22nd Conference The Association of Paediatric Surgeons of Pakistan
Karachi
April 9 - 11, 2010 PROGRAMME The Rufayda Al-Aslamiya Auditorium, School of Nursing Aga Khan University
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Day I – Friday - April 9, 2010 09:00 – 16:00
Pre-conference Workshop Paediatric Laparoscopic Workshop. Venue: Liaquat National Hospital. (Hands-on Workshop for registered participant only)
8:30 - 9:00
Workshop Registration
9:00 -12:00
Interactive session Break Fast and informal talk between SOLES and APSP Presentations
• • Lecture I Lecture II
Pediatric Laparoscopy Present and future - where do we stand Pediatric Laparoscopy Point of Technique How it is different DVD Session Formatted Edited DVD Presentation
Shabbir Hussain Muhammad Arshad
3minutes DVD followed by Discussion for 7minutes
12:00 -1:00
Introduction to Hands-on Workshop for Registered Participants only.
1:00 - 2:00
Lunch and Prayers
2:00 - 5:00
Hands on Workshop.
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Friday – April 9, 2010 Conference Venue: Rufayda Al-Aslamiya Auditorium School of Nursing - Aga Khan University 16:00 – 17:00
Registration
17:00 – 17:10
Recitation from the Holy Quran
17:10 – 17:25
Welcome address M. Arif Mateen Khan President – 22nd Conference of APSP
17:25 – 17:40
Presidential address Hazrat Ullah Khattak President - APSP
17:40 – 17:50
Address by the Chief Guest Farhat Abbas Dean, Faculty of Health Sciences The Aga Khan University
17:50 – 19:00
Introduction of Guest Speaker. State-of-the-art-lecture (Elluminate session) Topic: Biliary Atresia Mark Davenport Professor and Consultant Paediatric Hepatobiliary Surgeon King’s College Hospital - London
19:00 – 19:30
Hi-Tea
19:30 – 20:30
General Body Meeting of APSP
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Day II – Saturday - April 10, 2010 09:30 - 10:45
Scientific Session – I: Chairs: Nizam ul Hassan and Naeem uz Zafar Khan Moderator: M. Tahir
09:00 - 9:30
Invited Lecture - I: Pain management in Pediatric Surgical patients Mansoor Ahmad Consultant Paediatric Anaesthestist - AKU
09:30 - 09:40
Free Papers: Our Experience with Esophageal Replacement. Muhammad Saleem, Muhammad Afzal Sheikh, Muhammad Sharif and Muhammad Arslan, CH & ICH Lahore
09:40 - 09:50
Closure of Emergency Intestinal Stoma in the Same Hospital Stay. Ahmed, Nabila Talat and Mahmood Shaukat KEMU, Mayo Hospital Lahore
09:50 - 10:00
Our Experience in Endorectal Pull-through for the treatment of classic Hirschsprung’s disease. Khurrum Arif, Amjad Chaudhary and M. Zaheer Abbasi The Children’s Hospital, PIMS, Islamabad
10:00 - 10:10
Endorectal Pullthrough for Hirschsprung’s Disease: An Unpredictable Outcome. Naima Zamir, Soofia Ahmad and Jamshed Akhtar National Institute of Child Health, Karachi
10:10 - 10:20
Choledochal Cyst – A different disease in infants? Munira Abdul Aziz and Zafar Nazir Section of Paediatric Surgery, Department of Surgery, Aga Khan University, Karachi
10:20 - 10:30
Laparoscopic Surgery in children- 3 year institutional experience Hina Noorani, Muhammad Arshad and Shabbir Hussain Department of Pediatric surgery, Liaquat National Hospital, Institute of Postgraduate Medical Studies. Karachi
10:30 - 10:40
Laparoscopic pyloromyotomy for IHPS, Initial experience of 5 cases Ali Raza Brohi Paediatric Surgery Department People’s Medical College, Nawabshah
10:40 - 11:00
Tea Break 5
11:00 - 11:30
Poster Session Inauguration Poster Session
1. Congenital Cystoid Adenomatoid Malformation: Surgical management of a threeand a half-year child : A case report Ranish Deedar-Ali-Khawaja, and Saulat Hasnain Fatimi Aga Khan University Karachi 2. Revised Trauma Score (RTS) as a predictor of outcome in trauma patients: a retrospective review at a tertiary care hospital in Karachi, Pakistan Umair Zafar Malik, Omair Shakil, Ghulam Rehman Mohyuddin and Anwar Ul-Haq Aga Khan University, Karachi 3. Foreign Body Aspiration in children: An Alert. Maryam Arain, Soofia Ahmed and Jamshed Akhtar National Institute of Child Health Karachi 4. Penile Tourniquet Syndrome S M. Raees Taqvi., Muhammad Sajjad Ashraf, Javed Ahmed, Muhammad Shahab Athar and Muhammad Talat Mehmood DUHS Karachi 5. Modified Duhamel’s Procedure for Hirschsprung’s Disease Muhammad Sharif, Muhammad Saleem, Muhammad Afzal, Shahid Iqbal and Muhammad Afzal Sheikh Children Hospital & ICH Lahore 6. Outcome of two stage repair of Hypospadias at Liaquat University Hospital Jamshoro / Hyderabad Bilal Fazal Shaikh and Mahesh Kumar LUMHS, Jamshoro 7. Ovarian Masses: Experience at Mayo Hospital, Lahore Muhammad Qasim, Nabila Talat and Mahmood Shaukat KEMU, Lahore 8. Error, Negligence or Hyposkilia Junaid Afzal, Naima Zamir, Tayyaba Batool and Jamshed Akhtar National Institute of Child Health, Karachi 9. Audit of Neonatal Surgery – The Predictor of Survival Nasir Saleem Saddal, Yaqoot Jahan, Yousuf Aziz Khan and Junaid Afzal National Institute of Child Health, Karachi
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10. Bilateral Neonatal Ovarian Cyst with Gangrene on one side Maryam Arain, Naima Zamir. Soofia Ahmed and Jamshed Akhtar National Institute of Child Health, Karachi 11. Congenital Lobar Emphysema: A rare cause of respiratory distress in an infant Nida Sheikh, Naima Zamir, Soofia Ahmed and Jamshed Akhtar National Institute of Child Health, Karachi 12. Cloacal Exstrophy & Its Variants: Is there any good news for the patients? Azeem, Naima Zamir, Soofia Ahmed and Jamshed Akhtar National Institute of Child Health, Karachi 13. Anterior Abdominal Wall Defect: Omphalocele Anila Haroon, Rehan Ali, Shakeel Ahmed and Khalil Ahmed Department of Paediatrics, Aga Khan University, Karachi 14. Posterior Sagittal Approach for Sacrococcygeal teratomas Iftikhar A Jan, Soofia Ahmad, Ahmad Sharif, Anwar A. and Hazrat Ullah Khattak 15. Intraventricular Hemorrhage in Preterm Babies Anila Haroon, Muhammad Sohail Salat and Zaid Bhatti Department of Paediatrics, Aga Khan University, Karachi 16. Research publications from Paediatric Surgeons of Pakistan: A Case for Reviving Pakistan Journal of Paediatric Surgery Yusuf Aziz Khan and Jamshed Akhtar National Institute of Child Health, Karachi 17. Pediatric Tracheostomy: Complications and role of home care in a developing country. Sadaf Zia, Muhammad Arshad, Zafar Nazir and Sohail Awan Sections of Paediatric Surgery and ENT, Aga Khan University, Karachi 18. SPECTRUM OF INJURIES RESULTING FROM BOMB BLAST IN CHILDREN Sohail Asghar Dogar, Shabbir Hussain and Muhammad Arshad Section of Paediatric Surgery, Aga Khan University, Karachi 11:50 – 13:00
Scientific Session – II: Chairs: Abdul Hamid and Hazarat Ullah Khattak Moderator: Daulat Khan
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11:30 - 11:50
11:50 - 12:00
Invited Lecture - II: Post operative Management of Peadiatric Surgical Patients in ICU Anwar Ul-Haq Consultant Paediatric Intensivist – AKU Free Papers: Outcome of acute peritoneal dialysis in paediatric intensive care unit of a developing country. Riffat Rasheed and Anwar Ul-Haque Department of Paediatric and Child Health, Aga Khan University, Karachi
12:00 – 12:10
Role of Focused Abdominal Sonography for Trauma (FAST) in Pediatric practice Ahmad Vaqas Faruque, Saqib Hamid Qazi and M. Arif Mateen Khan Aga Khan University, Karachi
12:10 – 12:00
Stentless Pyeloplasty for UPJ obstruction Iftikhar A Jan, Hazrat Ullah, M Yusuf and M Irfan, Ali National Institute of Rehabilitation Medicine, Islamabad
12:20 - 12:30
Feminizing Genitoplasty in Female CAH. Experience at CH & ICH, Lahore Muhammad Afzal Sheikh, Taeed Ahmad Butt, Muhammad Sharif and Muhammad Saleem. Department of Paediatric Surgery & Endocrinology, The Children’s Hospital, Lahore.
12:30 - 12:40
Knowledge, Attitude & Practices Regarding Circumcision in Southern Punjab Muhammad Zafar Iqbal, M Jehangir and Shumaila Irum Sheikh Zayed Hospital, Rahim Yar Khan
12:40 – 12:50
Management of Neonates with Surgical conditions without ICU Support Khurram Arif, Amjad Chaudhary and M. Zaheer Abbasi The Children’s Hospital, PIMS, Islamabad
12:50 – 1:00
Effect of Ponseti Method in the correction of Congenital Talipes Equinovarus within 15 days of life Omar Khattab, Asif Hanif and Mahmood Shoukat Paediatric Surgery Department, KEMU, Mayo Hospital Lahore
13:00 - 14:15
Lunch & Prayers
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14:15 - 15:45
Seminar: Hirschsprung’s Disease Chair: Afzal Sheikh and Haroon Khurshid Pasha Moderator: Zafar Nazir
14:15 – 14:25
Introduction
Zafar Nazir
14:25 – 14:40
Role of Pathologist
Naila Kayani
14:40 – 14:55
Minimally Invasive Procedures Laparoscopy and Transanal Pull Through
M. Arshad
14:55 – 15:00
Transanal Pull Through procedure – An Experience Iftikhar A. Jan
15:00 – 15:10
Total Colonic Hirschsprung’s Disease AKU Experience
Saqib Hamid Qazi
15:10 – 15:15
Experiential Comments
Nizam ul Hassan
15:15 – 15:40
Discussion / Question and Answers
15:40 – 15:45
Concluding remarks
15:45 -16:00
Tea Break
16:00 - 18-00
Challenges in Paediatric Surgery Moderator: Jamshed Akhtar Department of Paediatric Surgery, National Institute of Child Health Karachi Panelists: Syed Mohsin Azhar Ali (Ex Dean ZMU Karachi) Mahmood Shaukat, Registrar KEMU, Lahore Haroon Khurshid Pasha, NMC, Multan Sikandar Ali Mughal, Registrar SMBBU, Larkana M Arif Mateen Khan, Conference President AKU, Karachi Aqeel Safdar, CMH, Rawalpindi Daulat Khan, PGMI, Quetta M. Talat Mehmood, DUHS, Karachi M. Amjad Chaudhry, Registrar QAPMC PIMS, Islamabad
16:05 – 16:12
Reflection of Interns on their rotation in Paediatric Surgery. Nida Shaikh Department of Paediatric Surgery, National Institute of Child Health, Karachi
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16:13 – 16:19
Trainees’ Perspective of Paediatric Surgery Residency Program. Sabeen Mujeeb Dept. of Paediatric Surgery, National Institute of Child Health, Karachi
16:20 -16:26
Status of Paediatric Surgeons and the specialty. Tayyaba Batool Dept. of Paediatric Surgery, National Institute of Child Health, Karachi
16:27 – 16:33
Some thoughts for up lifting Paediatric Surgery specialty M. Saleem Children Hospital & ICH, Lahore
16:34 – 16:40
Working for the Survival of Paediatric Surgery Daulat Khan PGMI, Quetta
16:41 – 16:47
Why University Hospital Department could not get recognition for training? M. Talat Mehmood Dow University of Health Sciences, Karachi
16:48 – 16:54
Future is not Bleak: Getting Recognition - A story of success Ali Raza Brohi Peoples Medical College, Nawabshah
16:55 – 17:01
Paediatric Surgery Curriculum: An area to work upon M. Amjad Chaudhry QAPMC PIMS, Islamabad
17:02 – 17:08
Post Graduate Training in Paediatric Surgery Haroon Khurshid Pasha Nishtar Medical College / Hospital, Multan
17:10 – 18:00
Question & Answer session
18:00 -18:30
Closing Session Chairs: Abdul Aziz and Jamshed Akhter Moderator: Muhammad Arshad Formulation of Consensus Document & Recommendations
19:30
Banquet Dinner – Village – Salt & Pepper Buses will leave from School of Nursing parking (All registered participants and by invitation only)
Day III – Sunday - April 11, 2010 9:00
Coaster will leave for Kemari Harbor from Dean’s office. Aga Khan University.
15:00
Back to AKU 10
ABSTRACTS
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SCIENTIFIC SESSION - I OUR EXPERIENCE WITH ESOPHAGEAL REPLACEMENT. Muhammad Saleem, Muhammad Afzal Sheikh, Muhammad Sharif and Muhammad Arslan Department of Pediatric Surgery, The Children’s Hospital, Lahore. Aims and objective: Our experience of esophageal replacement in 20 cases, majority with gastric pull-up. Design: retrospective analysis. Period: July 2005 to December 2009. Material and methods: During last 4 and half years all the cases of esophageal replacement were reviewed. Results During this period a total of 20 esophageal replacements were performed in our department. Out of these 14 were males and 6 females, with age range from 1 day to 15 years. The primary cause of replacement was non dilatable esophageal strictures in 16 cases, congenital esophageal atresia in 2 cases, congenital stenosis of esophagus in one cases, revision of esophageal replacement in last case. Two cases were dealt with colonic replacement and one jejunal replacement and 17 with gastric pull-up. In two cases retrosternal route, and in rest of 18 cases transheatal route was used. In two cases primary gastric pull-up for esophageal atresia was performed. There were three mortalities seen in this series, one with primary gastric pull in esophageal atresia due to sepsis, and other with esophageal perforation, in which esophagectomy and replacement was done same setting. Last patient died due to hypoxic insult to brain due to mechanical ventilatory failure, 1 ½ month after replacement. None of the patients developed stenosis, or anastomotic leak in this series. One patient developed fistula 3 years after replacement after having pulmonary cocks. All these 17 patients have reasonable good growth chart. Conclusion: We conclude that gastric pull-up through transheatal route gives satisfactory result in case of esophageal replacement.
CLOSURE OF EMERGENCY INTESTINAL STOMA IN THE SAME HOSPITAL STAY. Ahmed, Nabila Talat and Mahmood Shaukat, KEMU, MHI, MHL Background: A small or large bowel stoma is usually constructed to protect distal anastomosis doe in variety of conditions or stomas created as exteriorization of involved bowel segment dire to variety of pathology. Routine closures of these stomas are not theoretically performed before two to three months. Earlier closure might reduce stoma related morbidity improve quality of life and still effectively serve the purpose. This out study was done to assess the feasibility of early stoma closure i.e. during the same hospital admission as the initial operation. 12
Patients and Methods: This is a prospective, descriptive study conducted at the Department of Paediatric Surgery, King Edward Medical University/ Mayo Hospital Lahore. 40 patients were included in the study who presented between June 2007 to June 2009. / All Patients with a protective small or large bowel stoma were included. Distal loopogram was performed before closure in all patients. Results: All patients with no early post operative complication were selected. The mean period between initial operation and stoma closure was 22 days. In a series of 40 patients the average age of patients is 5.42 ± 3.05 years. There are 28 (70%) males and 12 (30%) female patients. Amongst the causes for surgery fire arm injuries was the commonest i.e. 16 (40%) followed by blunt abdominal trauma 14 (35%), road traffic accidents with perianal injury 10 (25%). Colostomy was performed in 24 (70%) patients while ileostomy was done in 16 (30%) patients. The average hospital stay was 28.85 ± 5.34 days and the mean time between stoma creation and closure was 22.3±3.62 days. After closure there was no complication in 34 (85%) patients. In one case there was wound infection requiring conservative treatment. One anastomosis disrupted (case of ileostomy) done for fire arm injury. There was partial disruption in one case with a fecal fistula treated conservatily. Conclusion: Closure of temporary stoma created during the initial operation in trauma can be safely reverted in the early post operative period. Key words: Intestinal stoma, early closure, complications.
OUR EXPERIENCE IN ENDORECTAL PULL-THROUGH FOR THE TREATMENT OF CLASSIC HIRSCHSPRUNG DISEASE A REPORT OF 30 CASES IN TWO YEARS Khurrum Arif, Amjad Chaudhary and M. Zaheer Abbasi Department of Paediatric Surgery, The Children’s Hospital, Pakistan Institute of Medical Sciences, Islamabad. Objective: An analysis of 30 cases during the last two years. Design: Retrospective study Setting: The Children’s hospital, Pakistan Institute of medical sciences, Islamabad. Method: This was a retrospective study of children treated for Hirschsprung’s Disease at the Children's Hospital, Pakistan Institute of Medical Sciences, Islamabad from 2007 to 2009. Introduction: In 1886, Harold Hirschsprung first described Hirschsprung disease as a cause of constipation in early infancy. Early recognition and surgical correction of Hirschsprung disease protects affected infants from enterocolitis and debilitating. Hirschsprung disease results from the absence of enteric neurons within the myenteric and submucosal plexus of the rectum and or colon. Enteric neurons are derived from the neural crest and migrate caudally with the vagal nerve fibers along the intestine. These ganglion cells arrive in the proximal colon by 8 weeks' gestation and in the rectum by 12 weeks' gestation. Arrest in migration leads to an aganglionic segment. This results in clinical Hirschsprung disease. 13
Presentation: In Neonatal period abdominal distention, failure of passage of meconium within the first 48 hours of life, and repeated vomiting. Delayed passage of meconium is very important as nearly half of all infants with Hirschsprung's disease do not pass meconium within 36 hours, and nearly half of infants with delayed first passage of meconium have Hirschsprung's disease. In Older infants and children present with chronic constipation that is resistant to the usual treatments and a daily enema may be required. Rarely have soiling and overflow incontinence, this is in contrast to children with functional constipation. The disease causes early satiety, abdominal discomfort and distension due to the constipation and this leads to poor nutrition and poor weight gain. Results: From November 2007 to October 2009, 72 patients with Hirschsprung's disease for Definitive Procedure admitted in the Department of Paediatric Surgery, The Children’s Hospital Pakistan Institute of Medical Sciences Islamabad. 30 Patients underwent for Modified Soave Endorectal pull-through, 42 patients treated by Martin’s procedures are not included in this report. All the patients were initially diagnosed and treated at our institution. Sixty-One (78%) had standard rectosigmoid disease; 9 (17%) had longer aganglionic segments; and 2 had total colonic aganglionosis. The diagnosis was made in 44 neonates (58%) and 21 infants (36%). Only 7 children were older than 1 year at diagnosis. The definitive Soave endorectal pull-through was performed in the majority of the patients before the age of 1 year. There was no mortality. A relatively low morbidity was encountered and all the patients are continent after follow-up periods of 1 to 3 years. In view of its gratifying results, Soave's endorectal pull-through is our preferred definitive procedure for Hirschsprung's disease in infants and young children. Conclusion: Trans Anal ERPT is cost effective and dependable way of treatment Hirschsprung’s Disease. It does not include use of expensive staplers and has less complication rate if compared to other procedures
ENDORECTAL PULLTHROUGH FOR HIRSCHSPRUNG’S DISEASE: AN UNPREDICTABLE OUTCOME Naima Zamir, Soofia Ahmed and Jamshed Akhtar National Institute of Child Health, Karachi. Introduction: Hirschsprung’s disease is a well known condition but still concepts about it are in evolution. Though surgical procedures described for it are quite standardized but still many areas are debated. This study was conducted to describe the outcome of endorectal pullthrough (ERPT) procedure for Hirschsprung’s disease (HD) in terms of unexpected complications and their management.
Method: This was a descriptive case series conducted at surgical unit B at NICH, from January 2008 to December 2009. All the patients who underwent ERPT for HD were included. Surgery was done in stages. Outcome was noted in terms of early post operative complications during initial hospital stay and later outcome in follow up. All patients remained in follow up. Results: A total of 26 patients were operated. Two staged ERPT procedure done in 18 patients. Eleven children discharged from hospital without any major complication. Two patients developed severe 14
abdominal sepsis and a covering stoma was made. One of them died. Three patients developed anal stenosis and required dilatations. One patient died in early postoperative period. One patient developed faecal fistula in perianal region and colostomy was made. This patient died of sepsis. In five patients repeated episodes of enterocolitis occurred after discharge and one. In latter six cases covering stoma was added to the surgery. Even then only 3 patients discharged without major complications. One patient each developed burst abdomen, abdominal wall gangrene spreading up till thigh with anal stenosis. One patient expired of renal failure secondary to sepsis in early postoperative period.
Conclusion: Surgical outcome of Hirschsprung’s disease is unpredictable. In the hand of same group with same procedure patients’ outcome was quite different. Even providing a third stage by adding covering stoma, no improvement in the outcome noticed.
CHOLEDOCHAL CYST- A DIFFERENT DISEASE IN INFANTS? Munira Abdul Aziz and Zafar Nazir Section of Pediatric Surgery, Department of Surgery, The Aga Khan University, Karachi, Choledochal cyst (CC) is a rare (1: 10,000 to 1: 25, 000 live births) congenital anomaly of biliary tree reported in all the age groups. The purpose of this presentation is to study the differences in presentation and pathology of CC in different age groups Patients and Methods:The medical records of 29 patients presenting with CC from 1988 to 2009 were reviewed for age at presentation, clinical presentation, biochemistry, radiology, surgical procedures and outcome. Choledochal cysts were classified according to Alonso-Leg and Todani classification. Patients were divided into 2 groups: Group I: Infants (Age < 1 yr) Group II: Children (Age >1 – 14 yrs) and adults Results: Twenty nine patients were seen over 21- year study period; Group I (n= 11), Group II (n=18).The majority (80%) were females and the age ranged from day 1 to 18 years (mean7.2). Patients in group I predominantly presented with jaundice (72 %) whereas; abdominal pain (89%) was common in group II. The classical triad of Jaundice, pain and abdominal mass was seen in only 2 patients of group 2. Moreover, Pancreatitis was seen only in group II. Two patients in group I had concomitant Biliary Atresia (BA) and another three were diagnosed antenatelly. All the patients in group I had abnormal liver histology: Biliary cirrhosis (3) and various degree of hepatic fibrosis (8) whereas liver was normal in most of the patients in group B. Inflammatory changes in the cyst wall and raised cyst fluid amylase levels were common in group II. Hepaticoduodenostomy was performed more often in group I as compared to Group II). Follow up ranges from 1 month to 15 years (mean2.8years). Complications were seen in 6 cases (wound infection (1), Bile leakage (3), Pancreatitis (1) and Cholangitis (2). Cholangitis only occurred in patients who had concomitant biliary atresia Conclusions: Choledochal cyst seem to a different disease in infants when compared to children and adults
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LAPAROSCOPIC SURGERY IN CHILDREN- 3 YEAR INSTITUTIONAL EXPERIENCE. Hina Noorani, Muhammad Arshad and Shabbir Hussain Department of Pediatric Surgery, Liaquat National Hospital, Karachi. Context: The horizon of pediatric minimal access surgery has widened so much that most of the pathologies are now safely tackled laparoscopically. These procedures are now common place and are performed worldwide with gratifying results as the learning curve of the surgeon attains plateau. We share our experience of this technically evolving modality of surgery, performed at our setup over a period of 3 years. We also review and individually compare the data for commonly performed procedures with other available series. Material & Methods: We performed 111 laparoscopic procedures in children aged between 3 months and 14 years of age between January 2007-December 2009. In all laparoscopic procedures the primary port placement was by the Hassonâ&#x20AC;&#x2122;s open technique. We have used 5mm and 3mm instruments. Our study included 31 Orchidopexies, 24 diagnostic laparoscopy, 22 Appendectomies, 11 cholecystectomy, 10 inguinal hernia repair,7 liver biopsies, 5 lap-assisted ERPT, 1 lap-assisted PSARP. Results: As we gained experience the operating time showed a decreasing trend, the complication rates and conversion rate also reduced. The advantages we come across were better post operative appearances, less pain and early return to unrestricted activities. LAPAROSCOPIC PYLOROMYOTOMY FOR IHPS, INITIAL EXPERIENCE OF 5 CASES Ali Raza Brohi Peopleâ&#x20AC;&#x2122;s Medical College, Nawabshah Objective: Hypertrophic pyloric stenosis is a common pediatric surgical condition. A Ramstedt pyloromyotomy is performed either via laparotomy or laparoscopy. We report our first 5 cases of laparoscopic pyloromyotomy at private hospital in Nawabshah Methods: From sept: 2009 to march 2010, we retrospectively reviewed our first 5 laparoscopic pyloromyotomies done at some private hospital. All patients had confirmed hypertrophic pyloric stenosis by ultrasound criteria. Three incisions were made, one 5-mm umbilical port, one 3-mm right upper quadrant port, and a third left upper quadrant working stab incision. A 5mm, 0 degrees scope was used in all cases. A longitudinal pyloromyotomy was performed using an arthrotomy scalpel. The pylorus was further separated with a laparoscopic myotomy spreader. At the completion of the pyloromyotomy, the stomach was insufflated with air to identify any mucosal injury. Results: Age range was 3 weeks to 7 weeks. Operating time has decreased from 70 minutes to 40 minutes. One conversion to an open procedure was necessary, because of low weight and technical difficulty. No mucosal perforations or incomplete pyloromyotomies have occurred. Feeds were started within 8 hours. Time to discharge ranged from 48 hours to 96 hours. 16
Conclusions: Laparoscopic pyloromyotomy is a safe, effective procedure for hypertrophic pyloric stenosis Laparoscopy permits excellent visualization, has comparable postoperative recovery, and superior cosmesis. Time duration is bit increased in initial learning curve.
Key words: Pyloromytomy, Laparoscopic, Infant SCIENTIFIC SESSION - II OUTCOME OF ACUTE PERITONEAL DIALYSIS IN PAEDIATRIC INTENSIVE CARE UNIT OF A DEVELOPING COUNTRY. Riffat Rasheed and Anwar-ul-Haque Department of Paediatric and Child Health, Aga Khan University, Karachi Introduction: Acute renal insufficiency and fluid overload accounts for high morbidity and mortality in critically ill children. Among various options for renal replacement therapies, peritoneal dialysis (PD) is the simplest and safe technique, underused in presence of various other modalities. We reviewed our experience to assess outcome of acute PD in critically ill children. Method: Medical charts of 26 children who had required PD from Oct 2006 – Oct 2008 at AKUH were reviewed retrospectively. Basic demographics, indications, duration and complications of dialysis as well as outcomes were recorded. Results: Mean age was 26.1 months (±SD: 29.6). 20(66.6%) were males. Indication of PD was primarily fluid overload 90% (27) and cumulative fluid before initiation of dialysis was 0.77 liters (±SD: 0.91). 24 (80%) children had oliguria at time of PD initiation. Mean duration was 7.5 days (±SD: 1.5). Negative fluid balance was achieved in 1.54 days (±SD:1.25) in 29 (96.6%) patients. Estimated creatinine clearance was improved from 18.6ml/min (±SD: 14.4) to 50.8 ml/min (±SD: 37.7) among survivors (p-value: 0.018). 3 patients had catheter malfunction. Mortalities with respect to primary diagnosis were as follows: 3/11 expired from renal disease, 3/7 from cardiac disease, 3/3 from sepsis, 2/2 post-operative and 6/8 from other reasons. Oliguric patients had increased mortality (p-value: 0.037). Survival rate was 43.3% (13/30) and recovery of renal function was 42% (11/26).
Conclusion: Adequate ultrafiltration and recovery of renal function can be achieved effectively by early installation of PD in critically ill children. The outcome of children requiring dialysis appears to be directly related to their underlying diagnosis
ROLE OF FOCUSED ABDOMINAL SONOGRAPHY FOR TRAUMA (FAST) IN PEDIATRIC PRACTICE. Ahmad Vaqas Faruque, Saqib Hamid Qazi and Muhammad Arif Mateen Khan Section of Pediatric Surgery, Department of Surgery, Aga Khan University, Karachi Introduction: Fast is a method where ultrasound is used in the emergency room by surgeons, emergency room physicians or radiologist to identify hemoperitoneum. It is a very quick & fast tool to evaluate blunt abdominal trauma in emergency situation. It should be considered as the 5th modality in assessment of trauma situation. 17
There is an overwhelming amount of current data supporting the use of the FAST exam as the initial screening tool for evaluation of the blunt abdomen trauma in adult practice. Use of FAST in pediatric trauma has been explored by a number of groups but its usefulness in pediatric blunt abdominal trauma is still not clear because most of pediatric abdominal injuries can be managed conservatively. The largest criticism about the use of FAST in children has been the limited sensitivity i.e. 45% to 55% because nearly 40% of abdominal injuries in children are not associated with free fluid. However combining physical examination with the FAST examination significantly improved the sensitivity of the evaluation. Objectives: To share our experience of using US FAST in blunt pediatric abdominal trauma at AKUH. Methodology: Retrospective study, 1st January 2000 â&#x20AC;&#x201C; 31st December 2009, Total numbers 174, SPSS 16 The inclusion Criteria: All children's from birth to 14 years presented with blunt abdominal trauma had US FAST done at AKUH emergency. The exclusion Criteria: Isolated pediatric traumas in which FAST not performed, Pediatric traumas discharged from emergency. Results: Most common age of presentation is school going age (71%), Males are mostly involved (65%), MVA and fall are the most common mechanisms of injury (37%), 3% children's have severe head injuries with blunt abdominal trauma, FAST were positive in 31/174, (18%) patients, 24 out of 31 (77%) childrenâ&#x20AC;&#x2122;s where FAST were positive later on had positive CT SCAN, There were 2 patients had negative FAST and positive CT SCAN, Only 33% of FAST done by pediatric radiologist, All patients who had negative FAST were discharged later on and had no complication, Our mortality rate in this study is 2%. Conclusion: Ultra sound FAST is a fairly reliable mode to assess blunt abdominal trauma in children, In our set up it has a high sensitivity and specificity, It is a useful tool to pick high grade solid visceral injury and hollow viscous injury. Key Words: FAST, FAST score, Sensitivity, Specificity STENTLESS PYELOPLASTY FOR UPJ OBSTRUCTION Iftikhar A Jan, Hazrat Ullah, M Yusuf and M Irfan, Ali National Institute of Rehabilitation Medicine, Islamabad Introduction: Stenting after pyeloplasty is common practice and helps in ensuring a patent anastomosis till healing has completed. The most popular is double J stent. External stents and drains are also used. All these tubes are source of significant inconvenience and increase the cost of management. The idea of stent-less pyeloplasty is not rare. We shall share our experience of stentless pyeloplasty for UPJ obstruction.
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Method: During the last one-year we prospectively analyzed the results of stentless surgery in patients with UPJ obstruction. 28 patients with UPJ obstruction were managed. 8 treated conservatively and one nephrectomy and were excluded. In two patients laparoscopic assisted pyeloplasty was performed. Open surgery was performed using a small lumber incision. A dismembered Pyeloplasty was performed in all the patients. Repair was performed using 7/0 or 6/0 PDS over a N/G tube, which was removed after the repair. A perinephric drain was placed and was removed when urine drainage stopped. Results: 20 patients with UPJ Obstruction were operated; one had nephrectomy for non-functioning kidney. Two had laparoscopic assisted pyeloplasty and 17 had open pyeloplasty. 7 had right, 10 left and three bilateral UPJ obstructions. Operative time 45 to 90 minutes. Perinephric drain removed average 2 days, mean hospital stay 3 days, cost of surgery to patient Rs 700 for purchase of PDS 7/0. Reduction in hydronephrosis in 80 % patients, two patients had increasing AP diameter and are under surveillance.
Conclusion: Stentless surgery for UPJ obstruction is safe, feasible, reduces the cost of surgery and avoids multiple procedures. FEMINIZING GENITOPLASTY IN FEMALE CONGENITAL ADRENAL HYPERPLASIA EXPERIENCE AT THE CHILDRENâ&#x20AC;&#x2122;S HOSPITAL & THE INSTITUTE OF CHILD HEALTH, LAHORE. Muhammad Afzal Sheikh, Taeed Ahmad Butt, Muhammad Sharif and Muhammad Saleem. CH & ICH, Lahore Objective: To evaluate surgical management and its outcome in female CAH patients. Design: Retrospective review Period: January 2007 to December, 2009 Setting: Department of Paediatric Surgery & Endocrinology, The Childrenâ&#x20AC;&#x2122;s Hospital, Lahore. Material & Methods: During 3 years all diagnosed cases of female CAH were included in the study. Results: 92 out of 103 (89.32%) cases of CAH were diagnosed as female CAH on the basis of clinical examination, increased serum 17-OH progesterone level and karyotyping. Age of presentation ranged from 01 month to 13 years with mean age of 07 years. Consanguinity was present in parents of 53 (57.6%) female CAH patients. 75 (81.5%) patients presented with ambiguity of sex and 17 (18.5%) patients with adrenal insufficiency. Initial gender assignment was given as males in 57(61.95%) patients. On pelvic examination clitoris enlargement with partial fusion of labia 4(%) and with perineal urethral opening 18(%), complete transformation of clitoris in to the penis along with complete fusion of labia and female type of genitalia with membrane covered vagina 4(%) were important findings. The main reconstructive procedures performed were vaginoplasties, clitoroplasties and vaginoplasties plus clitoroplasties. Invisible vagina, vaginal stenosis and vaginal retraction were the main complications found on follow up. Conclusions: We conclude that CAH is one of the important causes of disorder of sexual development out of which female CAH accounts for major bulk of patients. It requires multidisciplinary approach especially pediatrician/endocrinologist, pediatric surgeon, clinical psychologist and social worker for its medical and surgical management. This is a social and 19
psychological dilemma giving great torture to family so early diagnosis, reassurance of parents and plan of reconstruction can decrease the anxiety of family.
KNOWLEDGE, ATTITUDE AND PRACTICE REGARDING CIRCUMCISION IN SOUTHERN PUNJAB. Muhammad Zafar Iqbal, Muhammad Jahangir, Muhammad Anwar, Shumaila Irum, Sheikh Zayed Medical College / Hospital, Rahim Yar Khan. Introduction: Circumcision is the most commonly performed but neglected procedure in our country. Barbers, quacks and other non qualified inexperienced persons perform circumcision by their own methods without proper sterilization and without knowing the consequences. Peoples have little knowledge about circumcision especially in southern Punjab and upper Sindh. Most of them used to follow traditional methods without knowing the after effects. Aims & Objectives: The aim of our study is to evaluate the knowledge and assess attitude and practice regarding circumcision in southern Punjab and to scrutinize the results of different methods of circumcision performed by different operators. Patients & Methods: This was an observational study conducted in pediatric surgery department Sheikh Zayed Hospital, Rahim Yar Khan. 600 cases were interviewed according to a comprehensive Proforma. Attendants/parents having best knowledge regarding circumcision were interviewed and than related clinics were approached to know the methods of circumcision and sterilization techniques. Results: Out of 600 cases 157 (26.17%) were circumcised in 1st month of life, 92 (15.33%) in first year and 351(58.50%) between one to twelve years of age. 110 (18.33%) cases were circumcised by the barbers, 139 (23.17%) by quacks, 210 (35%) by GPs and 141 (23.5%) by Surgeons (General and Pediatric Surgeons). Bone cutter method was the commonest procedure 307 (51.17%), only 60 (10%) cases were circumcised by plastibell technique. Complications were more with barber method and less with plastibell technique. Conclusion: Our study showed that knowledge of people about circumcision is very disappointing. There is a dire need to educate the people regarding age and method of circumcision. In spite of all developments, a large number of people go to barbers without knowing the outcome. Key words: Circumcision, prepuce, Plastibell. MANAGEMENT OF NEONATES WITH SURGICAL CONDITIONS WITHOUT ICU SUPPORT A DATA OF 204 CASES IN 6 MONTHS Khurrum Arif, Amjad Chaudhary and M. Zaheer Abbasi Department of Paediatric Surgery, The Childrenâ&#x20AC;&#x2122;s Hospital Pakistan Institute of Medical Sciences, Islamabad. 20
Objective: To assess the outcome of neonates managed in surgical ward without I.C.U support (As this is the frequent pretext of referral of these neonates from other paediatric surgical departments) to ultimately find out feasibility of managing such cases without ICU support. To see pattern of congenital anomalies in neonates. To evaluate the understanding of referring community doctors/ Paediatric centers. Study Design: Descriptive study Setting : The Childrenâ&#x20AC;&#x2122;s hospital , Pakistan Institute of medical sciences, Islamabad. Method : This was a retrospective study of children treated for different surgical diseases at the Children's Hospital, Pakistan Institute of Medical Sciences, Islamabad without ICU support from Jun to Dec2009. Introduction: In Western world, ,in fetal period, most of the congenital anomalies are picked up by different diagnostic modalities and these neonates are born in specialized departments with ICU cover with prior arrangement and managed in NICU. Department of paediatric surgery at Pakistan institute of medical sciences has a huge catchment area including N.W.F.P ,AJK , Northern Areas, Northern Punjab and even Afghanistan, due to lack of paediatric surgical departments, dealing with complicated neonatal surgical problems in these areas. ICU Space is very limited in our setup and it is usually very difficult to accommodate such neonates in ICU. Results: From June to Dec 2009, out of 204 neonates(142 males,62 females), 184 patients underwent surgery and rest were either referred late or were in severely diseased condition so could not be operated.88 patients came from NWFP,58 from AJK, 34 from Islamabad and 24 from Rawalpindi. Out of 184 patients , 86% was the survival rate and 14% was the expiry rate which is comparable to the Neonatal ICU results as well as best centers world over which is quite encouraging. Conclusion: Since the space in the NICU is limited the neonatal with surgical problems can be managed in the general wards without ICU support. The paediatric surgical centers should refrain from transferring such neonates to other centers with the excuse of lack of ICU facilities. EFFECT OF PONSETI METHOD IN THE CORRECTION OF CONGENITAL TALIPES EQUINOVARUS WITHIN 15 DAYS OF LIFE Omar Khattab, Asif Hanif and Mahmood Shoukat KEMU, MHL, Lahore Background: Congenital talipes equinovarus (CTEV) or Club Foot is a multifaceted deformity of foot. The goal of treatment is to reduce or eliminate the deformities so that the patient has a functional, plantigrade foot, pain free, with good mobility and without calluses. This study was designed to see the effect of Ponseti method for the correction of severe and moderate types of CTEV who presented within 15 days of life, in our department. Study Design: Longitudinal interventional study. Sample size: 52 patients and 85 feet were taken in this study. Sampling Techniques: The patients were taken from Pediatric surgical OPD 21
Mayo Hospital Lahore. Inclusion Criteria: All the patients who presented within 15 days of age were taken for the correction of CTEV. Exclusion Criteria: The patients who were older than 15 days at the time of first presentation and patients with complicated severe CTEV were excluded. Methodology: After admitting the patients we applied a cast using the Ponseti method for the correction of feet. We manipulated & changed the POP after every 10 days and noted the outcome in terms of visual correction of feet. At 2 months of age a decision of whether to add a Tendo-Achillus Tenotomy or not was made. Results: In 52 patients a total 85 feet were studied. The average age of patients was 11 ± 2.6 days. The mean age at correction was 2.2 ± 0.68 months. The average number of POP application was 6.10 ± 1.37 which were applied to 85 feet. Tendo-Achillus Tenotomy was needed in 13 (15.3%) feet. Lastly, 80 (94.11%) feet were corrected and 5 (5.89%) feet needed another surgical procedure. Follow up: Patients were coming for follow up every 10 days till they were give Denis Brown shoes after that they were followed up monthly. Conclusion: Ponseti is a useful non-surgical technique for the correction of CTEV if applied earlier & in appropriately selected feet. Key Words: Clubfoot, CTEV and Ponseti Method.
POSTER SESSION: CONGENITAL CYSTOID ADENOMATOID MALFORMATION: SURGICAL MANAGEMENT OF A THREE-AND A HALF-YEAR CHILD. : A CASE REPORT Ranish Deedar-Ali-Khawaja and Saulat Hasnain Fatimi Section of Cardiothoracic Surgery, Department of Surgery, Aga Khan University Hospital – Karachi. Introduction: Congenital Cystoid Adenomatoid Malformation (CCAM) represents a rare developmental anomaly of lung and belongs to a group of congenital cystic diseases of lung. Clinical course of prenatally diagnosed CCAM varies widely; symptomatic or asymptomatic at birth. Method: We present a case of three and a half years-old girl presented with recurrent chest infections and fever since birth. Antenatal ultrasonography showed a congenital cystic malformation of the left lower lobe without any other congenital abnormalities. After birth, she was managed conservatively with nebulizers and frequent courses of antibiotics. Postnatally thoracic CT scan showed cystic malformation in left lower lung lobe. Due to continuing recurrent infections and with the risk of rupturing of the cyst with subsequent course to pneumothorax, it was decided to proceed with left lower lobectomy. Patient had an uneventful left lower lobectomy via postero-lateral thoracotomy. With a follow-up time of 10 months, the patient is living a normal routine without any morbidity. The gross specimen was 10x8x5 cm with cut sections showing multiple cystic spaces with smooth and shiny cyst wall. The histopathology showed lung parenchyma exhibiting variable sized interconnecting cystic spaces resembling bronchioles and lined by bronchial type epithelium. These features were consistent with Congenital Cystic Adenomotoid Malformation (CCAM) of Intermediate type. Patient did very well after the procedure and her symptoms resolved significantly. Conclusion: Surgical resection is the treatment of choice that includes pulmonary-saving resection, lobectomy via open thoracotomy, or video-assisted thoracoscopic (VATS) lobectomy. Parenchymasaving resection when compared to lobectomy, however, is advisable in children to avoid unnecessary pneumonectomy. 22
REVISED TRAUMA SCORE (RTS) AS A PREDICTOR OF OUTCOME IN TRAUMA PATIENTS: A RETROSPECTIVE REVIEW AT A TERTIARY CARE HOSPITAL IN KARACHI, PAKISTAN Umair Zafar Malik, Omair Shakil, Ghulam Rehman Mohyuddin, Anwar-ul-Haq Aga Khan University, Karachi
Introduction: Trauma scores help better classify trauma patients, and assist in clinical decisionmaking. The Revised Trauma Score (RTS) is widely used internationally but its effectiveness as a tool for predicting outcome in pediatric trauma patients in our local setting, has yet to be established, mainly owing to lack of use. The objective of this study is to test the hypothesis that RTS is an effective predictor of outcome in pediatric trauma patients in Pakistan. Method: We conducted a retrospective review of patient medical records at Aga Khan University Hospital, Karachi, from October 2006 to October 2009 and all patients aged <14 years, presenting with trauma were selected. Information was collected regarding demographics, vital signs at the time of presentation, length of stay (LOS) in the ward, ICU and the hospital, complications during hospital stay and mortality. Data was entered and analyzed in SPSS version 17.0. Results: The sample was 501 patients with a mean age of 5.3 years. Using available data, RTS was calculated for 394 patients, who were then divided into two groups based on the RTS. For patients with RTS â&#x2030;¤10 the length of stay in the ward, ICU and the hospital were all shorter than for patients with RTS >10 (p-value <0.001). Conclusion: In our setting, there is a statistically significant relationship between the RTS of a patient and the LOS in the hospital, ICU and the ward. This can be used as a reflection of the severity of injury, and hence also in clinical decision making. FOREIGN BODY ASPIRATION IN CHILDREN: AN ALERT Maryam Arain, Soofia Ahmed and Jamshed Akhtar National Institute of Child Health, Karachi. Introduction: To document morbidity and mortality related to, an avoidable condition, foreign body aspiration particularly betel nut.
Method: This is a seven month (from April 2009 to October 2009) data of all the cases with suspected foreign body aspiration managed at one of the two units of paediatric surgery at National Institute of Child Health Karachi. Results: Foreign bodies were removed from tracheobronchial tree in 213 patients at bronchoscopy. Pieces betel nut were removed in 173 cases. Majority of children were under 5 years of age and in large number of cases family is habitual of chewing pan. A significant number of children presented with acute onset of respiratory distress. No geographical location of province of Sindh and coastal Balochistan was spared. Four patients died. 23
Conclusion: Betel nut aspiration is a preventable condition for which a consolidated effort is needed to educate the community through print and electronic media. Death occurring with this condition is regrettable. Facility of emergency bronchoscopy must be made available at all district head quarter hospitals. PENILE TOURNIQUET SYNDROME. S M. Raees Taqvi., Muhammad Sajjad Ashraf, Javed Ahmed,Muhammad Shahab Athar and Muhammad Talat Mehmood Department of Pediatric Surgery, Dow Medical College and Civil Hospital, Karachi Introduction: Penile Tourniquet Syndrome is a constricting penile injury due to penile encirclement with different objects including, rubber bands, threads, rings, pipes, pieces of cloth and hairs. A descriptive study was conducted, to observe clinical presentation and analyze the outcome of cases of penile tourniquet syndrome.
Method: Data of all the patients admitted between Jan. 2005 to Dec. 2007 were reviewed with special reference to the encircling object, nature of the damage and their management. Results: A total number of fifteen cases of penile tourniquet injury were found. Patient’s age ranged from 11 months to 10 years. In 10 cases cause of encirclement was unknown. Four cases were iatrogenic, and in one case thread was self-tied. Encircling object was, hair in 10, Post circumcision bandage in three, plastibell and kite thread in one each. Mild penile injury was found in 6 cases, while 9 cases had urethral injury (urethrocutaneous fistula 6, complete urethral transaction 2, and urethral stricture 1). Cases of mild penile injury were managed conservatively. Urethral repair was done in eight patients and one patient did not turn up for surgery. Conclusion: Penile tourniquet syndrome is an uncommon clinical entity that needs high index of suspicion especially by hair in circumcised pediatric population. Early diagnosis and prompt treatment can prevent severe penile injuries. Always consider the element of child abuse. MODIFIED DUHAMEL’S PROCEDURE FOR HIRSCHSPRUNG’S DISEASE Muhammad Sharif, Muhammad Saleem, Muhammad Afzal, Shahid Iqbal and Muhammad Afzal Sheikh The Children's Hospital &The Institute of Child Health, Lahore Aims & Objective To see the outcome and follow up of modified Duhamel’s procedure for Hirschsprung’s disease. Design Retrospective analysis Period July 2005 to June 2009. Setting Department of Paediatric Surgery, the Children’s Hospital and the Institute of Child Health, Lahore. Material & Methods: During Four Years period 190 modified Duhamel’s procedures were donefor hirschsprung’s disease. 24
Results Out of 190 cases of duhamel’s procedure 145(76.32%) were males and 45(23.68%)were females with ages ranging from 8 months to 16 years. 130 (68.4%) patients were under 3 years of age. Average duration of operation was 2 ½ hours. 76.3% of cases belong to short segment hirschsprung’s disease. Common postoperative complications were wound infections, wound dehiscence bleeding PR, increased frequency of stool, painful defecation, Perianal rash, pouchitis, adhesion obstruction and leak. Follow up showed uneventful course in 80% of patients. Conclusion The presented retrospective review of 190 patients establishes the usefulness of duhamel’s procedure. The outcome of patients treated has been satisfactory with minimal complications OUTCOME OF TWO STAGE REPAIR OF HYPOSPADIAS AT LIAQUAT UNIVERSITY HOSPITAL JAMSHORO / HYDERABAD Bilal Fazal Shaikh and Mahesh Kumar Department of Plastic Surgery, LUMHS, Jamshoro / Hyderabad Objective: To evaluate the results & outcome of two stage repair of hypospadias. Method: This a retrospective analysis conducted in the department of Plastic & Reconstructive Surgery, Liaquat University Hospital, Jamshoro / Hyderabad from January 2005 to December 2009. Sixty eight patients were included in this study. All patients with proximal and distal hypospadias with or without chordee, circumcised cases and those who needed revision surgery were selected for two stage repair. In stage 1 splitting of the glans and grafting of the donor area with full thickness skin graft was done. In stage 2 the tabularization of the graft and covering the repair with a waterproofing layer of fascia was done 6-8 months later. Results: The common age of presentation was below 4 years. Distal penile hypospadias was seen in 32 patients, 16 cases had mid penile, 14 had proximal and 06 had peno-scrotal hypospadias. Chordee was seen in 28 cases. The urethrocutneous fistula occurred in 11 cases, metal stenosis in 06cases. The functional and esthetic results in all the operated patients were acceptable. Conclusion: It was found that two stage repairs of hypospadias offers unique flexibility, exceptional reliability and a sophistication of function and aesthetics is attained with two stage repair OVARIAN MASSES: EXPERIENCE AT MAYO HOSPITAL, LAHORE Muhammad Qasim, Nabila Talat., Professor Mahmood Shaukat KEMU, MH, Lahore Background: Ovarian tumors are one of the common malignancies all over world affecting all age groups and continue to be the cause of great concern for surgeons as well as pathologist 25
because even though they are morphologically similar, histologically there are striking overall contrasts. The correct diagnosis often has major implications in their subsequent management and prognosis. We report this series analyzing clinical presentations and histological patterns in our prepubertal population. Patients and Methods: This is a retrospective study of the records of all pre pubertal girls presenting or diagnosed to have ovarian masses at the Department of Paediatric Surgery Mayo Hospital Lahore in the period from 2007 to 2009. Their record was reviewed in detail for history, physical examination, imaging studies before surgery, tumor markers and operative findings. Complete resection of mass, lymph node biopsy and peritoneal fluid sampling was done in all cases and sent for histopathology / cytology. Further treatment was according to histopathology report. Results: 8 cases of ovarian masses were diagnosed from 2007 to 2009. 5 (62.5%) out of 8 cases were Benign tumors and 3 (37.5%) were malignant. 6 (75%) out of 8 were Germ cell tumors and 2 (25%) were other than germ cell tumors. Out of Germ cell tumors 4 were Benign (66%) and 2 (34%) were malignant. Teratomas were 62.5% of all ovarian tumors in prepubertal age. Conclusion: This study was institution based and had small sample size which may or may not represent whole population. Almost none of the international studies on ovarian tumors have been made focusing prepubertal age group only. So it is very important to report more and more studies to have confirmed literature regarding frequency of clinical and histological patterns of different ovarian masses in prepubertal age group. In our study most of ovarian masses are germ cell tumors. Benign tumors are more common than malignant tumors and teratomas are the most common histological type of ovarian tumors in this age group. Key Words: Ovarian tumors, Prepubertal Girls, Germ Cell tumors, Histopathological Pattern ERROR, NEGLIGENCE OR HYPOSKILIA Junaid Afzal, Naima Zamir, Tayyaba Batool and Jamshed Akhtar National Institute of Child Health, Karachi Introduction: Clinical examination skills are the mainstay of diagnosing a number of diseases. It does not just help in early diagnosis but significantly affects the outcome and avoid unnecessary investigations method. Method: The poster will depict two index cases of imperforate hymen where clinical diagnosis was missed. The importance of a good clinical examination is highlighted. Results: First case was a 21 days old female baby who presented with complaint of urinary retention. Since bladder was palpable on examination, catheterization was done by the nursing 26
staff on advice of a resident. Urinalysis and ultrasound turned out to be insignificant. On 5th day of admission it was noticed that despite catheter in place, lower abdomen is still distended, perineal examination at that point revealed imperforate hymen. Second case was 12 years old female who presented with lower abdominal mass. She was catheterized elsewhere for urinary retention but mass persisted. CT scan abdomen picked a cystic mass. In operation theatre perineal examination revealed an obvious bulge at vaginal orifice, another case of imperforate hymen. Hymenotomy was performed in both the cases. Conclusion: A complete medical history and a reliable physical examination was once a forte of a doctor. We need to revive this lost skill in our clinical practices. AUDIT OF NEONATAL SURGERY â&#x20AC;&#x201C; THE PREDICTOR OF SURVIVAL Nasir Saleem Saddal, Yaqoot Jahan, Yousuf Aziz Khan and Junaid Afzal National Institute of Child Health, Karachi Introduction: In a tertiary care hospital like NICH, neonatal admissions make almost one third of the total admissions. An audit was made for the year 2008 to look into the pattern of neonatal admissions, referrals and their effect on timing of surgery and outcome. Method: All neonates admitted to surgical neonatal unit A, from January 2008 to December 2008 were evaluated. Patients of congenital pathologies involving thoracic like esophageal atresia and abdominal problems causing intestinal obstruction and anorectal malformations were specifically evaluated for above mentioned protocol. Results: A total of 133 neonates admitted with these anomalies including 28 with esophageal atresia, 54 with anorectal malformations and other causes of intestinal obstruction like gut atresia, meconium ileus, Hirschsprungâ&#x20AC;&#x2122;s disease, malrotation made a total of 51 patients. The outcome was measured in terms of survival. The overall survival for esophageal atresia was 53.5%, Anorectal malformations 92% and other causes of intestinal obstruction remained 90%. Conclusion: The overall survival of neonates involving respiratory system bears high mortality as compared to gastrointestinal system. Early recognition and early referrals bear a significant effect on outcome. This needs to be streamlined with better planning and implementation process.
BILATERAL NEONATAL OVARIAN CYST WITH GANGRENE ON ONE SIDE. Maryam Arain, Naima Zamir. Soofia Ahmed and Jamshed Akhtar National Institute of Child Health, Karachi. Introduction: Bilateral torsion of cystic ovarian lesion is very rare in neonatal age group. It has a potential of permanent loss of functioning ovarian tissue with the life long consequences. Method: A case report of a neonate is being presented who was managed at National Institute of Child Health Karachi. 27
Results: A 27 days old female baby admitted in pediatric surgical unit B of NICH with swelling in right lower abdomen noted at birth. For the last five days patient developed vomiting (non bilious). On antenatal ultrasound scan at 26 weeks of gestation a diagnosis of bilateral ovarian cyst was already made. CT scan abdomen done on 7th day of life showed bilateral cystic lesion. The one on right side measured (4.0Ă&#x2014;3.5cm) while cystic lesion on left side measured (4.0Ă&#x2014;3.6cm). After resuscitation patient underwent surgery. At Laparotomy right sided ovarian cyst with torsion and necrosis found. It contained hemorrhagic fluid. Left ovarian cyst contained clear yellow fluid with normal ovarian tissue. Right oophorectomy and left cystectomy with preservation of ovarian tissue done. Post operative recovery was uneventful. Conclusion: All ovarian cysts are not considered simple cysts. Early surgical intervention can prevent torsion and gangrene of the ovary. CONGENITAL LOBAR EMPHYSEMA: A RARE CAUSE OF RESPIRATORY DISTRESS IN AN INFANT Nida Sheikh, Naima Zamir, Soofia Ahmed and Jamshed Akhtar National Institute of Child Health, Karachi Introduction: To describe the clinical presentation and outcome of an infant with congenital lobar emphysema. Method: This is report of a case managed at Intensive Care Unit at National Institute of Child Health Karachi in November 2009. Results: The patient was a 6 weeks old male baby who presented with acute respiratory distress and was admitted in moribund condition to ICU. Medical management brought little change in general condition and x ray chest revealed hyperinflation of lung on left side. Surgical opinion was then sought. Clinical impression of congenital lobar emphysema (CLE) was made and CT scan chest advised. It confirmed pre operative diagnosis. Left upper emphysematous lobe was removed at thoracotomy and baby made uneventful recovery. Conclusion: Pneumonia is a fairly common condition in neonates but rare causes like CLE should be kept in differential diagnosis too. It will help in preventing morbidity and at times mortality.
CLOACAL EXSTROPHY & ITS VARIANTS: IS THERE ANY GOOD NEWS FOR THE PATIENTS Azeem, Naima Zamir, Soofia Ahmed and Jamshed Akhtar National Institute of Child Health, Karachi. Introduction: Cloacal exstrophy is one of the most complex congenital anomalies posing a challenge to the pediatric surgeons. It is considered to be an index case for the discipline of pediatric surgery. Though busy surgical units do receive couple of cases every year, still no data is found from Pakistan. The objective of this poster is to highlight the needs of the patients with cloacal exstrophy. 28
Method: This poster shall describe one index case of cloacal exstrophy and display few pictures of patients with classical variety and variants of this anomaly. Results: Index case was a female baby with classical cloacal exstrophy shifted from private university hospital because of financial reasons. After investigations and counseling patient was operated. Intestinal plate was separated, tubularized and ilesotomy made. Bladder plate remained exstrophied. The post operative remained stormy with ileostomy related skin excoriations and poor weight gain. Later, on the request of parents abdominoperineal pull through was performed. A fecal fistula resulted as multiple serosal tears occurred during dissection. Early intervention was done and fistula repaired with abdominal wall closure using silo. Gradual improvement occurred but baby remained in miserable condition. Frustration was apparent on the faces of the family. Baby after some weeks admitted with profuse diarrhea and died because of renal failure. Conclusion: Cloacal exstrophy is an index case for pediatric surgeons but still nothing concrete is reported from Pakistan. We need to develop expertise to face such challenges. ANTERIOR ABDOMINAL WALL DEFECT OMPHALOCELE Anila Haroon, Rehan Ali, Shakeel Ahmed and Khalil Ahmed Aga Khan University, Karachi Introduction: Exomphalos is the midline defect, with a viable sac composed of amnion and peritoneum containing herniated abdominal contents with an incidence of about 1 in 4,000 live births. Associated major abnormalities can be syndromic, structural or due to chromosomal abnormalities in up to 70% of cases. The aim of this study is to find out the postoperative outcome of babies with omphalocele. Method: It is a retrospective study carried out in a tertiary care hospital, all the data of the last ten years, from June 1999-June 2009, with omphalocele has been reviewed. These were included age at presentation, antenatal diagnosis, place of delivery, other associated findings, and age at which surgery has been done, is reviewed. Results: Twelve cases of omphalocele have been found in ten years including omphalocele major and minor both. Termination of pregnancy due to omphalocele, were not included in the above cases. Out of these twelve patients only one was delivered at home, while the rest were delivered in hospital. Most of them were referred from other private hospitals in Karachi for surgical intervention. Out of twelve, cases only three were diagnosed antenatally. Six were omphalocele minor. Associated problems were present in two cases. Karyotype was done in only one patient and it was normal 46XX.All of them were discharged postoperatively, except one who died at around two hours of life without surgical intervention. Conclusion: The number of case were very small to assess the true incidence of omphalocele in Pakistan, in Western literature the incidence is high as compared to our part. Only 30% cases were diagnosed antenatally according to our result, so the true number is difficult to diagnose as we do not know the number of case in which pregnancy has been terminated because of omphalocele. The immediate postoperative outcome was very good in eleven cases who undergone surgical intervention, unfortunately one baby died before surgery. Three months follow up of growth and other parameters were also very good. Only one patient has prolonged NICU course and remained there for two months but successfully discharged at the age of two months and she is now two and a half year of age. 29
POSTERIOR SAGITTAL APPROACH FOR SACROCOCCYGEAL TERATOMAS Iftikhar A Jan, Sofia Ahmad, Ahmad Sharif, Anwar A. and Hazrat Ullah Khattak National Institute of Rehabilitation Medicine, Islamabad and NICH, Karachi Introduction: Chevron Incision has remained a satisfactory approach for sacrococcygeal teratomas. It however leaves a prominent transverse scar. Posterior sagittal approach gives better access for surgical resection, proper repair of the pelvic floor muscles and better cosmetic appearance. We shall share our experience of posterior sagittal approach for SCT. Method: From January 2002 to December 2010 we operated 18 cases of SCT exclusively through posterior sagittal approach. An elliptical incision was made for the excision of the tumor. Care was taken to preserve all the muscles and other vital tissue in this area. Coccygectomy was performed in all patients. Closure was performed in layers with pelvic floor muscle repair in midline and closure by subcuticular sutures. Results: None of the patients required revision of the incision. Surgical excision was satisfactory and post-operative recovery was smooth in most cases. Minimal wound dehiscence was noted in two patients who healed spontaneously. It was possible to perform excision even in very large masses. Residual tumor was present in two patients due to extensive presacral masses. Wound scar was satisfactory in most patients with good cosmetic appearance. Continence evaluation could not be performed adequately due to age of many patients. None of the older patients have presented with incontinence.
Conclusion: Posterior sagittal approach for SCT is feasible, with good access for tumor resection and gives better cosmetic appearance. Long term and comparative trial will help in comparing continence in two groups. INTRAVENTRICULAR HEMORRHAGE IN PRETERM BABIES. Anila Haroon, Muhammad Sohail Salat and Zaid Bhatti Aga Khan University, Karachi Introduction: Intraventricular hemorrhage is an important cause of morbidity and mortality in very low birth weight (VLBW) infants. A number of risk factors have been proposed for the development of IVH: low birth weight, gestatioanl age, maternal smoking, breech presentation, gender, premature rupture of membranes, intrauterine infection, mode of delivery, prolonged labor, postnatal resuscitation and intubation and transfer from one unit to another, early onset of sepsis, The reported incidence of IVH in infants with birth weight < 1500g, as detected by computed tompgraphy scanning is 43%. Real time ultrasound studies have demonstrated an incidence of between 46.7% to 90%. However, in the later study, one half of the hemorrhages were of a major degree. Real time ultrasound scanning is a sensitive and non-invasive method of detecting SEH and IVH, and for the detection of intra parenchymal extension of hemorrhage and posthemorrhagic ventricular dilation. 30
Method: A single center retrospective review conducted at Aga Khan University Hospital, Karachi, reviewed the files of all preterm with IVH between 2004-2009. Data includes prenatal demographic data details, maternal pregnancy history, details of delivery, the infantâ&#x20AC;&#x2122;s status at delivery, diagnosis, procedures and complications during hospitalization, and outcome at discharge have been reviewed.
Results: Total number of preterm babies admitted in NICU were 1160, from January 2004 through December 2009, and IVH were found in 60 babies. The risk of IVH in our population with limited resources was found to be of about 6.96%. IVH is more common with gestational age < 30 week, and was found in 75.5% of such cases. It is more common in male gender in our audit, developed in 70% while the rest were females (30%). Mode of delivery has no bearing on the development of IVH, it occurred in 49% of pre-terms who were born SVD, compared with 51% of those who were born by C/S. 83.7% were inborn while remaining 16.3% were referred from different hospitals for various reasons. In preterm babies who developed RDS the risk of IVH is 83.7% compared with 16.3% in babies who do not have RDS. Similarly babies on ventilator support had 85.7% incidence of IVH compared with 14.3% who did not require O2 supplementation. The conception method has no influence in the risk of IVH in our audit, 93.9% were born by spontaneous conception, while 4.1% and 2% by medications and IVF/ICSI respectively Signs and symtoms of sepsis were present in 61.2% of IVH cases while 38.8% were no evidence of sepsis. Real time ultrasounds were done in all premature cases and the frequency of ultrasound depends on the clinical course. Ultrasound done once in 61.2%, twice in 26.5%, thrice in 8.2% and more than thrice in 4.1% cases. There was no IVH in 12.2%, grade 1 in 55.1%, grade II in 8.2%, grade III in 18.4% and grade IV in 6.1%. The length of stay of preterms that developed IVH were 0-5days in 27.1%, 6-10days in 20.8%, 11-20 days in 20.8% and more than 20 days in 31.25%. The outcome of pretermers who developed IVH were 55.1 were expired and 44.9% discharged home with follow up in clinic. Conclusion: IVH is still very common in our set up, though, we do not know, exactly, the morbidity associated with it. For this, we need more extensive follow up, and neurologic examination and if needed neuroimaging of those babies.
We should make a protocol for more frequent ultrasound examination for all these preterm babies at different intervals to pick it up early and for an earlier diagnosis. RESEARCH PUBLICATIONS FROM PAEDIATRIC SURGEONS OF PAKISTAN: A CASE FOR REVIVING PAKISTAN JOURNAL OF PAEDIATRIC SURGERY. 31
Yusuf Aziz Khan and Jamshed Akhtar National Institute of Child Health, Karachi Introduction: Various medical and surgical associations publish the scientific journals to make the research related to their specialty visible to the readers. This is also used to provide future directions addressing the needs of specialties. This poster addresses the publications from paediatric surgeons from Pakistan so as to find out the possibility of reviving once published Journal of Paediatric Surgery of Pakistan (PJPS).
Method: The Pubmed and ten Pakistani medical journals (supposed to be active) were searched for publications from Pakistani paediatric surgeons between year 2008 and 2010. The papers published were further analyzed as to their institutions of publication, subject addressed, category of manuscript, indexing body of journal where research was published etc. Results: Journals searched from Pakistan were JPMA, JCPSP, PJMS, JAMC, JSP, PJS, JLUMHS, JPGMI, The Professional and JKEMU. Pubmed was also searched. Most of the published articles in international journals were either case reports or descriptive studies. Subject addressed in most of the reported articles did not add much to already known literature.
Conclusion: It is too premature to start publication of PJPS as present trend is not very encouraging. A journal is rated according to type and quality of research in addition to timeliness. It is time for the paediatric surgeons to decide what their priorities should be?
PEDIATRIC TRACHEOSTOMY: COMPLICATIONS AND ROLE OF HOME CARE IN A DEVELOPING COUNTRY. Sadaf Zia, Muhammad Arshad, Zafar Nazir and Sohail Awan Section of Paediatrics Surgery and ENT, Aga Khan University Hospital, Karachi, Pakistan. Introduction: Tracheotomy in its earlier days was most commonly performed for acute airway infection in children. Its indications are now changing; it is now most commonly performed for congenital malformations (McMurray and Prescott in Practical pediatric otolaryngology. W.B. Saunders Company, Philadelphia, pp 575-592, 1996). This shift in indication has increased the rate of survival of such patients, and therefore the number of children going home after tracheostomy has also increased. OBJECTIVE: This study was conducted (1) to observe the pattern of indication and complications for tracheostomy, in our part of the world, (2) the rate at which tracheostomy can help wean patients off the ventilator, and (3) the feasibility of sending these children home with tracheostomy. Materials and Methods: A retrospective study was done on 127 patients. The indications, final outcome and the complications encountered in and outside the hospital were studied through review of charts. RESULTS: Based on the main indications, patients were grouped into: prolonged ventilation group (PV) 61%, followed by mechanical obstruction group (MO) 22%, and the last being adjunct to surgery group (AS) 17%. The in-hospital complication rate was 30% and that at home was 18.11%. The most common complications included upper respiratory tract infections, and blockage or displacement of tubes. The late complication rate was 4%. Hundred (78.8%) patients on the ventilator could be successfully weaned off, with a p value of 32
0.001; 81 were sent home with the tracheostomy tube (TT). Forty of these were successfully decannulated and the overall decannulation rate was 48.8%. Conclusion: A large number of tracheostomies have been performed in the PV group to reduce the intensive care unit (ICU) stay and to prevent nosocomial infections. The need arises from the high cost of prolonged stay in an ICU setup, which is a cause of major economic burden, and lack of financial assistance for these patients worsens the scenario. Home care of the tracheostomy tubes remains a good option for patients requiring long periods of time to overcome their primary pathology SPECTRUM OF INJURIES RESULTING FROM BOMB BLAST IN CHILDREN Sohail Asghar Dogar, Shabbir Hussain and Muhammad Arshad Section of Paediatric Surgery, Aga Khan University, Karachi Background: In Pakistan, suicide bombing besides military personnel, civilians including children, is becoming a relevant and massive health problem and the human and economic costs of the injuries are tremendous .The spectrum of paediatric injuries seen after a bomb blast is poorly documented. The pathophysiology of blast injuries differs significantly from other forms of trauma and typically results in large numbers of injuries having distinct patterns. Objective: The aim of this study is to describe the spectrum of injuries and their management in children in suicide bombings in Pakistan. Methodology: All children younger than 14 years, 31 in total, who were injured during the 3 suicidal blasts since December 2009 onwards in Karachi and who presented at a tertiary care hospital in Karachi will be documented. A questionnaire will be developed for collection of information on the types, site, mechanism and severity of injuries with the treatment administered along with socio demographic characteristics of the children. Data will be collected from hospital patient records and from the victims themselves or their parents/ guardians after getting informed consent. Descriptive statistics will be computed and reported using SPSS version 16. Results: There were a total of 31 children.19 were admitted while other were discharged after treatment from emergency room. 3 Underwent major surgeries. 1 #Tibia/fibula. 6 Eye involvement: 2 Reconstruction of pinna. 1 Wrist drop. 1 Intra articular pallots (knee). 8 Wound debridement/laceration repair. Pallot injuries involved: • Limbs (including knee joint) lower more than upper. • Head & neck (including ear & eye). • Anterior chest (superficial involvement only). 33
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Abdomen(superficial & deep visceral involvement). Back, perineum, buttocks, teeth, occipit & joints were relatively spared. No liver, spleen, kidneys, adrenals, vessels, bladder, testes injury. All patients recovered well without significant loss of functions except 1 patient who lost his eye ball.
We identified patterns in primary and secondary injuries in child victims of suicidal blasts which could lead to better preparation and management of such injuries in case of an adverse event, such as a bomb blast in the city. The challenge is to provide appropriate treatment in spite of the potential severity of injuries. This requires adequate logistic management, surgical expertise and even collaboration within various surgical departments.
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