and prothrombine (time and concentration) among the three groups (p < 0.05). The three parameters were longest in group C when compared to the other two groups. No severe complications were recorded except in only one case. Also, no recurrence, no morbidities or deaths were recorded after 6 months follow-up. CONCLUSIONS: Button hole hernioplasty is a new simple surgical technique for treatment of umbilical hernia in cirrhotic patients with no significant complications.

Single high scrotal incision orchidopexy for unilateral palpable testis: a randomised controlled study.

BACKGROUND: Bianchi and Squire introduced single high trans-scrotal incision for mobilisation of palpable undescended testes to decrease the potential morbidity of the traditional inguinal approach. This incision has not gained widespread acceptance and there is still a considerable debate about its efficacy. This study evaluated the outcome of high single scrotal incision in comparison to the classic inguinal exploration for unilateral palpable testes regardless to its pre-operative location to assure its validity and safety. PATIENTS AND METHODS: This was a randomised controlled study conducted on seventy males with palpable unilateral undescended testicles from November 2009 to October 2013. They were divided into two equal groups; group I had high single scrotal incision and group II had the classic inguinal approach. The comparative parameters between both groups were the operative time, intra-and post-operative complications, post-operative pain and scar. RESULTS: There was statistical significant difference between both groups regarding the operative time (P < 0.001). The high scrotal approach (Group I) was not completed in three cases and were converted to the classic inguinal approach. No statistical significant difference between both groups regarding the post-operative complications. CONCLUSIONS: Single high scrotal incision orchidopexy for palpable undescended testis is safe, has shorter operative time but may not be suitable for proximally lying testis.

The use of PROCEED mesh in ventral hernias: a pilot study on 22 cases.

BACKGROUND: The management of major omphalocoele and large incisional hernias is a common problem and constitutes a great challenge for paediatric surgeons. In most cases, the abdominal cavity is so small and does not allow immediate reduction. Prosthetic materials are becoming increasingly popular for such repair, but direct contact between the bowel and these synthetic materials carries the risk of adhesions and intestinal obstruction. The relatively new PROCEED mesh with absorbable layer in contact with the bowel and another polypropylene non-absorbable layer against the abdominal wall may not produce such adhesions. The aim of this study is to evaluate the feasibility and outcome of this relatively new prosthetic mesh for repair of ventral hernia . PATIENTS AND METHODS: Between June 2009 and December 2012, a pilot study was conducted on 22 cases with large ventral hernias subjected to open surgical repair using PROCEED mesh. The inclusion criterion was cases with large ventral hernias (>4 cm). The evaluating parameters were all the early and late postoperative complications. RESULTS: The defect size ranged from 5 to 12 cm. The early postoperative complication (≤1 month) was seroma discharged from the wound in four cases, while the late complications were recurrent herniation and stitch sinus that occurred in three cases. No manifestations of intestinal obstruction, enterocutaneous fistula or mortality were encountered in any of the 22 cases. CONCLUSION: The use of PROCEED composite mesh in ventral hernias is feasible and has minimal complication rates.

Supraumbilical pyloromyotomy: a comparative study between intracavitary and extracavitary techniques.

BACKGROUND: Infantile hypertrophic pyloric stenosis (IHPS) is the most common cause of nonbilious vomiting in infancy, with an incidence of 1 to 3 per 1000 live births. Different approaches have been advocated for pyloromyotomy aiming to achieve better cosmetic results with least possible complications. Although many studies have shown that the umbilical pyloromyotomy is as safe as the traditional right upper quadrant approach with superior cosmetic results, still few studies reports high complication rates. The aim of this study was to assess intracavitary pyloromyotomy (ICP) in comparison with extracavitary pyloromyotomy (ECP) regarding the operative time, operative and postoperative complications, time to return to full oral feeding, and duration of hospital stay, as well as the final cosmetic results through supra umbilical skin incision. PATIENTS AND METHODS: Forty patients with IHPS were admitted to Assiut University Children Hospital from January 2008 to June 2010 and operated through supra umbilical incision. They were randomly divided according to the surgical technique into 2 groups: ECP group (20 patients) and ICP group (20 patients). The evaluating parameters were: pyloric muscle thickness, operative time, operative and postoperative complications, time to return to full oral feeding, duration of hospital stay, and final cosmetic results. RESULTS: There was no statistical significant difference between both groups regarding the patient's age, weight, pyloric muscle thickness, and duration of hospital stay. No mortality was encountered among all patients. There was a statistical significant difference between both groups regarding the mean operative time and time to return to full oral feeding. During the follow-up period (ranged from 6 weeks to 8 weeks) all patients were gaining weight satisfactorily and the scar was barely visible. CONCLUSIONS: ICP for pyloromyotomy is safe and can be done in large pyloric masses without wound extension. It gives best cosmetic results with minimal complications.

The role of surgery in management of necrotizing enterocolitis.

OBJECTIVE: Necrotizing enterocolitis (NEC) has become the most common gastrointestinal emergency among neonates and preterms admitted to the intensive care units. The aim of this study is to evaluate the surgical management of NEC as well as their outcome. PATIENTS AND METHODS: Thirty five cases were included in this prospective study (10 full terms, 15 preterm and 10 infants) with the diagnosis of NEC. The severity of NEC episodes were determined according to Bells classification into group A (stage I 10 cases), Group B (stage II 17 cases) and group C (stage III 8 cases). Full history and clinical examination were taken. Radiological studies (abdominal plain X-ray and ultrasound), blood and stool cultures were done. RESULTS: All risk factors such as sepsis, hypoxia, premature rupture of membrane (PROM) and eclampsia were statistically significantly higher among group C than group A. The commonest presenting symptom was abdominal distension followed by vomiting. All positive radiological signs were statistically significantly higher among both groups B&C than group A except for pneumopritonium sign. Medical treatment was started and complete clinical improvement was achieved in all cases of group A and in 2 cases from group B. The remaining 23 cases (15 cases from group B and the 8 cases of group C) failed to respond to the medical treatment and were operated upon. Resection anastomosis was done for 12 cases from group B while resection with stoma formation was done for 3 cases from group B and 8 cases from group C. The over all mortality was 11 cases out of 35 (31.4%). 5 cases from group B and 6 cases from group C. CONCLUSIONS: Early diagnosis and intensive medical and surgical treatment with laparotomy and resection of the affected bowel were mandatory to minimize both morbidity and mortality from NEC. Primary anastomosis is the procedure of choice as long as the condition of the remaining bowel is satisfactory.

Delayed presentation of anorectal malformations: the possible associated morbidity and mortality.

AIM: Anorectal malformations (ARMs) are one of the most common congenital anomalies dealt by pediatric surgeons with reported incidence of approximately 1 in 5,000 live births. The majority of patients usually presents during the neonatal period. However a significant number of patients report later during infancy or even late childhood. Such delayed presentation may affect the surgical management and contribute to functional and psychological problems for both babies and their parents. The aim of this study is to highlight the frequency of this problem, cause of delayed presentation, and how this delayed presentation of ARM contributes to morbidity and mortality. PATIENTS AND METHODS: During the 3-year study period, 104 cases with ARM (74 males and 30 females) were presented to pediatric surgery unit in Assiut university children's hospital. Delayed presentation means that the child came after the first 48 h or after 3 months of age in case of low ARM in females. RESULTS: Out of 104 cases, 20 fulfil the criteria of delayed presentation (11 females and 9 males). Their age at presentation ranged from 4 days to 14 years. Fourteen classified as low ARM (6 male and 8 female), whereas six classified as high ARM (3 male and 3 female). The causes of delayed presentation were delayed detection, wrong advice to the parents, inadequate treatment offered, and social causes. The associated morbidities encountered were chronic constipation, mega rectum, and unnecessary colostomy. Two mortalities were encountered; both were males presented on days 4 and 14 after birth. CONCLUSIONS: Delayed ARMs is not uncommon. Every neonate should be carefully examined and screened for such anomaly to avoid the possible morbidity and mortality which are directly related to this delayed presentation.