Management of Acute Appendicitis in Children During COVID-19 and Perspectives of Pediatric Surgeons From South Asia: Survey Study.

BACKGROUND: Nonoperative treatment (NOT) of pediatric appendicitis as opposed to surgery elicits great debate and is potentially influenced by physician preferences. Owing to the effects of the COVID-19 pandemic on health care, the practice of NOT has generally increased by necessity and may, in a post-COVID-19 world, change surgeons' perceptions of NOT. OBJECTIVE: The aim of this study was to determine whether the use of NOT has increased in South Asia and whether these levels of practice would be sustained after the pandemic subsides. METHODS: A survey was conducted among pediatric surgeons regarding their position, institute, and country; the number of appendicitis cases they managed; and their mode of treatment between identical time periods in 2019 and 2020 (April 1 to August 31). The survey also directly posed the question as to whether they would continue with the COVID-19-imposed level of NOT after the effect of the pandemic diminishes. RESULTS: A total of 134 responses were collected out of 200 (67.0%). A significant increase in the practice of NOT was observed for the entire cohort, although no effect was observed when grouped by country or institute. When grouped by position, senior physicians increased the practice of NOT the most, while junior physicians reported the least change. The data suggest that only professors would be inclined to maintain the COVID-19-level of NOT practice after the pandemic. CONCLUSIONS: Increased practice of NOT during the COVID-19 pandemic was observed in South Asia, particularly by senior surgeons. Only professors appeared inclined to consider maintaining this increased level of practice in the post-COVID-19 world.

Use of Spinal Anesthesia in Pediatric Laparoscopic Appendectomies: Case Series.

BACKGROUND: Owing to the widespread use of general anesthesia, administration of spinal anesthesia in pediatric patients is not widely practiced. Yet there is ample positive evidence demonstrating its safety, effectiveness, and success. OBJECTIVE: The objective of this study is to compare postoperative patient comfort, length of hospital stay, and cost-effectiveness of pediatric laparoscopic appendectomies performed under spinal and general anesthesia with the usual standard-of-care procedures employed in the hospital. METHODS: This is a case series of 77 consecutive pediatric laparoscopic appendectomies (involving 5-8-year-old children) that took place in a hospital in Chittagong, Bangladesh, in 2019. A total of 40 patients underwent spinal anesthesia and 37 patients underwent general anesthesia. Variables such as surgery and operation theater times, pain score, incidence of postsurgery vomiting, analgesic usage, discharge times, and hospital costs were recorded. Statistical analysis was used to analyze the data as a function of anesthesia type. RESULTS: The probability of vomiting when using spinal compared to general anesthesia was lower within the first 5 hours (P<.001) and 6 hours (P=.008) postoperation. A significant difference (P<.001) was observed between the total costs of the two procedures, with spinal anesthesia being less expensive. Patients were more likely to be discharged the same day of the procedure when spinal anesthesia was used (P=.008). CONCLUSIONS: Spinal anesthesia has many advantages compared to general anesthesia for pediatric laparoscopic appendectomies. Patient comfort is improved due to a significant decrease in vomiting. This allows for more rapid hospital discharges and substantial cost savings, without compromising the outcome of the procedure.

Laparoscopy-assisted cutaneous ureterostomy at suprapubic creaseline facilitates subsequent reimplantation.

BACKGROUND: Cutaneous ureterostomy is still practiced despite a trend towards primary surgical correction for obstructive or refluxive uropathy. For future open reimplantation, ureterostomy can be created by minimal invasive technique at the end(s) of the suprapubic creaseline. MATERIALS AND METHODS: From 1 January 2009 to 31 July 2012, seven children were treated with laparoscopy-assisted cutaneous ureterostomy followed by ureteric reimplantation. Indications were primary obstructive megaureter 3, hugely dilated ureters with reflux 3 and posterior urethral valve with poor general health 1. The distal manoeuverable part of tortuous ureter was pulled to the surface at either end of suprapubic creaseline to create the stoma. During reimplantation, this stoma was dismembered and brought inside urinary bladder obviating the need for stoma-site repair. RESULTS: Mean age was 4.6 ± 2.8 years with six males. There were three bilateral cases with total 10 lesions. Mean operating time was 39.8 ± 12.5 minutes. Mean follow-up was 1.7 ± 0.8 years and except for peri-stomal excoriations no major complication occurred. All these were reimplanted 6-12 months after ureterostomy and faring well except in one case. CONCLUSIONS: Laparoscopy-assisted cutaneous ureterostomy can be fashioned at suprapubic creaseline to facilitate future reimplantation without much jeopardy and extra scar.

Laparoscopic appendectomy in children: experience in a single centre in chittagong, bangladesh.

Background. Since the latter half of 1980s laparoscopy has become a well accepted modality in children in many surgical procedures including appendectomy. We present here the experience of laparoscopic appendectomy in children in a tertiary care hospital in Bangladesh. Subjects & Methods. From October 7, 2005 to July 31, 2012, 1809 laparoscopic appendectomies were performed. Laparoscopy was performed in all the cases using 3 ports. For difficult and adherent cases submucosal appendectomy was performed. Feeding was allowed 6 h after surgery and the majority was discharged on the first postoperative day. The age, sex, operative techniques, operative findings, operative time, hospital stay, outcome, and complications were evaluated in this retrospective study. Results. Mean age was 8.17 ± 3.28 years and 69% were males. Fifteen percent were complicated appendicitis, 8 cases needed conversion, and 27 cases were done by submucosal technique. Mean operating time was 39.8 ± 14.2 minutes and mean postoperative hospital stay was 1.91 days. About 5% cases had postoperative complications including 4 intra-abdominal abscesses. Conclusions. Laparoscopic appendectomy is a safe procedure in children even in complicated cases.

Cystoscopic removal of leeches in the lower urinary tract: our experience.

INTRODUCTION: The purpose of this study is to describe the experience of managing leech infestation in lower urinary tract from a tropical country. MATERIALS AND METHODS: Medical records (January 2002 to December 2010) of children with history of leech infestation in the urinary system, admitted in the Department of Pediatric Surgery, Chittagong Medical College & Hospital, Chittagong, Bangladesh were reviewed. All patients underwent saline irrigation through urethral catheter. When saline irrigation failed, cystoscopic examination was done with removal of leeches by flexible graspers. Follow-up was done 2 weeks later. RESULT: The study included 117 patients. Age ranged from 4 to 12 years. Male and female ratio was 3.7:1. All patients had per urethral bleeding. 51 (43.6%) patients had suprapubic pain. All children underwent saline irrigation through urethral catheter. Spontaneous expulsion occurred after saline irrigation in 57 (48.7%) patients. The expelled leeches were alive in 11 cases; dead in 46 patients. Cystoscopic removal of leeches was done in 60 patients (51.3%). In the cystoscopic group, 54 of the removed leeches were dead and 6 were alive. CONCLUSION: Cystoscopic removal can be a useful technique for the removal of leeches from the urinary tract when saline irrigation fails.

Leech infestation in children through body orifices: experience in a hospital in Bangladesh.

INTRODUCTION: Bangladesh harbors many leeches in its vast wetlands. Leeches have a tendency to enter through body orifices with potentially life-threatening consequences. Literature search revealed inadequate description of clinical manifestations and treatment of leech infestations in children. We describe our experience with leech infestations in children. METHODS: Between January 1, 2004 and December 31, 2010, 17 cases of leech infestation through body orifices in children were managed. This is a retrospective study on age, sex, route of leech entry, investigation and treatment, and outcome. RESULTS: Age ranged from 4.5 to 11 years (mean 6.4 ± 1.8) and females accounted for more than 70 %. The orifices of leech entry include urethra, vagina, and rectum. Leeches could be found in eight cases. Two boys with leeches in the urinary bladder needed suprapubic removal. Leeches were retrieved from the vagina under general anesthesia in three cases, and on three occasions leeches came out from the vagina after normal saline instillation. In nine cases with different routes of entry where leech was not found, instillation of normal saline was sufficient to stop bleeding. Fifteen cases presented with bleeding and transfusion was required in five cases with Hb% <7 gm/dl. CONCLUSIONS: Leech infestation through lower body orifices is common in children of rural Bangladesh. Prompt diagnosis is of paramount importance, and application of normal saline is effective in most cases. Sometimes surgical intervention is required.

Laparoscopic appendectomy in pregnant women: experience in Chittagong, Bangladesh.

BACKGROUND: Surgery may be needed during pregnancy for nonobstetric reasons, most commonly appendicitis, and laparoscopy is considered as safe as the open method, for both mother and fetus. The aim of the present study was to emphasize the feasibility of laparoscopic appendectomy during pregnancy in a developing country, and also to report the first study of its kind from Bangladesh. MATERIALS AND METHODS: From 7 October 2005 to 6 October 2010, 31 pregnant women were diagnosed with acute appendicitis. Diagnoses were based on clinical suspicion supported by ultrasonogram. Under general endotracheal anesthesia, laparoscopy was done in all 31 cases. One gynecologist was always present to monitor the conditions of the fetus preoperatively and postoperatively. Feeding was allowed 6 h after surgery, and the majority of the patients were discharged on the second postoperative day. Age, gestational period, operative time, hospital stay, maternal and fetal outcome, and complications were evaluated. RESULTS: Age ranged from 19 to 35 years and gestational period ranged from 6 to 31 weeks. Right lower quadrant pain was the presenting complaint in majority of cases. Average operative time was 34 ± 10.19 min, and there were no conversions to open surgery. There were no intraoperative or immediate postoperative hazards. Postoperative recovery was uneventful in all cases. Histopathology of 30 cases confirmed appendicitis. One patient, whose fetus was at 12 weeks gestation at the time of the appendectomy had a spontaneous abortion 1 month later. There were no adverse outcomes during the follow-up period. CONCLUSIONS: Laparoscopy is a safe and effective technique for the treatment of appendicitis during pregnancy and can be performed in a developing country.

Cystoscopy-assisted percutaneous removal of impacted urethral stone: a case report.

BACKGROUND AND PURPOSE: Although cystolitholapaxy is possible in children, the instruments are not available everywhere. For tiny impacted urethral stone, an alternate technique is described. CASE REPORT: A 3-year-old boy came with retention of urine and dysuria. On examination: bladder was full, suprapubic region was tender, and a stone could be felt at posterior urethra. We planned push back and suprapubic cystolithotomy. After general anesthesia, the stone was pushed back by instillation of lignocaine jelly into the urethra. Then, a cystoscope was introduced, and a stone was found inside the urinary bladder. Under cystoscopic view, a 5 mm laparoscopic port was inserted into the bladder just above the pubic symphysis in the midline. A 5 mm tissue holding forceps was introduced through this port, and the tiny stone was grasped and brought out along with the port. The port site was closed by a single stitch. A penile catheter was kept for 5 days. RESULTS: The boy did well in the postoperative period, and voiding was normal after removal of the catheter. CONCLUSIONS: Impacted posterior urethral stone can be retrieved by simple percutaneous technique.

Intestinal obstruction in children due to segmental enteritis: experience in Chittagong, Bangladesh.

INTRODUCTION: Acute segmental enteritis is also known as acute segmental necrotizing enteritis, segmental obstructing acute jejunitis, and enteritis necroticans. Children presenting with high fever, P/R bleeding, prostration etc. along with features of intestinal obstruction are not uncommon. Many of these cases had to be operated upon revealing no definite obstructing lesion, except a segment of small gut with different magnitude of inflammation. The principal author encountered many of these cases in the same hospital and also in the previous working places. This study was thus undertaken and this is the first report from Bangladesh on segmental enteritis. MATERIALS AND METHODS: From 1 January 2004 to 31 December 2009, 24 consecutive cases suffering from enteritis were managed. This prospective descriptive study evaluates the sex, age, presentations, physical findings, operative findings, hospital stay, outcome and complications. The inclusion criteria were an acute abdominal presentation, plain radiographic features of intestinal obstruction and intraoperative findings of segmental small intestinal involvement with ischemic lesions without definite obstruction. RESULTS: Fever and leucocytosis were present in all, abdominal tenderness in 17 and per-rectal bleeding in 15 cases. Jejunum alone was involved in 17, both jejunum and ileum in 5 and ileum alone in 2 cases. Scattered dark patches over the intestinal wall was found in 16, circumferential dusky lesions in 4, perforation in one and frank gangrene in 3 cases. Bacteriology of the peritoneal fluid in 17 cases revealed mixed flora. Histopathology of the mesenteric lymph nodes in 11 cases showed non-specific hyperplasic changes. Histopathology of four resected gut walls showed inflammatory infiltrates. In 17 cases recovery was uneventful. Seven cases suffered different complications including two (8.33%) deaths. One with ileal stricture and another with fecal fistula required reoperation. Mean hospital stay was 10.63 ± 3.00 days. The surviving patients were followed up for at least 6 months and faring well. CONCLUSIONS: Segmental enteritis is occasionally encountered as a cause of acute abdomen in children of Bangladesh. Operative treatment is required and mechanical obstructing lesion was found in none of the cases. Majority of cases improve on intraoperative measures other than gut resections or creation of stoma.

Laparoscopic cholecystectomy without handling the cystic artery: a new approach to minimize complications.

INTRODUCTION: Although laparoscopy has now become the procedure of choice for removal of gallbladder, complications especially injury to cystic artery and ducts are thought to be higher. We describe a technique that avoids handling and injury of cystic artery and resultant duct injuries. The video length is 2 minutes 13 seconds. MATERIALS AND METHODS: From October 7, 2005, to December 31, 2010, 17 patients were successfully operated by the cystic artery sparing technique. In this technique, dissection begins distal to cystic lymph node on the gallbladder wall using hook cautery, thereby clears the Calot's triangle without even touching the cystic artery. This maneuver eliminates the risk of injuring thus causing bleeding and any subsequent complications. Age, sex, and operative outcomes including follow-ups were evaluated. RESULTS: Age of the patients ranged from 3.4 years to 16 years with an average of 10.12 years. Males were predominant (10:7). Average operative time was 40 minutes. There were no intraoperative or immediate postoperative complications. Patients were allowed feeding 4-6 hours after operation and discharged the following morning. Patients were asked to come for follow-up at 1 week, 1 month, 3 months, 6 months, and 1 year and thereafter yearly. Follow-up period ranged from 6 months to 5 years. There were no operation-related complications other than minor abdominal pain in 3 patients and port-site pain in 2 patients which resolved on conservative treatments. CONCLUSION: During laparoscopic cholecystectomy, if handling of the main cystic artery is avoided then complications of hemorrhage and bile duct injuries can be minimized.

Anovestibular fistula with normal anus.

PURPOSE: The purpose of the study was to review a rare anomaly of anorectal malformations in girls, congenital anovestibular fistula (AVF) with normal anus, over a 12-year period. MATERIALS AND METHODS: A total of 24 female patients of AVF with normal anus were treated in the Department of Pediatric Surgery, Chittagong Medical College and Hospital, Chittagong, Bangladesh, from January 1994 to June 2006. Clinical features, operative findings, operative procedures, postoperative complications, and outcomes were analyzed. RESULTS: Age ranged from 1 day to 7 years (mean, 10.5 months). All 24 female patients presented with passage of stools through 2 perineal openings. In addition, vulvar abscesses were noted in 5 cases. Vestibular opening of the fistula was found behind the vagina in 18 patients, and the anal opening of the fistula was on the anterior anal wall above the dentate line in 20 cases. There were no associated abnormalities. After adequate bowel preparation, 22 patients underwent excision of the fistulous tract with reconstruction of anal wall without a diverting colostomy. All 5 patients with vulvar abscess experienced wound disruption and required reoperation. All 24 girls have normal bowel motions at follow-up. CONCLUSIONS: In the management of AVF with normal anus, primary repair without colostomy is a safe option. In cases of abscess or infection, definitive operation should be deferred until adequate healing is achieved.

Congenital double anus with total colon duplication: a case report.

Cases of congenital double anus are very rare. The number of cases of hindgut duplication of all kinds is slightly higher, and some series include patients with genitourinary and genitalia duplications but with a single anus. However, double termination with tubular duplication is rarely heard of. We report on the case of a patient with 2 well-formed ani, total colon duplication, and 2 vaginas.