Paediatric Surgery

Radiological response and histological findings in nephroblastoma: Is the any correlation? Pamela Josephine Middleton, Berhouz Banieghbal, Richard Denys Pitcher, Pawel Schubert African Journal of Paediatric Surgery 2020 17(3):39-44 Introduction: The Sociétè Internationale d'Oncologie Pédiatrique advocates for neoadjuvant chemotherapy in the management of nephroblastoma. Postoperatively, histological findings are used to assign risk classification to resected tumours. The aim of this study is to compare the response demonstrated by pre-operative imaging to the amount of necrosis seen on histology postoperatively. Patients and Methods: About 33 patients with nephroblastoma over a 10 year period had adequate imaging and histology records for this study. Three methods were used to assess tumour change following neoadjuvant therapy and were compared with histological records. 1. An estimation of necrosis, 2. Surface areas of apparent necrosis within the tumour measured on static imaging, 3. The change in volume of the mass. Pearson coefficient was calculated to measure the correlation between histologically observed necrosis and radiological changes. Results were considered significant if P< 0.05. Results: There was no correlation between radiological changes on pre-operative imaging and the percentage of necrosis seen on histology. Change in tumour size on radiological studies showed a moderate correlation to percentage tumour necrosis on histology but was unable to predict tumour risk classification. Conclusions: In nephroblastoma, there is a moderate correlation between the decrease in size of a mass noted on imaging following chemotherapy and the degree of necrosis found postoperatively on histology. Change in tumour size cannot be used to predict histological risk classification. It is not possible to predict the histological risk classification of a nephroblastoma based on the changes demonstrated on non-contrasted magnetic resonance imaging or computed tomography preoperatively.

Transhiatal isoperistaltic colon interposition without cervical oesophagostomy in long-gap oesophageal atresia Cigdem Ulukaya Durakbasa, Murat Mutus, Gonca Gercel, Selma Fettahoglu, Hamit Okur African Journal of Paediatric Surgery 2020 17(3):45-48 Background: Oesophageal colonic interposition in oesophageal atresia (OA) patients is almost exclusively done as a staged operation with an initial oesophagostomy and gastrostomy followed by the definitive surgery months later. This study presents a series of patients in whom a cervical oesophagostomy was not performed before the substitution surgery. Patients and Methods: Records of EA patients were evaluated for those who underwent colon interposition without cervical oesophagostomy. Results: There were five patients: three with pure EA and two with proximal tracheo-oesophageal fistula. A delayed primary repair could not be performed because of intra-abdominally located distal pouch. The mean age at the time of definitive operation was 5.54 (±2.7) months and the mean weight was 6.24 (±1.3) kg. A right or a left colonic segment was used for interposition keeping the proximal anastomosis within the thorax. The post-operative results were quite satisfactory within a median follow-up period of 33.2 months. Conclusion: Avoiding cervical oesophagostomy and its inherent complications and drawbacks is possible in a subset of patients with long-gap EA who underwent colonic substitution surgery. This approach may be seen as an extension of the consensus that the native oesophagus should be preserved whenever possible, because it uses the native oesophagus in its entirety.

Five-year experience of anorectal malformation with oesophageal atresia in tertiary care hospital Sarita Chowdhary, Pranay Panigrahi, Rakesh Kumar African Journal of Paediatric Surgery 2020 17(3):49-53 Aim: We had done this study for TEF with Anorectal malformation and TEF with no Anorectal malformation in terms of age, sex, surgical outcomes and mortality. Materials and Methods: This was a retrospective review of cases with clinical data (from April 2012 to April 2017). The participants of this study were 236 patients who had been diagnosed and managed for ARM. Among these patients, 25 patients associated with EA were selected as the subject patient group. Results: The incidence of tracheoesophageal fistula with ARM was 11.1%. The study has more male preponderance. All cases are of Type c except two cases of Type a. According to the classifications of ARMs, there were two cases with rectourethral fistula and eight cases with rectoperineal fistula and covered anus in the males. In females, there was a varied distribution of seven cases. There was one case (4%) presenting as a part of the Vertebral anorectal malformation cardiac tracheoesophageal renal and limb anomalies (VACTERL) association, which is the representative example of a complex anomaly. Most of the cases died due to cardiac problem and pneumonitis (due to delayed presentation). Conclusion: The study concludes the experience of EA (±fistulae) with ARM, their distribution, incidence and outcome of the tertiary care centre.

Ultrasonographic review of pediatric breast masses among Nigerian children in a tertiary hospital Sefiya Adebanke Olarinoye-Akorede, Phillip Oluleke Ibinaiye, Lawal B Suleiman African Journal of Paediatric Surgery 2020 17(3):54-58 X Background: Breast masses occur infrequently in children and adolescents. Most of these masses have proved that benign and conservative approach is the management of choice. Consequently, imaging has become crucial. The knowledge of the ultrasonographic features of childhood and adolescent breast masses is needed for age appropriate medical care. Aim: The aim of this study was to describe and document the ultrasonographic spectrum of breast masses in children and adolescents (0–19) years seen in the Ahmadu Bello University teaching hospital, Zaria. Materials and Methods: A 2-year retrospective review of breast sonograms of 25 consecutively presenting children and adolescents (3 males and 22 females) who had palpable breast masses. Ultrasound scans were performed with a Mindray Machine DC-8 using the linear transducer at 7.5–12 MHz transducer frequency. Histopathological confirmation of the solid masses was also obtained. The statistical analysis of the data collected was done using the SPSS software version 20 (SPSS Inc., Chicago, IL, USA). Results: The patients were between 40 days and 19 years old (mean 14.8 years and standard deviation 4.1). The ultrasonographic findings were those of infections, benign tumoral lesions and pubertal endocrine changes. Overall, fibroadenoma was the most common mass, seen in 14 (56%) of the patients. Other findings were simple cysts, non-puerperal and puerperal mastitis, juvenile papillomatosis and normal glandular pubertal breast tissue. The three male patients had gynaecomstia, pseudogynaecomastia and cystic lymphangioma of the chest wall presenting as unilateral breast masses, respectively. There was no malignancy recorded in any of the patients. Conclusion: Ultrasonographically, benign masses predominate which is concordant with surgical findings. Familiarity with these features would obviate the need for unnecessary invasive procedures which should be reserved for only deserving cases.

The coagulation profile as a marker for acute appendicitis in the paediatric population: Retrospective study Anna Morandi, Elisa Cipriani, Filippo Parolini, Dario Consonni, Edoardo Calderini, Stefania Franzini, Ernesto Leva African Journal of Paediatric Surgery 2020 17(3):59-63 Introduction: Appendicitis is the commonest and most frequently misdiagnosed acute abdominal surgical illness in the paediatric population worldwide. The aim of this study is to evaluate the role of coagulation profile in acute appendicitis (AA) in children. Materials and Methods: we retrospectively collected data of patients submitted to appendectomy from 2011 to 2017. According to histopathology, patients were divided into three groups: not histologically confirmed AA (NAA), simple AA (SAA) and complicated AA (CAA). White blood cell (WBC) count, relative neutrophilia (Neutr%), C-reactive protein (CRP), prothrombin time ratio (PTratio), activated partial thromboplastin time ratio (APTTratio) and fibrinogen (Fib) were compared among groups. Results: Three hundred and seven patients were included: 57 NAA, 184 SAA and 66 CAA. WBC was significantly different among groups: CAA (mean 16.67 × 103/ml), SAA (14.73 × 103/ml, P= 0.01) and NAA (10.85 × 103/ml, P< 0.0001). Significant differences were found for Neutr% (mean CAA 81.14 vs. SAA 77.03 P= 0.006, vs. NAA 63.86 P< 0.0001) and CRP (mean NAA 2.56, SAA 3.26, CAA 11.58, P< 0.0001). PTratio and Fib increased with the severity of AA receiver operator characteristic curves were similar for CRP (0.739), Fib (0.726), WBC (0.746) and Neutr% (0.754), while for PTratio and aPTTratio were 0.634 and 0.441, respectively. Conclusions: extrinsic coagulation pathway is altered in AA, especially in CAA. Coagulation can be useful in the diagnostic and perioperative anaesthetic management of AA in children. Fib seems to have the highest accuracy.

Study of management of appendicular abscess in children Nandkishor Shinde, Ravindra Devani, Mohammed Abdul Baseer, Kiran Desai African Journal of Paediatric Surgery 2020 17(3):64-67 Aim: To compare the outcomes in children who underwent emergency surgery and those who underwent percutaneous drainage for appendicular abscess. Materials and Methods: In this prospective study, 45 children of appendicular abscess detected on ultrasonogram (USG) were included in the study. The following characteristics were registered: age, gender, the time from onset of symptoms to seeking care, pain, vomiting, fever and general peritonitis; white blood cell count. The size, location of the abscess was noted on USG. After the diagnosis, we divided the patients into two groups based on the type of management. Patients who underwent emergency surgery and appendectomy (Group 1) which composed of twenty patients (14 males and six females) with their ages ranged from 3 to 18 years, and patients treated with ultrasound-guided percutaneous drainage and interval appendectomy (Group 2) which composed of 25 patients, (15 males and ten females) with their ages ranged from 2 to 18 years. Results: Group 1 included twenty patients and Group 2 included 25 patients. In Group 1, on USG the average size of the abscess was 7.2 ± 2.5 cm. After the surgery regained their functional recovery during a mean period of 3.2 ± 1 days. In Group 2, on USG average abscess size was 6.8 ± 2.4 cm. After the procedure regained their functional recovery on the second day. No major complications were noted in Group 2. On the contrary, 12 patients (60%) of Group 1 show complications in the form of wound infection in eight children and wound dehiscence in four children. Conclusions: USG-guided percutaneous drainage was safe and effective way of management of appendicular abscess.

Mitigating the challenges of laparoscopic paediatric surgery in Ile Ife: The trend so far and lessons learnt Arua Obasi Igwe, Ademola Olusegun Talabi, Collins Chijioke Adumah, Ibukun Olufemi Ogundele, Adewale O Adisa, Oludayo Adedapo Sowande, Olusanya Adejuyigbe African Journal of Paediatric Surgery 2020 17(3):68-73 Background: Paediatric laparoscopic surgery is fast growing worldwide, with many pathologies now being treated even in the youngest of patients. We hereby report our experience with the first 114 cases. Objectives: Our aim was to highlight our progress and lessons learnt practicing laparoscopic paediatric surgery in our institution. Materials and Methods: This is a retrospective study of the first 114 children who underwent laparoscopic surgery in our hospital. We focussed on demographics, indications, procedures performed, rate of conversion to open and complications. Records were retrieved from January 2011 to December 2019. Data were analysed using the SPSS software version 23 (SPSS Inc., Chicago, Illinois, USA). Results: There were 83 males and 31 females (ratio of 3:1). Age groups included infants (13.2%), 1–5 years (21.9%), 5–10 years (33.3%) and > 10 years (31.6%). There was a remarkable increase in the frequency and complexity of cases performed from an average of 5 per year between 2011 and 2015 to an average of 23.5 per year between 2016 and 2019. The conversion rate was 6%, 5 appendectomies, 1 Swenson pull-through, 1 diagnostic laparoscopy and 1 Ladd's procedure. Four complications were noted; one recurrent adhesive intestinal obstruction, one residual intra-abdominal abscess, one port site abscess and one excessive bleeding from liver biopsy requiring conversion to open surgery. Conclusion: We have demonstrated that the routine use of laparoscopy in children is feasible and safe in our environment. However, the need for training, endurance through a steep learning curve and the willingness to battle the technical challenges are necessary for success.

Presentation and management outcome of childhood corrosive oesophageal injury in Benin City Stanley U Okugbo, GA Anyanhun, CA Efobi, OT Okugbo African Journal of Paediatric Surgery 2020 17(3):74-78 Background: Corrosive ingestion in children occurs usually at home and frequently results in debilitating strictures. Prevention and early intervention programs are very important for good outcomes. Aims and Objectives: This study aims at examining the immediate causative factors and problems of this subset of patients with a special focus on treatment and outcome. This study was to audit the management of patients in the paediatric age group who presented for treatment with history and sequelae of corrosive ingestion seen by the cardiothoracic unit of the University of Benin Teaching Hospital from January 2005 till December 2018. Materials and Methods: This is a 14year retrospective study of patients that presented with oesophageal burn injuries from ingestion of corrosive agents to the Cardiothoracic Unit at the University of Benin Teaching Hospital between January 2005 and December 2018. Essentially the first 5years were retrospectively included but the subsequent years were prospective. All available medical data on these patients were retrieved and studied for epidemiological, clinical and operative procedures and outcome. Results: A total of 49 patients were seen and admitted during the period under review. Male (29) : Female (20) ratio was 1:1.4 Mean age was 4.7±4.8 years with a range of 1-16years, The males presented earlier and had worse strictures as well as more surgical procedures. Caustic soda preparations ingested more (93.9%), all ingestions were within the household setting, and all had first aid given by way of oral palm oil. Only two (4.1%) ingested acids with only one flat battery ingestion. 45.5% of the patients had dilatation only and of these 50% recovered after 3 sessions and required no more sessions. A further 50% were lost to follow up. 38.8% had oesophageal replacement with colon following oesophagectomy.Conclusion: In conclusion, corrosive oesophageal stricture is a debilitating disease in children and affects males more, but it is treatable by multiple dilatations and oesophageal replacement with colon. Prevention should be actively pursued as well as early intervention.

Challenges, constraints and failures that are related to the posterior sagittal anorectoplasty approach to anorectal malformations in a low-resource context: An experience from a sudanese tertiary referral centre Pierluigi Lelli Chiesa, Antonio Aloi, Mariagrazia Andriani, Paolo Giambelli, Faisal A Nugud, Osman T. M Osman, Angela Riccio, Fabio Rossi, Diaaeldinn Y Salman, Alessandro Calisti African Journal of Paediatric Surgery 2020 17(3):79-84 Background: Anorectal malformations (ARMs) in the sub-Saharan Africa are a common cause of neonatal referral for intestinal obstruction, and the posterior sagittal anorectoplasty (PSARP) approach is rapidly spreading. The small number of paediatric surgeons and the low-resource context limit children's access to care and constrain the quality of results. A retrospective, observational study has been done on a consecutive series of ARM cases admitted to a Sudanese tertiary paediatric surgical centre within the framework of a partnership between Italian and Sudanese academic institutions addressed to review and upgrade the standard of care of major congenital anomalies. Materials and Methods: The authors collected 94 ARM cases in a 3 years' period. Conditions on referral, operative procedures, post-operative course and follow-up were recorded and examined. Their correlations with complications and outcome were analysed. Results: The male/female ratio was 47/47. Eighty patients presented with an untreated ARM; 66 had a divided stoma and 14 had already a PSARP procedure, followed by a poor outcome or sequelae. In 25% of the cases, colostomy required re-doing. In 57 cases, a staged PSARP (primary or re-do) was done. Surgical-site infections occurred in nine patients. Some patients were lost to follow-up after preliminary colostomy. Post-operative dilatation programme suffered from the lack of systematic follow-up, and colostomy closure was possible in 46% of the cases due to problems in travelling and accessing hospital care. Anal stenosis was frequently observed among unfollowed patients. Conclusion: Despite PSARP's widespread adoption in Africa, the risk of complications and failures is high. Primary management is often inappropriate, and a high rate of colostomy-related complications is observed. Poverty and lack of transportation reduce attendance to follow-up, hampering the final results. Investments in healthcare facilities and retention of trained health providers are needed to improve the standard of care.

Prevalence and pattern of birth defects in the two tertiary hospitals in Enugu, South East Nigeria: A hospital-based observational study Kevin Emeka Chukwubuike, Ignatius Ozor, Nnenna Enyi African Journal of Paediatric Surgery 2020 17(3):85-89 Background: Birth defects have medical, surgical and aesthetic consequences. The impact of birth defects is particularly severe in low-income countries where health-care resources are limited. Aims and Objectives: The aim of this study was to determine the prevalence and types of birth defects in live newborns delivered at the two tertiary hospitals in Enugu, South East Nigeria. Materials and Methods: This was a hospital-based observational study carried out on neonates delivered in the maternity units of the University of Nigeria Teaching Hospital Ituku/Ozalla and Enugu State University Teaching Hospital Parklane, Enugu during the periods of January 2015 and December 2018. All the live-born babies born in the two hospitals during this period were recruited into the study. The neonates were examined by a paediatrician for the presence of birth defects. The birth defects were classified according to the system involved and also into major and minor. Results: During the study period, 9492 babies were born, of which 166 had birth defects, which gave a prevalence of 1.75%. The predominant system affected by birth defects was the musculoskeletal system (45.2%) followed by the central nervous system (34.9%), urogenital system (10.8%) and gastrointestinal tract (9%). 13 (7.8%) patients had their birth defects diagnosed prenatally during the maternal ultrasound scan. Fifteen (9%) and 13 (7.8%) mothers of the neonates who had birth defects were diabetics and hypertensives, respectively. Most of the neonates were delivered vaginally. Conclusion: Birth defects are not uncommon. This study showed a prevalence of 1.75% in the two tertiary hospitals in Enugu, South East Nigeria. The most commonly affected system was the musculoskeletal system.

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