Mesocolic hernia, a case series

INTRODUCTION AND IMPORTANCE

Paraduodenal hernias are difficult to diagnose due to their unusual presentation. Herein, five new cases are added to the literature.

CASE PRESENTATION

Four male and one female child complained of paraduodenal hernias, two on the right side and three on the left side. The intestinal part that herniated inside the hernia sac was also malrotated in four patients. One patient had Meckel's diverticulum with a herniated intestine. One infant had extrahepatic biliary disease, a single atrium, polysplenia, intestinal malrotation, and a left paraduodenal hernia. Exploratory labarotomy was done for reduction of the intestine, reorientation, and repair of hernia orifices.

CLINICAL DISCUSSION

Paraduodenal hernia is a component of malrotation. Cautious dissection of the hernia orifice is required to keep away from injuries to the inferior mesenteric vein or left colic artery in the course of the restoration of the left paraduodenal hernia. Also, the superior mesenteric vessels may be injured in the course of the restoration of the right paraduodenal hernia.

CONCLUSION

There is a correlation between the occurrence of PDH with malrotation. The diagnosis of malrotation can be made with an ultrasound abdomen; however, it is true that ultrasound cannot make a confirmed diagnosis in all patients. Once the diagnosis of a mesocolic hernia has occurred, surgical repair is mandatory by closure of the defect.

Outcomes after surgery for children in Africa (ASOS-Paeds): a 14-day prospective observational cohort study

BACKGROUND

Safe anaesthesia and surgery are a public health imperative. There are few data describing outcomes for children undergoing anaesthesia and surgery in Africa. We aimed to get robust epidemiological data to describe patient care and outcomes for children undergoing anaesthesia and surgery in hospitals in Africa.

METHODS

This study was a 14-day, international, prospective, observational cohort study of children (aged <18 years) undergoing surgery in Africa. We recruited as many hospitals as possible across all levels of care (first, second, and third) providing surgical treatment. Each hospital recruited all eligible children for a 14-day period commencing on the date chosen by each participating hospital within the study recruitment period from Jan 15 to Dec 23, 2022. Data were collected prospectively for consecutive patients on paper case record forms. The primary outcome was in-hospital postoperative complications within 30 days of surgery and the secondary outcome was in-hospital mortality within 30 days after surgery. We also collected hospital-level data describing equipment, facilities, and protocols available. This study is registered with ClinicalTrials.gov, NCT05061407.

FINDINGS

We recruited 8625 children from 249 hospitals in 31 African countries. The mean age was 6·1 (SD 4·9) years, with 5675 (66·0%) of 8600 children being male. Most children (6110 [71·2%] of 8579 patients) were from category 1 of the American Society of Anesthesiologists Physical Status score undergoing elective surgery (5325 [61·9%] of 8604 patients). Postoperative complications occurred in 1532 (18·0%) of 8515 children, predominated by infections (971 [11·4%] of 8538 children). Deaths occurred in 199 (2·3%) of 8596 patients, 169 (84·9%) of 199 patients following emergency surgeries. Deaths following postoperative complications occurred in 166 (10·8%) of 1530 complications. Operating rooms were reported as safe for anaesthesia and surgery for neonates (121 [54·3%] of 223 hospitals), infants (147 [65·9%] of 223 hospitals), and children younger than 6 years (188 [84·3%] of 223 hospitals).

INTERPRETATION

Outcomes following anaesthesia and surgery for children in Africa are poor, with complication rates up to four-fold higher (18% vs 4·4-14%) and mortality rates 11-fold higher than high-income countries in a crude, unadjusted comparison (23·15 deaths vs 2·18 deaths per 1000 children). To improve surgical outcomes for children in Africa, we need health system strengthening, provision of safe environments for anaesthesia and surgery, and strategies to address the high rate of failure to rescue.

FUNDING

Jan Pretorius Research Fund of the South African Society of Anaesthesiologists and Association of Anesthesiologists of Uganda.

Safety and Efficacy of Hook Diathermy in the Dissection of the Mesocolorectum During Laparoscopic-Assisted Pull-Through for Hirschsprung Disease in Low-Resource Settings

Background: Surgical correction is the main line of treatment for the congenital disorder Hirschsprung's disease (HD). Laparoscopic techniques proved their safety and efficacy in previous studies. LigaSure™ is the gold standard for colorectal dissection. However, other sealing methods could be used during the unavailability of LigaSure. Purpose: This study aimed to assess the safety profile of the hook diathermy technique compared to LigaSure in colorectal dissection during laparoscopic-assisted pull-through for HD. Materials and Methods: This case-control study was held in the pediatric surgery department at Assiut University Hospitals between September 2017 and January 2023. The study included 57 HD patients who were surgically operated on during a laparoscopic-assisted pull-through. They were divided into 2 groups according to the sealing methods: the ligasure group included 25 patients, and the hook diathermy group included 32 patients. Results: Both groups had no statistically significant differences regarding age, sex, or weight. The transition zone was present in all patients, and most transition zones were rectosigmoid. No cases reported intraoperative blood transfusion or conversion to an open or transanal approach. Minimum intraoperative blood loss was reported in both groups, with no significant differences. As regards postoperative complications, including bleeding, leakage, perianal excoriation, and enterocolitis, no significant differences between both groups were found. Conclusion: The LigaSure and hook diathermy techniques are safe and effective sealing methods for colorectal dissection during laparoscopic-assisted pull-through for HD.

Painful knee

INTRODUCTION

A bipartite patella is a rare anatomical variant of the patella. A patella bipartite is often asymptomatic and is often an incidental finding on radiological imaging. The patella remains bipartite when secondary ossification centers fail to fuse. Herein, a case of bipartite patella improved after knee arthroscopy and surgical removal.

PRESENTATION OF THE CASE

A 57-year-old male with a history of polytrauma. He complained of progressive pain in the right knee area. A radiological investigation reported a right bipartite patella. The condition improved after the open removal of the accessory patella.

DISCUSSION

This case is considered type III according to Saupe's classification. Due to its location and radiological appearance, it is a painful synchondrosis of a bipartite patella.

CONCLUSION

After the failure of conservative management, the removal of the bipartite patella was necessary and unavoidable to restore everyday activities.

Management of penile post-circumcision ischemia by pentoxifylline infusion and hyperbaric oxygen therapy

BACKGROUND

Post-circumcision penile ischemia is a devastating complication. We will present our experience in managing children with various forms of penile ischemia.

MATERIALS AND METHODS

This cohort prospective observational and interventional study was performed on all male children with post-circumcision penile ischemia between April 2017 and October 2021. A designed and approved protocol includes a combination of early pentoxifylline infusion, hyperbaric oxygen inhalation, early catheterization, and appropriate surgical debridement were applied for patients with deep ischemia 11/23, mainly the necrotic skin and subcutaneous tissues. Data of patient age, anesthesia method, monopolar diathermy usage, early presentation and positive wound culture were collected and analyzed statistically.

RESULTS

During the study period 3,382 children were circumcised for non-medical reasons; 23 children were diagnosed with penile ischemia (0.7%), among other complications (9%). Most of the penile ischemia is associated with the use of monopolar diathermy (74%). The use of compressive wound dressing to control post-circumcision bleeding and infections is also responsible for ischemia in 52.2% and 43.5% of the cases. Inexperienced physicians were commonly responsible for ischemia (73.9%). Patients managed at first 24 h had better outcomes than those who were presented later (p = 0.001).

CONCLUSION

In children with post-circumcision penile ischemia, a combination of hyperbaric oxygen therapy and pentoxifylline is especially effective for patients with skin and facial necrosis, this management reduces penile tissue loss.

Post-cesarean section laparoscopic cholecystectomy: a case report

BACKGROUND

Laparoscopic cholecystectomy at the time of cesarean section is novel in medicine. It is safe, feasible, and cost-effective.

CASE PRESENTATION

A 29-year-old G3P2 + 0 woman had two previous cesarean sections. She was pregnant at 32 weeks. The fetus had anencephaly. She had acute cholecystitis. Laparoscopic cholecystectomy done at the time of termination of pregnancy by cesarean section.

CONCLUSIONS

In a critical period, such as acute cholecystitis, the combination of laparoscopic cholecystectomy immediately post cesarean section is effective if the surgeon is highly qualified and experienced.

Surgical correction of epispadias associated with buried penis

INTRODUCTION AND IMPORTANCE

Isolated male epispadias is a rare entity with incidence of approximately 1 in 120,000 live births. Epispadias usually presents with a phimotic preputial orifice where glans is not visible and hence is also known as concealed epispadias. Buried penis in children is defined as a congenital insufficient penile skin with an unretractable foreskin that keeps the penis deep inside the pre-pubic fat. This congenital malformation of the penile envelopes is usually isolated. However, in some cases the concealed penis hides an underlying penile anomaly. We present surgical repair of a very rare case with concealed epispadias.

CASE PRESENTATION

A nine-month-old infant had buried his penis, and his mother was seeking his circumcision. Local examination revealed concealed penopubic epispadias. A pediatric surgeon operated on this patient using the modified partial penile disassembly technique. The patient was doing well at follow-up visits at one, three, and six months. There were no urethral stricture or obstructive urinary symptoms. The parents were satisfied with the cosmetic outcome.

CLINICAL DISCUSSION

The embryogenesis and development of the urethra and the prepuce are linked. Urethral development defects (as in hypospadias or epispadias) are frequently coupled with faulty prepuce on the same side. The goal of surgical management for epispadias is to correct the dorsal chordee and reconstruct the epispadiac urethra and glans. Based on the cosmesis of the penis reconstruction, preservation of erectile function, and achieving urine continence, the outcome is evaluated.

CONCLUSION

Concealed epispadias is frequently ignored because patients appear with buried penis, non-retractile prepuce, and a normal urine stream. Preoperative diagnosis and parent counseling are critical for the effective treatment of this uncommon entity. The modified partial penile disassembly procedure, in which the tunica albuginea is stitched to the pubic periosteum at 3 and 9 o'clock, can be used to correct buried epispadias.

Perforated gallbladder in neonates with review of literature

INTRODUCTION

Neonatal perforated gallbladder is a rare and implausible surgical emergency. Pneumoperitonium and neonatal intestinal obstruction are the main clinical presentations. Many cases of neonatal perforated gallbladder had no clear pathology. Most proper treatment is cholecystectomy during formal exploration.

CASE PRESENTATION

We reported a case of male neonate in his first days of life, presented with abdominal distention and pneumoperitonium and so, surgical exploration revealed perforated gallbladder for which cholecystectomy done.

CLINICAL DISCUSSION

Idiopathic gallbladder perforation is seldom condition and is hard to discover before exploration. Besides, pathogenesis remains unknown. In our presented case, the real cause of perforation was unknown and main presentation was pneumoperitonium.

CONCLUSION

Although perforated gallbladder is a rare entity and in most of cases does not cause pneumoperitonium, but perforated gallbladder should be taken in account of all cases of pneumoperitonium.

Watchful waiting for communicating hydrocoele in infants

Background

One of the commonest pediatric surgeries is hydrocele. There are suggestions to wait for spontaneous resolution than to operate these cases without harmful adverse events. Herein, we evaluated the outcome of the watchfulness of these cases over 18 months.

Methods

The study included 93 infants with communicating hydrocele for the Pediatric Surgery Department, Faculty of Medicine (Assiut, Egypt). They were planned to be followed up for 18 months, and indications for intervention included hernia, increasing in size, being tense, and completion of 18 months of follow-up without improvement.

Results

The gestational age of the included patients was 38.5 ± 2.2 weeks and the age at the time of presentation was 50 (7, 495) days. Most cases were bilateral, reducible, and had an intermittent course. After 18 months of follow-up, 60.2% of the patients resolved spontaneously and 39.8% were surgically treated. Age at the time of presentation was higher among operated patients. Patients with reducibility criteria on clinical examination and lack of intermittent course had higher frequency among operated patients (89.2%).

Conclusions

It is safe to wait and not to operate on infants with hydrocele up to 18 months as long as there was no hernia. Higher age at presentation and reducibility on examination are indicators that favor the need for surgery.

The effects of curcumin as dietary supplement for patients with COVID-19: A systematic review of randomized clinical trials

Accumulating evidence has been reported regarding the effect of curcumin as a dietary antiviral on patients with COVID-19; however, findings are controversial. Our systematic review aimed to evaluate the effects of curcumin in patients with COVID-19. Electronic databases (PubMed, EMBASE, Scopus, Web of Science, Cochrane Central, and Google Scholar) were systematically searched to identify only randomized clinical trials (RCTs) that assessed curcumin in patients with COVID-19 from inception to September 23, 2021 relevant keywords. The Cochrane risk-of-bias tool for randomized trials was used to evaluate the risk of bias. After a critical review of 1,098 search hits, only six RCTs were selected for discussion. A total of 480 patients were included, with 240 amongst the curcumin groups and 240 in the control group. The lymphocyte count was significantly higher in the curcumin group compared to the placebo group. Curcumin was found to decrease the number of T-helper 17 cells, downregulate T-helper-17 cell-related factors, reduce levels of T-helper-17 cell-related cytokines, yet increase the gene expression of Treg transcription factor forkhead box P3 (FOXP3), and decrease T-Box transcription factor 21 (TBX21). Our review revealed that curcumin might have a positive effect on relieving COVID-19 related inflammatory response due to its powerful immune-modulatory effects on cytokines production, T-cell responses, and gene expression. These findings suggest that curcumin confers clinical benefits in patients with COVID-19. However, due to the limited number of the included studies, further high-quality studies are needed to establish the clinical efficacy of the curcumin.

A spectrum of epididymis and vas deferens anomalies among children with cryptorchidism: a retrospective multi-center study

Background

Vasoepididymal anomalies are not rare among children with cryptorchidism. They may affect fertility following orchiopexy. Herein, we describe the cases of abnormalities of the vas deferens and epididymis in children undergoing orchidopexy for cryptorchidism. Data were collected retrospectively from six centers providing care for patients with undescended testicles from September 2017 to February 2019. All patients whose congenital anomalies of the epididymis or vas deferens were discovered incidentally during operative intervention for cryptorchidism and where photographs of the anomalies were taken were included.

Results

The total incidence of congenital anomalies on the 467 testicles which had operations was 13.2%. Congenital epididymal and vas deferens anomalies were more common on the left side than the right side in patients with cryptorchidism (P = 0.038). Attachment anomalies between the epididymis and testis were the most common epididymal anomaly (36.3%), while a vanished vas deferens was the most frequent vas deferens anomaly (18%). Three patients had absent vas deferens, two had curled vas deferens, two had vas deferens separated from the epididymis, and one had a duplicated vas deferens. Three patients had an epididymal cyst, one had an enlarged appendix of the epididymis, and one had epididymal agenesis.

Conclusion

Attention must be paid during any surgery on an undescended testicle as an anomaly of the vas deferens could lead to unexpected complications. Anomalies of the vas deferens or epididymis that present in cases of cryptorchidism occur mostly on the left side.

An ileo-ileal intussusception secondary to polypoid lipoma in a child, a case report and review of the literature

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Small intestinal lipoma is a rare reason for ileoileal intussusception but should be included in the differential diagnosis for lead points causing intussusception in children.

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Dexamethasone as an adjuvant treatment may improve the outcome in cases of intussusceptions but this point needs future researches.

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Intermittent attacks of small intestinal intussusception may lead to dilation of the distal segment (Intussuscipiens). This mechanism may delay vascular compromise.

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High level of clinical suspicion needs to diagnose intussusception with unusual presentation.

Background

Intramuscular intestinal lipoma is one of the rare benign tumours of the small intestine in children and acts as a lead point of intussusception.

Presentation of case

We describe a case in which a 4-year-old boy presented with recurrent attacks of colicky abdominal pain and non-bilious vomiting. Abdominal examination was irrelevant. Per rectum (PR) examination indicated an empty rectum without red currant jelly stool and non-palpable mass. Abdominal ultrasonography revealed a target sign of intussusception. After a period of conservative treatment, the child passed normal coloured and well-formed stool. Exploratory laparotomy referred to a long segment ileo-ileal intussusception with a polypoid lipoma as a lead point. Microscopic examination showed a benign non-capsulated intramuscular ileal lipoma.

Discussion

Small bowel lipoma produces symptoms of intermittent bowel obstruction. Herein, the child presented with non- bilious vomiting, we attribute this to reflex sympathetic stimulation of the pylorus leading to pylorospasm.

Conclusion

Small intestinal lipoma is a rare finding in children that may cause intussusception which does not resolve spontaneously.