Paediatric Surgery

ORIGINAL ARTICLES
	Role of laboratory markers in predicting severity of acute appendicitis	p. 1
	Samarth Virmani, Padubidri Santosh Prabhu, PT Sundeep, Vijay Kumar DOI:10.4103/ajps.AJPS_47_16   Background: Accurately differentiating simple and complicated acute appendicitis (CAA) in children preoperatively can be challenging. The aim of this study is to evaluate the ability of the neutrophil-to-lymphocyte ratio (NLR), total leukocyte count (TLC), percentage lymphocyte, and percentage neutrophil counts to predict the type of appendicitis a patient has preoperatively and to determine the better indicator among these. Materials and Methods: Record of 233 patients under 18 years of age who underwent appendectomy from 2005 to 2014 was evaluated. Based on perioperative findings of the surgeon, the patients were grouped under categories simple acute appendicitis (SAA) and CAA. Information such as age, gender, and laboratory investigations of the patients were recorded and analyzed. Results: SAA included 185 patients and CAA included 48 patients. An NLR >4.8, TLC >13,500 cells/mm3, percentage lymphocyte count <14.8%, and percentage neutrophil count >75% were found to be associated with complicated appendicitis. The highest sensitivity and specificity among these findings were found with the percentage lymphocyte count, which were 70.8% and 63.8%, respectively. Conclusion: The preoperative percentage lymphocyte count serves as a better indicator than TLC, NLR, and percentage lymphocyte count and is a useful parameter in differentiating simple and complicated appendicitis and can be used as a valuable adjunct to the surgeon's clinical evaluation.
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	Indocyanine green clearance test to evaluate liver function in rat model of extrahepatic biliary atresia	p. 5
	Hemonta Kr Dutta, DN Rao, DK Gupta DOI:10.4103/ajps.AJPS_78_16   Background: Indocyanine green clearance test (ICG-K) has been shown as a sensitive marker of liver function in patients with cirrhosis. However, its role in the assessment of liver function in children with biliary atresia is not well established. The present study was undertaken to evaluate the ICG-K in an experimental model of cholangitis and partial biliary obstruction. Materials and Methods: Thirty albino rats were divided into 3 groups of 10 each. After exploration under anesthesia, a vial of OK-432 diluted in 0.2 ml of normal saline was injected into the common bile duct (CBD) in rats of Groups B and C. In the control Group A, only saline was injected. Re-exploration was done at 3 weeks in Groups A and B and at 6 weeks in Group C, and freshly prepared ICG was injected into the inferior vena cava. Blood samples were collected at periodic intervals, optical density of the serum was measured, and half-life of ICG and fractional clearance (K) were calculated. Blood and tissue samples were obtained for biochemical tests and histological examination. Results: The histological changes in CBD and liver were maximum in Group B; this correlated well with the K-value in this group, which was significantly delayed. In Group C, clearance was delayed than the control group with histological changes ranged from mild to moderate inflammation. The control group had normal histology of liver and CBD, and only four rats showed mild portal inflammation. Conclusion: ICG clearance rate is a reliable marker of liver function and can be utilized for evaluation of liver function in postoperative extrahepatic biliary atresia patients.
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	Congenital pouch colon associated with anorectal malformation: A rare anomaly of Asian Region – experience of Kurdish centre	p. 10
	Rossella Angotti, Qadir Qadir Mohamed Salih, Francesco Molinaro, Francesco Ferrara, Marina Sica, Edoardo Bindi, Mario Messina DOI:10.4103/ajps.AJPS_84_16   Background: Congenital pouch colon (CPC) is an unusual malformation associated with anorectal malformations (ARMs) that are seen especially in Asia. The aim of this study was to analyse our series of CPC associated with ARM in our centre and report our experience based on the rarity of pathology. Materials and Methods: This is a retrospective study conducted at the Department of Paediatric Surgery in North Iraq. We identified patients from a prospectively kept database, including all patients managed between 1997 and 2014. Results: In total, 17 patients (3 females and 14 males) were included; all had CPC and high ARM; male:female ratio was 5.6:1. Two females had colo-vestibular fistula, 1 had a colo-cloacal fistula, all males had imperforate anus with colovesical fistula. Pre-operative diagnosis of CPC was made in eight patients (47%). Four patients (23.5%) had an incomplete pouch colon (Type III and IV), and 13 (76%) had complete pouch colon (Type I and II). All patients were managed with staged surgery. Mortality rate was 17.6% (3/17). Conclusions: CPC associated with ARM can be defined as 'Asian' complex malformation. Few cases are reported in Literature from Europe and USA. However, it is known that it is ever more frequent the collaboration between Asian and European surgeons (as in our study), so the suspicion should be considered in all patient high ARM who come from Asian region. We reviewed literature and report our experience of 15 years, after a retrospectively analysis, to share it and add our data to their reported.
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	Congenital pouch colon: Our experience with coloplasty	p. 16
	Sudhir Singh, JD Rawat, Piyush Kumar DOI:10.4103/ajps.AJPS_88_16   Background: Congenital pouch colon (CPC) or congenital short colon is an entity found mainly in Indian subcontinent. In CPC, colon is replaced with partially or completely abnormal pouch connected to the genitourinary tract by a fistula (colovesical). Management protocol is different in different institute. In this article, we are sharing our three stage standard management approach; principle and technique of coloplasty in cases in which colon length is not adequate for pull through and their follow-up. This study aims to show the result of coloplasty in complete CPC. Materials and Methods: This is retrospective observational study, of 5 years duration. The medical record of these patients was reviewed for demographic information, clinical features, investigations performed, operative notes, post-operative events and the outcome of surgery. Results: Total of 626 ARM cases were managed in 5 years duration in which 64 were of pouch colon. The age of presentation was 1–15 days. In fifty patients who completed their, all stage in that 34 patients were in which coloplasty were done in rest of 16 cases excision of CPC and colonic pull through done in view of adequate colonic length (type III and IV) for pull through. In 34 patient in which coloplasty were done showed satisfactory cosmetic and functional out came after stoma closer in follow-up. Conclusions: Properly created coloplasty and three stage procedure for complete pouch colon give better result and less complications. Excision of pouch is not requiring in all cases of CPC.
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	Nephrectomy in children with wilms' tumor: 15 years of experience with "Tumor Delivery Technique"	p. 22
	Yoram Mor, Dorit Esther Zilberman, Roy Morag, Jacob Ramon, Chaim Churi, Itamar Avigad DOI:10.4103/ajps.AJPS_113_16   Background: The contemporary surgical approach to Wilms' tumors follows that used in adults with renal cell carcinomas, namely, early occlusion of the renal vessels and then removal of the kidney as an intact mass. For years, the surgical approach at our institution has been different, starting with blunt separation of the kidney from the surrounding tissues, followed by its delivery outside the abdominal cavity while it is only attached to the major blood vessels which are subsequently ligated. We aimed to present this "tumor delivery technique" and evaluate its outcomes. Materials and Methods: We retrospectively reviewed medical records of children who underwent nephrectomy for Wilms' tumor using "tumor delivery technique." All procedures were performed by the same team, according to the same surgical principles. Results: Between 2000 and 2015, 36 children were operated. Median age was 31 months (interquartile range [IQR]: 6–45 mo), and median maximal tumor diameter was 10 cm (IQR: 8–13.9 cm). Tumors were located to the right side in 47%, left side in 42%, and bilateral in 11%. Twelve children have received preoperative neoadjuvant chemotherapy. Capsular disruption and tumor spillage were documented in 4 cases (11%). Conclusions: "Tumor delivery technique" is an easy and safe approach which might reduce the overall complication rates and the incidence of intraoperative tumor spillage.
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	Infantile hypertrophic pyloric stenosis – Our experience and challenges in a developing country	p. 26
	Uchechukwu Obiora Ezomike, Sebastian Okwuchukwu Ekenze, Christopher Chim Amah, Elochukwu Perpetua Nwankwo, Nene Elsie Obianyo DOI:10.4103/ajps.AJPS_51_16   Background: This study aims to evaluate the experience and challenges in managing patients with infantile hypertrophic pyloric stenosis (IHPS). Patients and Methods: From January 2007 to December 2015, data from patients with IHPS were retrospectively acquired and analyzed using SPSS version 15. Pearson correlation used to assess linear relationships and Student t-test to compare means. P < 0.05 was taken as statistically significant. Results were expressed as percentages, means ± standard deviation and illustrated in tables and graphs. Results: Twenty-six cases were managed with the mean age at diagnosis of 49.16 ± 21.4 days. Mean birth weight was 3.7 kg and mean weight at presentation was 3.3 kg. Firstborn was affected in 29%; 91% were term deliveries; 9% were post-term; none was preterm; and 36% were exclusively breastfed. Mean duration of symptoms was 25.6 ± 18.9 days. Hyponatraemia was seen in 36%, hypokalaemia 37.5%, alkalosis 35% and hypochloraemia 62%. Mean pyloric tumour length was 22.85 ± 6.56 mm and pyloric wall thickness 5.51 ± 1.36 mm. There was a significant correlation between duration of symptoms and serum potassium level (R = −0.6326, P = 0.002). Mean symptom duration in patients with hypokalaemia was 39.88 ± 23.41 days and without hypokalaemia 17.15 ± 9.78 days (P = 0.006). Mean hospital stay was 9.45 ± 3.27 days. Four patients developed four complications and three patients died (11.5%). Mean age at presentation for pre-operative mortalities was 84 ± 39 days and 46 ± 17.98 days for others (P = 0.015). Conclusions: IHPS presents late in our environment and occurs mainly in term males. There is a significant positive relationship between duration of symptoms and serum potassium level and the mean duration of symptoms was significantly longer in those with hypokalaemia. Pre-operative mortality was significantly associated with longer duration of symptoms.
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	Role of ano rectal myomectomy in children with chronic refractory constipation	p. 31
	Rajeev Gurunath Redkar, Vinod Raj, Anant Bangar, Varun Hathiramani, Swathi Chigicherla, Shruti Tewari DOI:10.4103/ajps.AJPS_99_17   Background: Chronic refractory constipation (CRC) is an uncommon type of constipation. These children have persistent symptoms even after treatment with high dose laxatives, which may cause abdominal distension, vomiting, cramping and bloating. We conducted this study to assess the diagnostic and therapeutic role of anorectal myomectomy in children with CRC. Materials and Methods: This study includes 107 patients who fit the criteria of CRC. Complete bowel preparation with polyethylene glycol solution, enemas and antibiotics was carried out before surgery in all patients. The anorectal myomectomy was carried out under general anaesthesia with the patient in the high lithotomy position. The patients were followed up from 6 months to 13 years postoperatively. The success of myomectomy was based on the daily and complete passage of stools without the need for medication or enemas. Results: A total of 99 patients were included in the study, of which, 86 (86.86%) patients showed a good response to anorectal myomectomy. Of these, 32 patients had normal histology, 14 had histology suggestive of Hirschsprung's disease, 8 had hypoganglionosis, 10 had ultra-short segment Hirschsprung's disease and 22 had hypertrophic nerves with immature ganglia. Poor response was seen in 13 (13.13%) patients of whom 5 had normal histology, 5 had Hirschsprung's disease, 2 had hypoganglionosis and 1 had ultra-short segment Hirschsprung's disease. Conclusion: Anorectal myomectomy is an effective and technically simple procedure in selected patients with CRC for both diagnostic and therapeutic purposes.
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	Functional assessment of the patients with perineal and vestibular fistula treated by anterior sagittal anorectoplasty	p. 36
	Naoki Hashizume, Kimio Asagiri, Suguru Fukahori, Shinji Ishii, Nobuyuki Saikusa, Naruki Higashidate, Motomu Yoshida, Daisuke Masui, Saki Sakamoto, Shiori Tsuruhisa, Yoshiaki Tanaka, Minoru Yagi DOI:10.4103/ajps.AJPS_91_17   Background: Anterior sagittal anorectoplasty (ASARP) has been a standardised operative treatment for anorectal malformation (ARM). This retrospective study was undertaken to evaluate patients with perineal fistula (PF) and vestibular fistula (VF) treated by ASARP in our institution. Patients and Methods: Twenty patients (PF, n = 14; male, n = 8 and female, n = 6 and VF, n = 6) were evaluated. Eighteen patients underwent primary ASARP without protective colostomy. Two patients underwent colostomy because of intestinal atresia and suspected of other type ARM. The age range of operation was from 4 months to 5.0 years. Sixteen patients (PF, n = 13; male, n = 7 and female n = 6 and VF, n = 3) over 3 years of age were evaluated according to the Krickenbeck classification. Results: Operative complications occurred in one patient. Minor wound dehiscence occurred in six patients. Mucosal prolapse occurred in two patients. According to the Krickenbeck classification, amongst male patients with PF, all patients had voluntary bowel movements (VBMs) and two patients had Grade 1 soiling, while four patients had Grade 2 constipation. Amongst female patients with PF, all patients had VBM and no soiling, one patient had Grade 1 and two patients had Grade 2 constipation. In patients with VF, one patient was continent with Grade 1 soiling. One patient had Grade 2 and two patients had Grade 3 constipation. Conclusions: ASARP without colostomy carried a risk of wound dehiscence. The ASARP technique provided normal or moderate outcomes for VBM and soiling. However, in about half of patients, defecation management with laxative therapy was required to achieve a normal condition.
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	A 1-year randomized controlled trial to compare the outcome of primary repair of hypospadias with vascular cover using tunica vaginalis flap with those using preputial dartos fascia	p. 42
	Santosh B Kurbet, Ramesh S Koujalagi, V Geethika, Vikram Nagathan DOI:10.4103/ajps.AJPS_104_17   Background: Tubularized incised plate (TIP) urethroplasty is the most common technique noted to correct hypospadias. However, urethrocutaneous fistula (UCF) is still one of the most common complications of this technique. Several techniques of providing vascularized flaps to the neourethra have been recommended to decrease this complication rate. The aim of the study was to assess the outcome of primary repair of hypospadias using tunica vaginalis (TV) flap with those using preputial dartos (PD) fascia. Patients and Methods: Children diagnosed with hypospadias between the age group of 9 months to 18 years, who fulfilled the criteria were randomly divided into two groups by computerized randomization technique. Initially, TIP urethroplasty was done. Children with PD vascular cover were included in Group A and those with TV vascular cover were included in Group B. All the patients were followed up for a minimum of 6 months after surgery. Results: Two (10%) patients in Group A developed UCF and one (5%) patient developed stricture urethra in the follow-up period. None of the patients developed UCF in the Group B. One (5%) patient had stricture urethra in Group B. Two (10%) patient developed meatal stenosis in Group A. Two (10%) patient in Group B developed meatal stenosis. Conclusions:TV flap could be an alternative to PD flap as a vascular cover of neourethra in patients undergoing primary hypospadias repair by TIP urethroplasty.
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CASE REPORTS
	A staged operation for anopenile urethral fistula	p. 48
	Issei Kawakita, Shohei Honda, Hisayuki Miyagi, Masashi Minato, Kazuyoshi Okumura, Akinobu Taketomi DOI:10.4103/ajps.AJPS_52_17   Anopenile urethral fistula (APUF) is not rare, but there are only a few detailed reports regarding its surgical treatment. We describe a patient with APUF who had no anal opening, and meconium was discharged from the external urethral orifice. The patient was treated with a staged operation.
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	Metanephric stromal tumor: An unusual presentation of a rare paediatric renal neoplasm	p. 50
	Nouha Ben Abdeljelil, Rim Hadhri, Manel Njima, Yosra Sghaier, Lassaad Sahnoun, Abdelfatah Zakhama DOI:10.4103/ajps.AJPS_56_17   A 2-year-old boy with prenatal diagnosis of a malformation uropathy was referred to paediatric surgery department. On systemic examination, there were no palpable masses. An ultrasonography of abdomen with color Doppler, a renal artery angiographic and scintigraphy revealed a preostial aneurysm at the left renal artery. The patient had a left nephrectomy. Grossly, the specimen measured 75 mm × mm 50 × 20 mm with renal artery aneurysm measuring 30 mm × 35 mm. On cut section, the renal parenchyma contained a whitish tumor that measured 35 mm × 10 mm. Histopathologically, this tumor was diagnosed as metanephric stromal tumor.
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	Spontaneous common hepatic duct perforation in a child: A rare case report	p. 53
	Kanoujia Sunil, Archika Gupta, Ajay Kumar Verma, Abhishek Kumar Singh, Shiv Narain Kureel, Anand Pandey DOI:10.4103/ajps.AJPS_74_17   Spontaneous perforation of common bile duct is a rare phenomenon; few cases are reported in literature. Hence, there is a dilemma for the management of these cases, but with modern radiological equipment and high degree of suspicion, it is possible to diagnose early. The overall prognosis of this condition is good, provided an early surgical intervention is instituted; we are reporting a case of a 6-year-old male with spontaneous perforation of common hepatic duct. Managed by repair of rent over T-tube, postoperative period was uneventful, T-tube was removed after 3 weeks, and the patient is doing well in follow-up.
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LETTERS TO THE EDITOR
	Meckel's diverticulum: Is this the time for a large multicentric study?	p. 56
	Mirko Bertozzi, Antonino Appignani DOI:10.4103/ajps.AJPS_12_17
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	The evolving surgical approaches in challenged resource settings	p. 58
	Mirko Bertozzi, Antonino Appignani DOI:10.4103/ajps.AJPS_13_17
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	Plastibell circumcision	p. 60
	Sora Yasri, Viroj Wiwanitkit DOI:10.4103/ajps.AJPS_16_18
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	Extrahepatic biliary atresia, liver function tests, and hemoglobin variants	p. 61
	Ioannis Kyriakidis, Athanasios Tragiannidis, Nikolaos Gompakis DOI:10.4103/ajps.AJPS_124_16
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