Annals of Pediatric Surgery Vol. 6, No 1, January 2010, PP 447-71 EPSA 2009 Abstracts

Abstracts Presented at the 25th Annual International Meeting of Egyptian Pediatric Surgical Association (EPSA) December 8-12, 2009, Luxor, Egypt

Memorial and Guest Lectures

EPSA 2009 - Honorary Membership Lecture standards, particularly amongst women, limited health care resources and a constant brain drain of health care Effects of Arabic- Turkish Medicine on Development of professionals. Africa bears 24% of the global burden of Paediatric Surgery; Children’s Rights and Ethical disease but only 3% of the health care work force and only Issues in Paediatric Surgical Procedures During 1% of its financial resources are designated for health. Ottoman Period. Thirty-six of the 57 countries do not meet basic standards S.N. Cenk Buyukunal for health care. There is also the added burden of the Department of P. Surgery, Section of P Urology , HIV/AIDS epidemic and internecine strife. Despite this, Cerrahpasa Medical Facultyty, University of Istanbul, Turkey Africa’s population is estimated to increase by 1 billion in the next 45 years. Children constitute more than half this Almost all medical historians believe that Abu-Kasım-ul- population. Surgical disease in Africa will increase with Zahravi (Albucassis) was the most important founding surgical infections, trauma and congenital abnormalities surgeon as far as pediatric surgery is concerned.With his being the major demand areas with 85% of children surgical textbook(Cordoba,Endulucia)he was almost the first requiring a surgical treatment before the age of 15yrs. Late one who showed the pictures of instruments and even some presentation and advanced pathology is the rule. Those pediatric surgical techniques.A 15th century surgeon from health care workers that are trained, frequently leave for Anatolia,Turkey, Sabuncuoglu Serafeddin(1460) was the greener pastures or are overwhelmed by the gargantuan first one who presented colourful pictures of the operations task before them. Despite this enormous task paediatric and also surgical instruments. He was highly effected by surgeons in Africa are beginning to mobilize, communicate Zahravi ;however he made some additional ,important and move forward as a group. Training is becoming better contributions to his book. defined and paediatric surgeons are making inroads into the During Ottoman reign childrens’rights in health issues was surgical care of children by first setting standards of care. very important , and every effort was made by the There are clearly problems with serving rural areas as >90% community to preserve pediatric patients’ rights. In this of paediatric surgeons practice in urban areas. Nursing, lecture some informed consents about the pediatric general surgical and anaesthetic services need to be operations from 15th, 16th century will be presented. expanded. Training of paediatric surgeons should take place Besides there will be a comparison of so called “children in Africa. Practical steps to improve care are better rights” between East and European civilisation. education in the early recognition of disease, improvement During this short presentation, the remarkable contribution in communication and transport, bedside emergency of Arabic and Turkish-Ottoman medicine to pediatric management of neonates, enteral tube feeding, staged surgical field will be presented in details. surgical procedures, anaesthesia which avoids intubation and strong support to general surgeons who for the EPSA 2009 - Kaddah Memorial Lecture foreseeable future will be doing most of the surgery for children. We live in the hope of progress Challenges for Paediatric Surgery in Africa Alastair J. W. Millar Professor of Paediatric Surgery, Red Cross War Memorial EPSA 2009 - Bahnassy Memorial Lecture Children’s Hospital. Rondebosch, Cape Town, South Africa Ex Utero Intrapartum Treatment (EXIT): Outcomes and Most African countries struggle with problems of high birth Lessons Learned rate, high rates of infant mortality, poverty, poor educational Richard G. Azizkhan EPSA 25th congress abstracts.

Cincinnati Children’s Hospital Medical Center, Cincinnati, Routine evaluation and harvesting of DNA, chromosomes USA and cell lines forms the base of the transition of knowledge The lessons learned from fetal surgical treatment of in humans to animal models. congenital diaphragmatic hernia led to the development of In the past mainly teratogenic models have been used for a the Ex Utero Intrapartum Treatment (EXIT) procedure. number of so-called index diagnoses with a questionable Recently there has been a significant expansion of this significance for our understanding of the ethiology and technique to a number of clinical conditions, especially pathogenesis of these anomalies. those with fetuses with perinatal airway compromise. EXIT The integration of basic concepts of organ development and strategy is being employed for patients with Congenital High the respective effects of both genes and transcription factors Airway Obstruction (CHAOS), large neck masses, severe has resulted in new insights in anomalies like congenital micrognathia, high risk CDH, and hypoplastic left heart diaphragmatic hernia (CDH) and trachea-oesophageal syndrome with restrictive atrial anatomy. The airway is fistula (TOF). established under controlled environment in these high risk Our approach in these specific anomalies will be highlighted patients. However, these maneuvers are only possible while as a model for a fundamental change of thoughts towards utero-placental gas exchange is preserved by maintaining major congenital anomalies. Apart from a mono-specialistic uterine relaxation and optimizing maternal and fetal approach pediatric surgeons should integrate their research hemodynamics. It is important to preserve uterine volume in departments of cell biology and/or genetics as financial using a rapid amniotic infuser to minimize abruption and to restrictions will otherwise be the limiting factor for prevent cord compression. Vigorous intraoperative approaches like genome wide analysis and gene cloning. monitoring is employed continuously to treat potential Collaboration both on a national as well as an international problems that may lead to abrupt termination of the intended level is a pre-requisite for future success given the relative procedures. The EXIT team composed of multiple low incidence of many of the anomalies treated primarily by disciplines must be prepared for the unexpected to ensure pediatric surgeons. maternal safety and to minimize fetal complications. During EXIT to airway procedures, the head and neck and the EPSA 2009 - Guest Lecture – II upper torso of the fetus is externalized from the hysterotomy, the airway is assessed using multiple Advances in Molecular Genetics of Cryptorchidism. modalities. These may consist of direct laryngoscopy and Hadziselimovic Faruk, bronchoscopy. If endotracheal intubation is unsuccessful, a Kindertagesklinik, Liestal, Switzerland tracheotomy with retrograde intubation or tracheostomy should be performed. In some instances, mass resection Cryptorchidism affects 1-3% of boys and is the most has to be performed before a secure airway can be common endocrine disease in childhood. Cryptorchid testis achieved. has a typical histology; depletion of germ cells and impaired Conclusion, the EXIT procedure successfully ensures maturation of gonocytes accompanied by intestinal fibrosis prolonged utero-placental gas exchange and fetal and Leydig cell atrophy. Endocrine and primary endorgan hemodynamic stability. The EXIT procedure can be used to failures are the two etiological factors most frequently held secure difficult fetal airways, and allows for a variety of other responsible for the increased incidence of infertility in procedures to be performed to ensure successful transition unilateral and bilateral cryptorchidism. The ultimate aim of to the postnatal environment. But most importantly, it all therapeutic approaches to cryptorchidism is to have both converts a possible catastrophic emergency into a testes in the scrotum and achieve normal fertility potential. controlled planned procedure. 70% of cryptorchid patients have a hypo-gonadotropic hypogonadism. In boys with unilateral cryptorchidism, EPSA 2009 - Guest Lecture – I testicular pathology caused by hormonal imbalance was bilateral; 71 % of scrotal testes had a reduced number of Major congenital anomalies, do you understand. A germ cells and 75 % had impaired gonocytes transformation translational approach. into Ad spermatogonia. D. Tibboel Evidence of a relative postpubertal gonadotropin deficiency Erasmus MC Sophia Children’s Hospital Rotterdam, The became even clearer when LH plasma values were Netherlands correlated to the presence of Ad spermatogonia. While both high infertility risk and intermediate infertility risk groups had Pediatric surgeons are the main players in the treatment normal basal LH levels, the low infertility risk group had LH and consequently understanding of major congenital levels in the hypogonadotropic range. In our long term, anomalies. prospective follow-up study, hormonal analyses confirmed Giving the developments in developmental biology and previous observations of an inverse correlation between clinical and molecular genetics new approaches enable us FSH and sperm count . Furthermore, we confirmed that to understand both normal and abnormal development of a patients with bilateral cryptorchidism had higher FSH variety of organ systems. plasma values compared to those with unilateral Apart from the underlying genotype the variability in cryptorchidism .At the first glance, these findings suggest phenotype adds to our understanding of the underlying that a primary testicular failure causes the mechanism and the role of both genes and transcription hypergonadotropic hypogonadism found in cases exhibiting factors. low sperm counts and elevated FSH levels. However,

Annals of Pediatric Surgery 48

EPSA 25th congress abstracts gonadotropin levels were more highly correlated with the who otherwise would develop infertility, despite successful presence or absence of Ad spermatogonia than with the orchidopexy. Therefore, our results favor the hypothesis that number of undescended testes. The patients with the EGR4 is the master gene controlling fertility development. greatest impairments to mini-puberty and who completely Although all patients studied had isolated cryptorchidism in lacked gonocytes transformation into Ad spermatogonia comparable undescended position and identical age, HIR were those with the most severe infertility. Despite identical group had significantly lower EGR4 expression indicating severity of testicular pathology in the high risk infertility that intact EGR4 function is not mandatory for descent of group of patients with cryptorchidism, we observed only a epididymo-testicular unit. This is new observation,that marginal FSH elevation, indicating a relative FSH seriously questions the current dogma that undescended insufficiency. At least 70 % of our patients experienced a position itself is the only factor responsible for infertility relative FSH deficiency. Thus, the relative FSH and LH development. deficiencies observed in most of our patients support the In agreement with the decreased expression of EGR4, observation that hypogonadotropic hypogonadism is the DDX25/GRTH, an RNA helicase involved in gene-specific etiologic factor in cryptorchidism. mRNA export and protein translation during Mini-puberty and Ad spermatogonia spermatogenesis was significantly downregulated in the HIR Development of male fertility depended on a successful group. DDX25 is stimulated by LH/HCG via cyclic-AMP- mini-puberty and the transformation of gonocytes into Ad induced androgen formation in testicular Leydig cells. spermatogonia. During mini-puberty, a time between 30 and Practical aspects: 90 days of postnatal life in male infants, the substantial • 70% of the males with isolated cryptorchidism have an increase in GnRH secretion induces an increase in hypogonadotropic hypogonadism as the cause of gonadotropin and testosterone production. Testicular undescended testes. changes during the mini-puberty are further characterized • Ad spermatogonia develop in infancy during the mini by a mini-peak of testicular weight and volume. As, a puberty and are the stem cells for spermatozoa consequence transformation of gonocytes into Ad • Infertility in cryptorchidism is linked to EGR4 gene spermatogonia takes place. Adult dark (Ad) spermatogonia • Hormonal treatment of all patients prior to orchidopexy appear at 3 months of age and remain for the rest of the life. and those at high infertility risk (no Ad spermatogonia) Transformation of gonocytes into Ad spermatogonia, is not a with Kryptocur (for inducing epididymo-testicular simply another step in a succession of developmental descent) and Buserelin (LH-RHa) for preventing infertility stages but a major transformation; the switch from the fetal is recommended. reservoir of stem cells (gonocytes) to the adult reservoir of stem cells (Ad spermatogonia) from which all future germ Abstracts of Panel Presentations cells are replenished. Based, on results from our previous work we know that development of Ad spermatogonia is LH and T dependent. Expression pattern of prepubertal germ Implementation of Quality Standards in pediatric cells indicates that genes involved in meiosis and post surgical services: meiotic germ cell development were already up regulated Amel Hashish before puberty. Cryptorchid boys lacking Ad spermatogonia Tanta, Egypt. have low basal and stimulated gonadotropin plasma values, compatible with hypogonadotropic hypogonadism. If Quality Standards in health care requires doing the right transformation during infancy of gonocytes into Ad thing, at the right time, in the right way, for the right person spermatogonia fails, infertility is inevitable. This was first and having the best possible results. This trend requires a reported in 2001by us and has been reconfirmed by Kim complete communication structure and coordination of care. and coworkers who analyzed the histology of testicular Pediatric surgical procedures is one of the surgical biopsies from patients with bilateral cryptorchidism and disciplines that highly demand implementation of quality confirmed the prognostic importance of Ad spermatogonia standards for fertility. Furthermore, there is strong evidence that In many places there is a is fragmented health care system cryptorchid boys with a high infertility risk will develop that lacks the clinical information that is required to prevent infertility, despite early and successful orchidopexy. unnecessary duplication of services, long waiting times and EGR4 master gene for fertility in cryptorchidism delays in services and making the best use of the available The major observation in the most current work was that the resources. early growth response gene EGR4 was not expressed in There are many scientific tools to measure quality standards boys in the HIR group. Since EGRs are pivotal for LH to review and improve the quality of provided health care. A secretion, this is indirect evidence that EGR 4 is important quality measure is information from a patient's record or an for Ad formation and that LH-T axis is involved in this operational process that is converted into a rate, developmental process. Patients belonging to HIR group percentage, or time that shows how well health care had severely reduced EGR4 expression and identical providers are taking care of their patients in the pediatric testicular histology as Egr1/Egr4 double mutant infertile surgical unites. mice, with severe tubular and Leydig cell atrophy. As in Egr Quality measurement is a relatively new science and mutant mice, treating boys with cryptorchidism and HIR, requires a large amount of resources to develop and collect following orchidopexy, with buserelin (a GnRH receptor the information. The goal of this science is to make these agonist) normalized sperm parameters in 86% of patients measures more reliable, uniform, and helpful to in achieving

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EPSA 25th congress abstracts. better health care service to all patients especially in the multiple nephrogenic rests or nephroblastomatosis. Our pediatric age group. series of patients is consistent with this profile in every regard, apart from the absence of associated syndromes, MD Paediatric Surgery (A New Break): and all tumors in the synchronous group were local stage I Osama Nagger or II at first presentation. Ain Shams, Cairo, Egypt BWTs present a therapeutic challenge, particularly with delay in presentation, when there is a poor response to Pediatric surgery practice and training in Egypt evolved chemotherapy and when associated with through different phases. It started within general surgery nephroblastomatosis. The primary aim of management is departments thanks to the efforts of pioneers surgeons like eradication of neoplasm while at the same time preserving late professor Bahnasy and professor Draz. the efforts of renal function. whom were the corner stones of what we are talking about Twenty-three BWTs were seen in our service between today. The need of a process of certification to ensure a 1981- 2009. This represented 10% of the 210 patients with more standardized way of training and production of a Wilms’ tumours seen during this period. . There were 15 competent pediatric surgeon was always needed and girls and 8 boys ranging in age from 7 months to 8 years. dreamed for. Year 2009 witnessed the occurrence of this Eighteen had synchronous presentation, one of whom had dream as reality as from now our pediatric surgery liver metastases at diagnosis. Three of the 5 metachronous institutions in Egypt are offering a doctorate degree in tumours had their initial nephrectomies done elsewhere. pediatric surgery paving the way toward a new era to Nephroblastomatosis was identified in 19 of the patients implement the highest possible standards to cope with the (83%). Treatment was in most cases according to National future needs in surgical education . A description of this Wilms Tumour Study (NWTS) Group protocols, with initial process as well as the difficulties that still face us is at the bilateral biopsy, neoadjuvant chemotherapy and heart of this communication. tumorectomy. Where indicated, nephrectomy (partial or complete) involved using ice dam topical cooling and Medical Mistakes: History and Facts: vascular control, and in one case bench surgery and Amin Gohary extensive renal reconstruction with orthotopic UAE autotransplantation. Revision tumorectomy was utilized on 3 occasions for recurrence in areas of nephroblastomatosis. For 2500 years patients believed that they were treated by There were 6 extra-renal relapses. None required good doctors serving them good medicine. The fact is for transplantation. 2400 years they were wrong. The Hippocratic medicine was Twelve are alive free of disease 1 to 17 years after based on the 4 humors theory and the only medical help treatment (55%), all with well preserved renal function. that could be offered is bloodletting , purgatives and (lowest recorded glomerular filtration rate was 85 inducing vomiting. With the development of good medicine ml/min/1.73m2). Eleven have died (2 of unrelated disease), after the discovery of the germ theory in the mid 19th including 6 of the 7 with spread outside the kidney. All 3 with century we had another type of bad medicine based on unfavorable histology are alive. Four of the 5 with doctors mistakes. These mistakes are either diagnostic or metachronous presentations are alive, as are 8 of 10 therapeutic ones. In this presentation will discuss the presenting in the last decade. causes , prevalence and ways of preventing medical Conclusions: Appropriate chemotherapy and conservative mistakes. nephron-sparing and innovative surgery can achieve good results with preservation of adequate renal function in nearly Bilateral Wilm’s Tumor: all cases. Nephroblastomatosis was a frequent finding and Alastair Millar requires close monitoring as Wilms’ tumours developed in Children’s Hospital. Rondebosch, Cape Town, South Africa residual suspect areas. Revision surgery was effective. Unfavorable histology did not have a reduced survival in our Synchronous bilateral Wilms’ tumors (BWTs) represent 4% series. Metastatic spread outside the kidney had a poor to 7% of all Wilms’ tumors. They generally present at a prognosis. younger age than unilateral Wilms’ tumors (mean age, 2.6 vs ~3.3 years) . Approximately 10% of synchronous BWTs Primary Intestinal Lymphoma in Egyptian Children: have unfavorable histology, and are associated with Role of Surgery and Study of Survival: genitourinary abnormalities, aniridia, hemihypertrophy, or Yasser Saad Eldeen one of the overgrowth syndromes in up to 20% of cases. Alexandria, Egypt Variables for poor prognosis identified have been unfavorable histology, advanced local stage, and age over 3 Purpose: The objective of this study was to report cases of years at diagnosis. About 1% of unilateral Wilms’ tumors abdominal lymphoma managed in Alexandria University develop subsequent contralateral disease; the risk is Hospital, Egypt with special emphasis on cases of primary increased in children younger than 12 months with gut lymphoma to study the role of surgery and survival. nephrogenic rests at diagnosis. Nephrogenic rests may be Method: A total number of 121 cases of abdominal seen in up to 90% of synchronous BWTs and 94% of lymphoma were recorded with a median age 5.45 years. metachronous BWTs (78% in our series); about 70% of Non-Hodgkin's lymphoma was encountered in 103 children with synchronous BWT in the NWTS series had cases(85.1%) with lymphoblastic lymphoma was the most

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EPSA 25th congress abstracts common followed by Burkitt' lymphoma. Among these rate was 38% (n=16). Histopathological diagnosis included primary intestinal lymphoma with its specific criteria was simple follicular cyst (n=16), corpus luteum cyst (n=10), recorded in 32 cases. Twenty seven of these were mature cystic teratoma (n=5) and others (n=11). Mean presented with acute abdomen as follows: intussusception duration of hospital stay was 2.5±2.3 in laparoscopy group, (19 cases), volvulus (5 cases), and intestinal perforation (3 and 5.0±5.1 in laparotomy group. Follow up period varied cases). These cases were treated with: right hemicolectomy between 6 months to 42 months (mean 16.4±10.2 months). in 23 cases and ileal resection in 4 cases. Two years In our series, acute abdominal pain and ovarian lost rates survival of all cases of the study was correlated to the stage were markedly high. The morbidity may be decreased by and it was as follows: stage I (70.5%), stage II (50%), stage early diagnosis and treatment. Additionally laparoscopy was III (16.2%), and stage IV (0%). the preferred mode of intervention with lower morbidity. Conclusion: *Primary intestinal lymphoma in children is a special entity Turkish Experience of VU Reflux: of abdominal lymphoma. Changing Trends in The Treatment of Vesicoureteric *It is more likely to present with acute abdomen. Reflux *Surgery is indicated for the treatment of acute abdomen, Ali AVANOĞLU resection of a localised tumor mass and to get a Professor of paediatric surgery, Department of Paediatric histopathological diagnosis. Surgery, Division of Paediatric Urology, Izmir, Turkey

Ovarian Cysts in Children: The association of vesicoureteral reflux (VUR) with urinary Gungor Karaguzel tract infection and nephropathy is a well known entity for Turkey decades. So the idea of “surgical correction of this congenital anomaly simply prevents kidney damage” is Cystic ovarian lesions occur at a rate of 2-5/100.000 girls in accepted as a global fact and many types of operations are pediatric population. Etiology, clinical presentation, popularised. There are a lot of different surgical techniques. management and outcome of childhood ovarian cysts differ The story began with the introduction of Politano-Leadbetter from those in adults. Ovarian cysts may be classified as operation (J Urol 1958, 79(6):932-41) and functional or dysfunctional, non-neoplastic or neoplastic. ureteroneocystostomy became one of the most frequently Neoplastic lesions are mostly benign epithelial in nature but performed operations in paediatric surgery, may have been may be malignant rarely. There are no standard partly responsible for the birth of paediatric urology as an management protocols for the ovarian cysts. Therapeutic independent subspecialty. approaches are affected by clinical picture, characteristics of In early years the academic interest was focused on the the cyst and institutional experience. Acute and severe comparison of the different techniques instead of the effects abdominal pain suggesting torsion or rupture is a strong or the long term outcome of the different techniques in large indication for surgical intervention. Although there are no control groups. definite surgical parameters for cyst size and Although the reflux mechanism is simply described as a ultrasonographic characteristics, the cysts larger than 5cm congenital anatomic anomaly, in fact, the urinary tract in diameter and/or complicated in structure are popular function is a very complex phenomenon. VUR can be a points among the surgeons. In non-neoplastic ovarian cysts, primary congenital anatomic abnormality, or secondary to preservation of as much normal ovarian tissue as possible bladder dysfunction, or both. And it is not easy to determine has a paramount importance. Similarly, the ipsilateral the long term outcome of the disease and the surgical fallopian tube should be also spared because of its potential correction because a sophisticated tool to analyze the role during tubal transport of ovum. Recently, these surgical urodynamic properties of the bladder, ureter and the renal strategies have been accomplishing via laparoscopic pelvis is not available. surgery because of its advantageous effects on The long term complication rates of the surgery, the overall postoperative pain, hospital stay and cosmesis. success rate, and the effects of the surgery on the renal In our institution, 42 patients with ovarian cyst underwent functions are not studied in all above mentioned groups in surgery at the last five years. Patients' records were large series. examined for demographical data, clinical findings, There are numerous types of operations to correct reflux. diagnostic work-up, surgical technique, histopathology and The most important complication of the anti-reflux surgery is morbidity. All patients were evaluated by ultrasonography. obstruction. The scar formation in VUR is only secondary to The lesions measured as 4>cm (infants) or >5cm (older infection but postoperative high intrarenal pressure children) in diameter and/or complicated cyst underwent accelerates the deterioration of the kidney and causes surgery. Patients’ age ranged between 6/365 and 17 years. sometimes hypertension. The complication rate is not more 19 patients had acute abdomen, whereas 23 symptomatic than 2% in the best hands, but if occurs permanent damage patients were operated on under elective conditions. to the kidney is inevitable. Recurrence is commonly due to Ultrasonography showed simple ovarian cyst in 12 and unrecognized bladder dysfunction. complicated cyst in 30. While 18 patients have been In 1984 Barry O’Donnell and Prem Puri described and performed open surgery, 24 patients underwent reported the injection treatment for reflux in children (Br Med laparoscopy. Cystectomy, cystectomy with oopherectomy, J 1984, 289:7-9). Till than the procedure has been widely and cystectomy with salpingooopherectomy were carried used in children with different inert materials. The procedure out in 26, 13 and 3 cases, respectively. Total ovarian loss was limited only with the primary cases at the very

51 Vol 6, No 1, October 2010

EPSA 25th congress abstracts. beginning but nowadays it is now used in all types of VUR advantage. Living without the risks of VUR and difficulties related to neuropathic bladders, posterior urethral valves or of long term medical treatment is important for some duplex ureters as the open surgical procedures. Different families inert materials are discussed in the literature mainly with the concern of distant migration and obstruction; professionals Abstracts of Oral Paper Presentations switched from one material to other in years. Theoretically, the indications for surgery or injection must be the same in patients with VUR. Number of the VUR surgery General Pediatric Surgery decreased in years. Today any kind of intervention is only restricted to older children with persistent VUR or with Surgical Mangement Strategies in Childhood Thyroid recurrent urinary tract infections. Injection therapy seems to Nodules. be the first option even in the patients with secondary VUR. Emre Divarcı, O Ergün,A Çelik, S Özen, D Simsek, S Darcan Bengü Demirağ, Zeynep Burak, Müge EndoscopicTreatment of VUR Under One Year of Age Tunçyürek, Ege, Izmir, Turkey S.N. Cenk Buyukunal ( Section of Pediatric Urology, Department of P. Surgery, Background/purpose: Surgical management of childhood Cerrahpasa Med. Faculty. University of Istanbul. thyroid nodules has distinct properties. We aimed to outline the basis for requirements of diversity of childhood thyroid Background/purpose: Most of the p. Surgeons and p. nodules. urologists believes that to stay on the conservative side in Materials and Methods: Retrospective analysis of children infants VURs under one year of age. The ongoing “nerve referred and operated for thyroid nodules between 2006 and development process” of the bladder ,probably one of the 2009 was performed. Data including age, sex, underlying most important factors in this decision. Besides according thyroid diseases, diagnostic and management strategies to clinical experience majority of VURs may disappear in and outcomes were reviewed. couple of years. The aim of this study was to treat those Results: There were 11 girls and 6 boys, and mean age children, especially with high grade VUR , in their early life was 11.3±3.6 years (4-16). Main presenting symptom was and to see the benefits of early treatment (if there is any) visible/palpable mass (15/17 patients). Mean size of the Patients and methods: thirty seven patients (25 M,12 F) nodules was 20 mm (7-39 mm). No clear association of aged 2 weeks -12 mos(mean:6.8 mos) were selected for warm or cold nodules with malignant disease existed on this study.24 of those had bilateral VUR and 61 ureters scintigraphy. Fine needle biopsies performed in 7 patients were treated. Recurrent breakthrough infections, high grade were either nondiagnostic or irrelevant with final diagnosis. associated malformations, scar formation in Frozen biopsies of nodules form seven patients were ט(VUR(IV or V DMSA scan, low family compliance for longstanding malignant, and bilateral total thyroidectomies (BTT) were medical treatment, follow-up difficulties due to difficult performed. Surgery was discontinued in four patients with geographic localisation were the main indications in this inconclusive frozen studies; BTT was performed in tree patient selection. During cystoscopy ,circumcision was further reported to be malignant. Four patients with lymph routinely performed in males. Besides if there is an node metastasis required radical neck dissection. obstructive ureterocele it was punctured by using bugbee. Nodulectomy was curative in benign nodules in tree For follow- up USG(3rd week),VCUG (3rd month) and patients. Histopathologic diagnosis were papillary (8), DMSA scan(6 to 12 mos),urine culture studies were the follicular (1), medullary (1) carcinomas, multinodular goitre main follow-up tools (2), Hashimato thyroiditis (1), Graves’ disease (1) and Results: In these 61 ureters the distribution of VUR were solitary nodules (3). Risk factors included radiotherapy to as follows: G-V(12),G-IV(22),G-III(17),G-II-I(10).The last two the neck (for lymphoma) in two, and family history of groups were all contralateral sides refluxing ureters ( in medullary carcinoma in one. There were no major surgical these group the other ureter had GIV or V reflux).The complications. Hypocalcemia were seen in two patients after mean follow –up period was 3.6 years. Ureterocele+ duplex total thyroidectomy that received oral calcium replacement system (4), duplex system with double ureteric orifice, valve but resolved spontaneously at follow-up. Length of stay was remnants(1), PUV+ syringocele (1), penoscrotal 2 days. Mean follow-up ranges from one month to 2.5 years, hypospadias(1), anorectal malformation(1) were the main and there is no mortality. associated anatomical malformations in this series. In 4 Conclusion: There is a higher rate of malignancy in patients the follow-up period was inadequate. According to childhood thyroid nodules. FNB’s are inconclusive and the results in 33 patients, with single injection VUR unnecessary. Warm or cold nature of the nodule on disappeared in 52 percent, downgrading in VUR (to G- scintigraphy is indeterminate of a malignant disease. I,II)was detected in 64%.However after2nd injection these Nodules bigger than 1 cm necessitate surgery and BTT in results were improved to 67% and 85%. 15 % of total series malignant disease. Multidisciplinary approach is mandatory. were treated by open surgical techniques after 1-3 year period. Beyond 8 years: Long-Term Follow-up in Pediatric Conclusion: Endoscopic treatment of VUR in infancy can Living-Related Liver Transplantation. be taken as an “alternative conservative treatment” policy. Hesham M.Abdelkader, Hatem A.Safaan, Mohamed Improvement in VUR rates seems remarkable. For males Shaker, Ahmed Mokhtar, Amr Abdelaal, Mohamed Fathi, simultaneous circumcision in general anesthesia is an Mahmoud Elmetani, and Alaa F.Hamza.

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EPSA 25th congress abstracts

Cairo, Egypt. Conclusion: While Surgicel does not lead to macroscopic adhesions, intraperitoneal use of ABS for bleeding may Background/purpose: Difficulties of cadaveric donation cause adhesion of intraperitoneal organs. Haemostatic and serious donor shortage have led to the development effects of ABS mostly depend on formation of protein and popularization of living-related donor liver graft network and interactions between ABS and fibrinogen, transplantation (LRLT). Pediatric liver transplant patients are resulting in significant decrease of hydroxyproline. now routinely surviving 10 years or more. Beyond the first Therefore, the adhesions are not secondary to newly year after transplant, surgical biliary or vascular organized collagen. The adhesions are weak and do not complications are rare, and the incidence of acute rejection cause severe obstructions. Although ABS is a useful blood episodes falls precipitously. The objective of this study was stopper, care must be taken during its intraperitoneal to analyze a single center's 8-year experience with 41 LRLT application. in pediatric patients with end-stage liver diseases. Patients and methods: The medical records of Severe Abdominal Trauma Involving Bicycle Handlebar 41consecutive patients who underwent LRLT at our hospital in Children. from November 2001 to September 2009 were reviewed. Murat Alkan, Selcan Türker, Serdar H İskit, Süreyya The recipients were comprised of 24 males and 17 females. Soyupak, Recep Tuncer, Cemal Parlakgümüş, Actuarial patient/graft survival rates were determined at 1, 3, Ünal Zorludemir, Erbuğ Keskin, and 5 years. The type and incidence of post transplant Adana, Turkey. complications were analyzed, as was long-term graft function Background/purpose: Bicycle handlebar injuries may Results: Results revealed that the survival of post cause severe intraabdominal damages in children. The aim transplant patients or grafts at 1, 3, and 5 years was 97%, of the study was to evaluate our experience with bicycle 93.3%, 90% respectively. The incidence of vascular handlebar injuries. complications was 9.75%(4\41), biliary complications was Patients and methods: Data of children admitted to our 12.19%(5\41), and acute rejection was 4.87%(2\41). clinic with handlebar injuries between September 2007 and Conclusion: Our results indicate LRLT is an excellent September 2008 was retrospectively reviewed. The age, therapeutic modality for patients with end-stage liver sex, nature of injury, time period between the injury to disease. Better pre transplant conditions appeared to be admission, diagnostic tests, length of hospital stay, advantageous in gaining better survival outcomes of management and follow-up period were recorded. patients undergoing LRLT. Results: Eleven children with handlebar abdominal injuries were identified. Male/female ratio was 9/2 with a mean of Ankaferd Blood Stopper® : Is The Source of age of 8.8 years. The mean period of time for admission to Intraperitoneal Adhesions? our emergency department was 38.9 hours in this series. All Unal Bıçakcı, Devran Fatma Bildircin, Migraci Tosun, Burak the patients had an imprint of handlebar on the abdominal Tander, Rıza Rızalar, Ender Arıtürk, Ferit Bernay, Ondokuz wall. After evaluating the clinical condition with the help of Mayis, computed tomography, we determined pancreatic laceration Samsun, Turkey. (3), liver laceration (3), duodenal hematoma (1), duodenal perforation (1), jejunal perforation (1), choledochal rupture Background/purpose: Ankaferd® Blood Stopper (ABS) is (1) and laceration of the abdominal wall (1). Among 11 a plant extract used as haemostatic agent in Turkish children, 8 of them were operated. The average length of traditional medicine. Its haemostatic effects is still unknown. hospital stay was 18.9 days. All patients have remained well ABS could be used in case of intraperitoneal bleeding. We with no late sequela after a mean of 12 months follow-up. aimed to evaluate the intraperitoneal adhesions possibly led by ABS. Fibrous Tumors in Infancy and Childhood Materials and methods: Thirty Wistar albino female rats Nabil Dessouky, Nasser Abdel Aal were divided into three groups. Group 1 was control group Division of Pediatric Surgery, Children's University with laparotomy. Group 2 was Surgicel® (Oxidised Specialized Hospital, Cairo, Egypt regenerated cellulose) group with laparotomy and bleeding on the rat’s uterus with application of Surgicel (1x1cm). In Background/purpose: Tumors of the neonate are group 3, ABS was constituted in rat’s uterus bleeding and infrequent representing 0.5-2% of all neoplasms in children. apply of ABS to that site (2 ml). After 21 days, rats were They have a distinct incidence, pathology, clinical behavior killed. The adhesions were scored according to their degree and response to therapy from those of older children. of severity, whereas no adhesion was defined as score 0 Material and Methods: Patients with solid tumors whose and dense adhesions were scored as 3. The collected complaints had started in the early 28 days of life were specimen were detected for hydroxyproline levels as well. reviewed. Their incidence, pathological types, clinical Results. Macroscopically, there was grade 1 and 2 presentations, diagnosis, efficacy of therapy and sequelae adhesions in ABS group (median score: 1). In control and were analyzed. Surgicel group, there was no significant adhesion (median Results: Eighty patients who showed their symptoms in the score: 0). The hydroxproline level of the control group was first 28 days were divided according to timing of diagnosis significantly higher than Surgical and ABS groups (3.28, into 2 groups: The first group included 51 cases that were 2.11, and 2.48 respectively). diagnosed in the first 28 days of life, the second group being

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EPSA 25th congress abstracts. diagnosed after 28 days included 29 patients. The median Twenty five of the patients could have been reached by age in both groups was 14 days (1-28) and 5 months phone. Five of these children abandoned using the stoma (28days-12 months) respectively. The M/F sex ratio was due to previous perforation in 2 patients and stricture in 1. 22/29 and 13/16 in both groups respectively. Cases who The remaining two gave up using their stomas because they have their symptoms in the first day were 35 (68.6%) in the do not like the idea of it. Sixteen of these patients are first group and 8 (27.5%) in the second. Teratomas- (30 completely clean. Three patients have occasional soiling. cases: sacrococygeal 18, cervical 7, oral 3, retroperitoneal Only one patient was not satisfied with using ACE stoma 2) were the commonest type of tumor in both groups and stated that it did not improve her condition enough. followed by the soft tissue tumors (29 cases). The majority Eight of the patients complained about duration of the of teratomas were of the mature variant (19), with immature enema (longer than 1h); however, 5 of them refuse to use forms 10 and a single malignant form. Congenital granular the stoma every day. One patient insists on using the stoma cell gingival tumor (9) and fibrosarcoma (6) were the once a week and is continent. Only one patient reported no commonest soft tissue tumors, others included olfactory change in QOL, all others perceived a significant neuroma (3), rhabdomyosarcoma (2), hemangiopericytoma improvement. Mean QOL scores before and after the (2), fibromatosis (1) etc. Other neonatal tumors included procedure was 5.8(2-9) and 11.5(5-14) respectively. neuroblastoma (4) with 2 cases stage 4S, renal (5 cases: 3 Conclusions: ACE stomas provide a satisfactory Wilms’, 2 mesoblastic nephroma), hepatic (7 cases with 3 improvement in quality of life. Stoma related complications hepatoblastoma) and retinoblastoma (5). There were 35 are not rare. Strictures are the most common problem malignant tumors: 21 in the first group and 14 in the second. followed stoma leakage. Laparoscopic procedures, although Mortality resulted in 19 cases- 23.7%- (8 & 11 in each group limited, are faster to perform and less problematic. respectively) with the poor results in the cases of hepatoblastoma and rhabdomyosarcoma. Intraoperative Parathormone (PTH) Monitoring Conclusions: Surgery remains the mainstay of treatment Corrborates Success of Parathyroidectomy in Children. with safer chemotherapeutic measures . The prognosis was Emre Divarcı, A Celik, O Ergün, S Özen, D Simsek, S worse in infants diagnosed after 28 days of life specially Darcan, cases of hepatoblastoma and rhabdomyosarcoma Izmir, Turkey

Success of Malone’s Antegrade Continence Enema Background/purpose: Parathyroid diseases are very rare (ACE) from the Patient’s Perspective. in pediatric population. We hereby report the efficacy of Sibel Tiryaki, Orkan Ergün, Ahmet Çelik, Ali Avanoğlu, intraoperative parathormone (PTH) monitoring to confirm İbrahim Ulman, the efficiency of parathyroidectomy. Ege,Turkey. Patients and methods: Intraoperative PTH monitoring during parathyroidectomy was performed in four children. Background/purpose: Fecal incontinence (FI) is a Tree patients had parathyroid adenomas (single gland devastating problem for children. Failure of optimal medical disease) while one patient had primary hyperparathyroidism. treatment may require further interventions such as One patient had two previous surgical attempts to remove appendicocutaneostomy. We hereby report the patients’ the parathyroid glands; however, PTH levels remained high perspective for the success of Malone procedure for FI. with persistent symptoms of hyperparathyroidism. Patients and methods: The records of 32 patients who had Immunoradiometric analysis was used for PTH undergone ACE procedure in recent 9 years were reviewed. measurements. Preoperative PTH values were obtained to Patients and families were contacted, and telephone monitor baseline levels. Serum samples were collected 20 inquiries were conducted to assess the overall success of minutes after removal of the adenoma/parathyroid gland(s), the operation. Questionnaire included concerns of and compared with preoperative values. Specimens were patients/families about the stoma, functional results and also confirmed by frozen section histopathologic change in the quality of life (QOL). examination. Results: The indications for ACE stomas included Results: There were three boys and one girl, and mean age meningomyelocele in 17 patients, anorectal malformation in was 10.3 years (range 3 months-16 years). Mean 8, Hirschsprung's disease/NID in 3, spinal tumor in 3 and preoperative PTH values were 208.5±92.6 pg/ml (range: traumatic spinal injury in one. Seven laparoscopic and 25 143-274 pg/ml), and intraoperative values decreased to conventional operations were performed. Vermiform 18.7±5.5 pg/ml (range: 13-24 pg/ml) following removal of the appendix was used in 27 of the patients and cecal flap was gland(s). Normal calcium levels were achieved with used in 5. Mean operating time for laparoscopic procedure adequate management following surgery. One patient (with was 17 minutes. However, operative time for open multiple surgeries found to have an ectopic parathyroid procedures varied (45- 90 min.) depending on the type of gland) had hungry bone syndrome after the operation, and the conduit. Most frequent complication was stenosis of the was treated successfully. There were no major stoma orifice observed in 14 patients. Eight patients complications. All patients maintained normal responded to dilatations while 6 patients required minor calcium/phosphor levels in the follow-up ranging from 5 surgical revision. There were two perforations during months to 2.5 years. catheterization, and required surgical repair of the conduit. Conclusion: An ectopic parathyroid gland or another Five of the patients had a mild leakage problem from stoma; undetected adenoma can be overlooked during surgery. all were open ACE procedures, and required revision. Owing to short life of the hormone, intraoperative PTH

Annals of Pediatric Surgery 54

EPSA 25th congress abstracts monitoring to determine PTH clearance proved to serve as a is an invasive method. The aim of this study is to investigate feasible marker for adequacy and safety of surgery, and if there is a diagnostic expressive difference of angle of "cure". HIS, upper and lower esophageal diameter(UED and LED), wall thickness of cervical esophagus (WTCE) measured by Does Seasonal Variation in Mediterranean Diet Affect cervical and transabdominal USG between GER(+) and the Course of Acute Appendicitis. GER(-) children. Evangelia Rahmani, X. S. Roussis, E. Rahmani, E. Material and Methods: sixty three children were Gougoudi, X. Synopides, A. Zavitsanakis, Aristotle separated into three groups. Thessaloniki, Greece. Group1:(n=30)normal physical findings and GER(-) by USG. Background/purpose: To assess if high roughage Group 2: (n=13) Had complaints related to GER but were containing food during the summer months which is habitual GER(-) by USG in Mediterranean countries can affect the pathophysiology of Group 3: (n=20) Had complaints related to GER and were acute appendicitis. GER(+)by USG and esophageal pH monitoring. Patients and Methods: We conducted a retrospective The USG examinations were completed after having study of the case notes of all patients who were operated on observed 3 episodes of reflux or after 30 minutes if no reflux for acute appendicitis within 2007 and 2008. Patients were was detected .The cardioesophageal angle of HIS, UED, divided into two groups: plain acute appendicitis and LED, WTCE were measured. In 24-hour esophageal pH advanced acute appendicitis. In the first group were monitoring acid contact to proximal or distal probe greater included all patients with catarrhal appendicitis. In the than 5.0% of total time below pH 4 was accepted as second group were included all patients who had advanced pathologic reflux. All subjects were divided into another appendicitis: suppurative, gangrenous and perforated three group according to their ages. appendixes. Patients who were operated on for appendix Results: The age range of 63 children was 4-13 years(38 mass or appendix abscess were included in the second boys). In terms of age and gender groups were statistically group of patients. The seasonal distribution of the patients similar. Values of HIS, UED, LED WTCE were compared into the two groups was carried out to define any variations between age dependent groups and no statistical difference in the clinical and pathology characteristics of the disease was observed. In group2 values of angle of HIS, UED, LED, throughout the year. For this purpose the year was divided WTCE were not greater than the same values in group1.So into six winter months from October to March and six we accepted group1 and group 2 as GER(-) group and summer months from April to September. It is well known group 3 as GER(+).In GER(+) children increased UED, the high content of roughage in the Mediterranean diet LED, WTCE was statistically significant however increased within the summer months whic! h is connected with the angle of HIS was not statistically significant customary increase in the local production of fruit and Conclusion: In diagnosis of GER in children measurement vegetables. of UED, LED and WTCE by USG which is a noninvasive, Results: A total 249 patients underwent appendectomy readily available, repeatable, cheap, fast technique has a within 2007 and a total 241 within 2008. In the summer high diagnostic value. season of 2007, 126 patients were treated for appendicitis and in the winter months 123 patients. 64 patients had Preoperative Oral Ranitidine Administration in Children advanced appendicitis in the summer season and 45 in the With Pyloric Stenosis Can Help to Resume Feeds After winter. 62 patients had acute appendicitis in the summer Pyloromyotomy. and 78 in the winter. Similarly 66 patients had advanced Rahmani, X.S. Roussis, E. Rahmani, E. Agakidou, X. appendicitis in the summer of 2008 and 48 in the winter. 60 Synopides, A.Zavitsanakis, patients had acute appendicitis in the summer and 67 in the Aristotle University of Thessaloniki, Greece. winter of 2008. Conclusion: The incidence of advanced appendicitis within Background/purpose: To assess if administration of the summer months is higher than the incidence in the ranitidine suspension after diagnosis of pyloric stenosis winter months and it is statistically significant for both 2007 prevents postoperative vomiting. and 2008. This supports the initial hypothesis that seasonal Patients and methods: Over a period of two and a half increase in high roughage diet within the summer months years we have randomized 20 patients with pyloric stenosis accelerates the course of acute appendicitis due to increase for the administration of ranitidine suspension after in the bowel flora. diagnosis of pyloric stenosis was confirmed with ultrasound. Mean age of the patients was 43 days and median age was Transcutaneous Cervical and Transabdominal 45 days old. Sixteen were boys and four were girls (male/ Ultrasonography as A Diagnostic Tool in female ratio: 4/1). None had abnormal pre-operative serum Gastroesophageal Reflux in Childhood. biochemistry or full blood count. All patients underwent Karabulut Bilge, Bostanci Ilknur, Kacar Mahmut, Karaca Ramstead’s pyloromyotomy within 36 hours from diagnosis, Gokhan,Kosar Pinar through a transverse upper abdominal incision. All but one Ankara, Turkey. were started progressively on formula feeds twelve hours post operatively. One patient was kept on intravenous fluids Background/Purpose: 24-hour esophageal pH monitoring and nasogastric tube drainage for three days post is considered a gold standard in the diagnosis of GER but, it operatively after inadvertent perforation of the mucosa

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EPSA 25th congress abstracts. within the pyloric incision. narrowing at the peri- anastomotic area. A novel way of Results: Seven patients (three girls) were given ranitidine management is presented. suspension and thirteen were not. Six (30%) out of seven Conclusion: There is no doubt that CES can affect the peri patients who took ranitidine were fed with formula milk full anastomotic site and should be considered in the etiology of strength 12 hours post operatively with no vomiting. One peri anastomotic stricture and esophageal dysmotility. patient was fasted for three days because of pyloric mucosa Taking a surgical specimen routinely from the tip of the LEP perforation and was excluded. All patients who did not take during primary repair of EA is highly recommended. ranitidine were attempted to feed at 12 hours post operatively. Five (25%) had vomits for more than 24 hours Esophageal Replacement With Collis Gastric Tube in up to three days and then settled on full strength feeds. Six Long Gap Esophageal Atresia. (30%) had one vomit within the first 12 hours from the start Celayir AC, Gul C, Alver D, Pektas OZ, Zeynep Kamil, of feeds and two (10%) had no vomit at all from the post Istanbul, Turkey. operative start of feeds. Conclusion: All patients with pyloric stenosis who took Background/purpose: Esophageal replacement is ranitidine suspension from the preoperative period adapted indicated for long gap esophageal atresia when primary well to the feeding regime postoperatively. In eleven anastomosis is not possible, especially in cases without patients (85%) out of 13 who were not given ranitidine it fistula or when elongation techniques have failed. The took them at least twenty four hours to settle on full feeds. authors show their technique and analyze preliminary This suggests that preoperative administration of ranitidine results of the collis gastroplasty for esophageal replacement suspension can reduce the incidence of post operative for long gap esophageal atresia. vomiting in children with pyloric stenosis perhaps by Case 1: Two days old boy operated with esophageal atresia alleviating gastritis. with distal fistula underwent thoracotomy shortly and had a long gap preventing primary anastomosis. Only distal fistula The Right of The Fetus (Pro Choice Vs Pro Life). was ligated due to very long gap, and a lateral Amin El Gohary esophagostomy in the proximal pouch. He discharged home Abo Dhabi, UAE. on G-tube feedings. While he was one year old, we examined to assess the gastric vascularization during the There are 2 camps with different views about the right of the operation with laparotomy, we prepared a 6 cm gastric tube fetus. The pro choice group stating the right the mother in for replacement of distal esophagus using a linear stapler deciding for what she carries which mean the right for from Hiss Angle trough small curvature. Surgical steps abortion. On the other side there is the pro life camp who included releasing the stomach while preserving the left and defend the right of the fetus for survival. Both camps have right gastric and gastroepiploic arteries at the beginning, their arguments . The point that need to be addressed in this than cutting the left gastric vessels required because gastric conflict is the legal aspect of abortion. In other word when tube and distal esophagus pulled up through mediastinum, abortion of a baby consider to be unlawful act that should be and primary esophageal anastomosis were done easly. punished by law. This depends on the age at which the Therefore, esophageal replacement using a collis baby is considered a full human being. In my presentation I gastroplasty tube performed successfully. He had severe will discuss the different religious and legal aspects of gastroesophageal reflux, an antireflux procedure is planned (person hood). 6 months later. Case 2: Two days girl baby operated with isolated Congenital Esophageal Stenosis Associated With esophageal atresia, underwent gastrostomy and lateral Esophageal Atresia: A Proof That it Can Affect The esophagostomy. She discharged home on G-tube feedings. Anastomotic Site. While she was four months old, we operated for Ashraf H. M. Ibrahim, Ibrahim Abdul Raheem, Ahmed replacement of esophagus. We prepared a gastric tube Kandeel , Mohamed Bazeed, using a linear stapler from Hiss Angle trough small Khamis Mushit, KSA. curvature, cutting the left gastric vessels required because 7 cm gastric tube and distal esophagus pulled up through Background/purpose: the site of congenital esophageal mediastinum, and primary esophageal anastomosis were stenosis (CES) associated with esophageal atresia (EA) is done easily. She had a jejunostomy tube for nutrition and a said to be in the distal esophagus and away from the esophageal anastomotic fistula after 5 months later, we anastomotic site. The aim: is to prove that CES associated planned an esophagostomy closure procedure after three with EA can affect the anastomotic site and it should be months later. considered in the etiology of the peri anastomotic stricture Conclusion: Esophageal replacement with the Collis and esophageal dysmotility. Gastroplasty Tube could be safely performed in two infants Patients and methods: We present a case of EA with Long Gap Esophageal Atresia, even after a previous associated with CES proved by histologic examination of a mediastinal operation in one of them; however, larger surgical specimen obtained from the fistulous end of the comparative series are required in the future. lower esophageal pouch (LEP). The histology showed tracheobronchial remnants (TBR) including cartilage. Initial Hirschsprung’s Disease: an Odd Presentation and a contrast esophagogram was normal. Repeat study at one Novel Way of Management. month showed delayed major esophageal dysmotility and Ibrahim M. abd El Raheim , Hamad A. Hader , Ashraf H. M.

Annals of Pediatric Surgery 56

EPSA 25th congress abstracts

Ibrahim Only 5 of the proximal brachio-basilic AVFs needed second Khamis Mushit, KSA stage superficialisation. All others did not need Background/purpose: Delayed diagnosis of superficialisation as the basilic vein was accessible for Hirschsprung’s disease (HD) beyond one week after birth dialysis beneath the deep fascia. Complications occurred in and long segment disease are important risk factors for 8 cases (20%). Thrombosis occurred in 3cases (7.5%), steal neonatal Hirschsprung’s enterocolitis (HE). Management phenomenon in one (2.5%), aneurysmal dilatation in 2 includes series of rectal dilatations, rectal washouts, cases( 5%) and infection & rupture in 2 cases( 5%). antibiotics, and a stoma if a long segment is suspected. Conclusion: AVF in children provides an ideal dialysis Definitive surgery then follows. The mortality rate may be as access which is durable and easy to use. high as 30%. Case report: We present an 8- day old boy with HE. The Neonatal Surgery: Clinical Experiences in Pentalogy of clinical picture was odd and the diagnosis was challenging. Cantrell. The management was simple, definitive and novel. Gence A, Alver D, Celayir AC, Kurt G, Conclusion: Delayed diagnosis of HD can lead to HE. In Istanbul, Turkey. This case, HE did not respect the length of the affected segment. A novel simple way of management is presented. Background/purpose: Prognosis is mostly affected by cardiac anomalies accompanied by congenital Luxor and The First Surgical Text in History. malformations and the size of abdominal defect in Cantrell Abdelrahman kamaleldeen, Salah kamaleldeen, Pentalogy. If pentalogy is complete, mortality is higher. This London, UK. study is designed to consider the difficulties in diagnosis and treatment of pentalogy of Cantrell in line with literature It was in the city of Luxor in 1862 that the first surgical knowledge as it is very rare anomaly group. treatise came to light. \"An American farmer of Luxor\", as Patients and methods: Cases with Cantrell Pentalogy who Edwin Smith described himself, was the man who bought had presented different styles were discussed with their the ancient artefact from Luxor market. The Edwin Smith characteristics, treatment modalities and prognosis. papyrus, as it came to be known dates back to 3000-2500 Results: Patient I: Giant epigastric omphalocele was left for B.C., and gives detailed descriptions of 48 surgical cases. secondary healing for 2 months. She had got also severe The papyrus adds to our knowledge of the advanced state cardiac murmur. When three years old, the patient admitted of ancient Egyptian surgical practices. The text describes with 25x20 cm diameter giant ventral hernia. During hernia the systematic approach to injured patients; eliciting history, repair successfully with mesh, short sternum and anterior clinical examination, diagnosis and treatment. It gives diaphragm defects were observed. We decided that this instruction on pain relief, wound and fracture treatment and case was a Cantrell. Patient II: Two days old male were the prevention of infection. Indeed the Egyptians' operated due to mild epigastric omphalocele. Pericardial observations led to the use of mouldy bread in wound defect and ectopia cordis protrude to the abdominal cavity infections millennia before Alexander Fleming extracted from diaphragm defect were seen when sac was opened, penicillin from moulds in 1928. The Ancient Egyptian and omphalocele repairing with Ladd skin flaps were done; surgical practices documented in the Edwin Smith papyrus but diaphragmatic defect closed by leaving a small opening were thousands of years ahead of their time, and are due to cardiac arrhythmia. Cardiopulmonary arrest occurred mirrored in modern surgery today. at 26th day post-op. Patient III: In this complete type, were detected in 34. gestational weeks, and perinatologist, Arteriovenous Fistula (AVF) as Chronic Dialysis Access neonatologist, geneticist and pediatric surgeon and family in Pediatrics. decided to secondary healing because of severe cardiac Adham El-Saied anomaly. Mesh repair with silo method was performed Mansoura, Egypt. urgently, because liver and small intestines were eviscerated at 17th day. Cardiopulmonary arrest occurred at Background/purpose: The incidence of end-stage renal 2nd hour post-op. disease (ESRD) in pediatric patients has increased over the Conclusion: Timing of the surgical treatment and technique past two decades. Hemodialysis (HD) continues to be the to be used are equally important in Cantrell patients. most frequently utilized modality for renal replacement Surgery can be delayed to avoid high abdominal and therapy. Choosing the best vascular access option for thoracic pressure. A team of perinatologist, neonatologist, pediatric HD patients remains challenging. Purpose: To pediatric cardiologist, geneticist and pediatric surgeon report our experience in the creation of arteriovenous should be formed to determine the best approach from the fistulas (AVFs) in children with emphasis on the details of prenatal period. patient selection and the surgical technique. Patients and methods: During the period of March 2008 to Pyloric Atresia Associated With Epidermolysis Bullosa: June 2009, 40 patients with ESRD underwent AVFs as Report Of Two Cases And Review Of The Literature. Chronic Dialysis Access. Patient age at the time of surgery Unal Bıçakcı, Burak Tander, Rıza Rızalar, Ender Arıtürk, ranged from 3-15 years. 7 AVFs were distal radio-cephalic, Fatma Çakmak Çelik, Ferit Bernay, 20 were proximal brachio-cephalic and 13 were proximal Samsun, Turkey brachio-basilic. Results: Primary success occurred in all cases (100%). Background/purpose: The coexistence of pyloric atresia

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EPSA 25th congress abstracts.

(PA) and epidermolysis bullosa (EB) is a rare but well- omphalocele offers many challenging problems to the known surgical emergency in neonates. PA/EB is described pediatric surgeons. The management of omphalocele is by the association of atresia of the pylorus and bullous controversial and no single treatment method is applicable lesion on the skin. Nintyone cases were reported in the to or optimal for all types. This study aims to compare literature so far. We present two new cases and evaluate between two methods of surgical treatment of omphalocele association of PA/EB, its ethiopathogenesis and clinical with visceroabdominal disproportion (VAD); primary skin flap properties. closure and staged surgical closure using silo. Case I: Patients and methods: Thirty neonates with omphalocele Three days old female presented with nonbilious vomiting, and visceroabdominal disproportion (VAD) were included in and bullous lesions 2-3 cm in diameter on extremities. this study; 17 cases underwent primary skin flap closure Abdominal X-ray showed a single air-fluid level at left upper (group A), and 13 neonates underwent staged reduction, quadrant. At laparotomy, we found a pyloric atresia and using a sterile blood collecting bag as a silo , followed by performed a pyloropylorostomy. The patient died due to definitive fascial closure at the same admission (group B). sepsis complication of EB 2 months after surgery. The two techniques were compared as regards achieving Case II: closure of the defect with the lowest morbidity and mortality Two days old male presented with severe dermal bullous taking in consideration the size of the defect, eviscerated lesions on trunk, neck and extremities. He had dilated mass, gestational age, birth weight and associated stomach and no gas distal to it. We found pyloric atresia and congenital anomalies. performed gastroduodenostomy. Initially, he tolerated the Results: The mean age was 1.7 day at time of first feeding well, but he died due to severe sepsis on intervention. Slight male sex predominance was reported. postoperative 23rd day. There was no significant statistical difference between the Conclusion: Almost all neonates born with the PA/EB have groups as regards the gestational age or birth weight. a fatal outcome in the first few years. The complications Postoperative ventilatory support was required in 2 related to EB are usually the cause of death. Even after neonates belonging to group A. Flap edge ischemia successful repair of PA, skin lesions lead to death due to occurred in 2 cases from group A, in one of them necrosis infection. occurred that required debridement and re-closure. Death occurred in 4 cases and was related to non-surgical Necrotizing Enterocolitis With Short Bowel Syndrome: comorbidities from the associated congenital anomalies. A Neonatologist/ Pediatric Surgeon Dilemmas. Conclusion : No single treatment method is applicable to or Sulaiman alsaad MD, Ashraf Al.kholy MD optimal for all types of omphalocele. However, both primary Ibn sina hospital, State of Kuwait. skin flap closure and staged surgical closure using a sterile blood collecting bag as a silo followed by definitive fascial An increasing number of cases of necrotizing enterocolitis closure at the same admission are safe and effective (NEC) are more frequently encountered since the options. Selection between the two can be based on the advancement of care and technology. NEC is a known degree of visceroabdominal disproportion, the presence of leading cause of short-bowel syndrome (SBS) in infancy. other anomalies, and the available resources. Studies on the acute medical and surgical management of NEC have traditionally focused on short-term morbidity and The Importance of the Stoma Leveling of Pouch Colon mortality, with less emphasis on long-term outcomes. Acute in Cases With Persistent Cloaca. surgical management of NEC involves priorities of Kurt G, Celayir AC, Sarıca K, controlling sepsis as well as preserving bowel length. Istanbul, Turkey. Bowel-preserving strategies for NEC, designed to limit SBS, are based on peritoneal drainage, limited resection, or a Background/purpose: The type 1 pouch colon according combination of both. From a neonatologist perspectives; to Narasimharao classification are seen with an ileum these approaches are difficult to predict and less likely to opening to a dilated pouch colon, and sometimes with succeed in this population of extreme low birth weight together most complex anorectal malformations like babies. persistent cloaca. Pouch colon in persistent cloaca is very We are describing our experience and approach to such rare anomaly. We reported a case with pouch colon in dilemmas in a tertiary NICU setting along with the paediatric persistent cloaca diagnosed to underline the importance of surgeon in another hospital being involved. The decision the stoma levelling on the definitive operation. making in these patients to fulfil the abovementioned goals Case Report: thirty two gestational weeks girl baby was as well as the outcome and the long term morbidities are to operated on the second postnatal day because of be discussed. Persistent cloaca. Preoperative abdominal X-ray showed dilated distal colon and ultrasonography findings were Primary Skin Flap Closure Versus Staged Surgical bilateral hydronephrosis and 8 cm diameter cystic mass at Closure in the Treatment of Omphalocele With Viscera- the left lower quadrant. Preoperatively the spectacular abdominal Disproportion. formation was 10 cm dilated colon, which completely Ahmed M Abdelmonem Ali Gafar, covering the lower quadrants. There was totally 50 cm Sohag University, Egypt. intestine between distal to Trietz ligament and distal ileum was ending directly with dilated pouch. There was no Background/purpose: The newborn who has an appendix and no colon. Any colonic segment to open a

Annals of Pediatric Surgery 58

EPSA 25th congress abstracts colostomy could found, so ileostomy was created 5 cm Ain-Shams University, Cairo Egypt proximal to cystic mass. When she was two years old, in the beginning of the A case of acute appendicitis presented clinically by picture definitive operation, cystoscopy was showed 6 mm diameter of acute scrotum in 17 days old neonate, on exploration we common channel with 3 cm length and very short urethra (8- found hernial sac containing inflamed appendix, 10 mm) with a wide opening to the bladder. There was a appendectomy and herniotomy was done with uneventful meatus between urethral opening and double vagen orifice postoperative period. which was estimated to be the rectal fistula. The operation was started with muscular stimulator control to determine the anal sphincter. Posterosaggittal incision was made to Pediatric Urology common channel was incised along the posterior border towards the introitus of the vaginal orifice. Bladder neck was Circumcision: A safe Operation or Disastrous wide and the urethra was short (less than 1 cm). Urogenital Complication; Management of Severe Penile Shaft sinus mobilisation was done with rectum and double vagina Injuries. and urethral plane. Rectum was mobilised only 3 cm. So, M. S. El-Debeiky, H. A. Soliman abdominal exploration with stomal circumcision plus hockey Cairo, Egypt. stick incision were done. 4 cm diameter ouch colon was determined; between cloacal orifice and distal stoma edge Background/purpose: Circumcision remains to be the were approximately 4 cm. Pouch colon totally excised and oldest known surgical practice to Mankind. For ages, its proximal stoma pulled thorough to perineum and the popularity was based on religious and ethnic backgrounds. abdomen was closed. 3 cm neourethra was reconstructed Nowadays, there is a growing worldwide acceptance of from common channel, vaginal septum was excised and performing circumcision to all males particularly with the vaginal orifice was reconstructed by vaginoplasty, perineal assumptions of decreasing the incidence of genital body reconstructed, and the intestine was pulled through the malignancies as well as sexually transmitted diseases. perineum into the anal channel Postoperative treatment Despite the vast experience in performing circumcision with consisted of parenteral nutrition and antibiotherapy. various techniques, it is not devoid of complications which (Aminoglikozit, cefazolin and metronidazole). The gaita are infrequently devastating and difficult to manage. The passage became at the 3’th day, a Foley catheter balloon purpose of this study was to evaluate the outcome of a put into the rectum for cutting of the stool passage, oral th reconstructed penis after a sever shaft injury following feeding started at the 15 day, the bladder catheter was circumcision. taken out 21th day and the anal calibration programme was Patients & Methods: fourteen patients with severe penile given after 3 weeks. She is good, after the 4 mouths of the shaft injury after circumcision where subjected to staged operation. reconstruction. Based on the remaining corporeal tissues Conclusion: These problems make the operation and skin, the reconstruction was planned using local flaps, difficulties. Management of the pouch colon, to be careful release of trapped corpora and excision of scar tissues as about stoma levelling is mandatory. The abdominal well as using more distant grafts. approach was obligatory because of short colon didn’t give Results: All of the 14 patients achieved acceptable penile permission for pull trough. The other difficulties was that tissue length, erectile function and distal urethral meatus. very short distal colon had opened between urethra and Cosmetic appearance although appreciated by the parents double vagina and bifid vagina with short urethra in cases is yet not comparable to the original. with persistent cloaca. Conclusion: Despite the safety, short learning curve and frequent practice, circumcision seems to present a rare but Mesenchymal Hamartoma in a Neonate. serious risk. Penile shaft injuries are very challenging to Khaled Desouky, reconstruct and requires a tedious planning and operation. Cairo, Egypt. Good results after reconstruction do not affect the necessity of a safe practice for circumcision to avoid the need for such a case report of liver mesenchymal hamartoma in a 7 days reconstruction. old boy presented with abdominal mass, obstructive jaundice and vomiting. his total bilirubin was 20mg,direct Preliminary Results of a Two-Stage Technique for bilirubin 18mg. Hb 7mg. his alph fetoprotein was>1000. Proximal Hypospadias With Severe Chordee: Creation Abdominal U/S and CT scan showed a mass occupying the of Urethral Plate by Using Vascularized Preputial Island whole of the left lobe of the liver pressing over the biliary Flap. tract. He had a laparotomy and left lobe resection of the liver Yunus Söylet, Ebru Yeşildağ , Cem Kara ,S.N. Cenk using combined CUSA and diathermy devices .Pathology Büyükünal, proved the lesion to be a mesenchymal hamartoma a İstanbul, Turkey. benign rare hepatic tumor .He made a tremendous recovery and was discharged on the 9th post operative day. Background/purpose: While the algorithms of the operative techniques in distal hypospadias are mostly Neonatal Appendicitis Presented by Acute Scrotum: A standardized, it still is exacting to decide whether a single- Case Report and Review of the Literature. stage or two-stage operation should be carried-on in cases Khaled El-Asmar and Hisham Abdel-Kader

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EPSA 25th congress abstracts. with proximal hypospadias. Many of those who prefer two- end-on digital photograph of the penis, using MillenMed stage approach in these patients use genital or buccal DICOM viewer program for image analysis. Two techniques mucosa grafts to form the urethral plate. The aim of the were used to correct penile torsion. In group A (9 patients), study is to evaluate the results of our experience in patients we used the technique of degloving and repositioning the with primary proximal hypospadias in whom two-stage penile skin. In group B (10 patients), we applied the operation was indicated and pediculated rectangular technique of dorsal dartos flap rotation . preputial flap was used to form urethral plate in the first- Results: Penile torsion was present in 19 out of 58 patients stage. with anterior hypospadias (32.8%). Follow-up showed Patients and method: Two-stage operation was performed complete correction of penile torsion in 3 out of 9 patients in between 2005 – 2008, in 10 children with primary proximal group A; and in 8 out of 10 patients in group B. hypospadias with severe chordee. The minimum of 6 Conclusion: Penile torsion is a common association with months is preferred to wait to proceed to the second stage. anterior hypospadias (32.8%). Dorsal dartos flap rotation In the first stage, a rectangular flap was prepared from the seems to be more effective for correction of penile torsion preputial mucosa similar to pediculated preputial tube than simply degloving and repositioning the penile skin. preparation of Duckett. Following the correction of the ventral curvature, this flap, without being tubularized, was lied between the original urethra and glans tip. Few fixation Concise Metanalysis of Current Bladder Extrophy sutures were placed for the adhesion with tunica albuginea. Outcomes. Tiny incisions were performed on the flap in order to provide Mohamed Aboheba the blood and fluid collection behind it. In the second stage, Alexandria , Egypt. the urethroplasty was carried-on by tubularizing the flap prepared in the first stage. An urethral catheter was placed Background/purpose: Current trends in bladder exstrophy in both stages and an elastic dressing was covered over the include: complete primary repair, planned multistage repair Mepithel or Bactigrass that was placed right over the wound. & primary urinary diversion using sigma-rectum (Mainz II) Results: The mean age of the cases was found to be 3 pouch. While each concept has its merits, there exists years (1 – 3,5 years). While both stages were completed in tremendous controversy in current exstrophy literature all of the cases in this series (with an average of 7,5 months among supporters of each trend as to recommend the 'ideal between two stages, averaging 6 – 11 months) . The approach' that yields the best long-term outcomes along the urethral catheter was removed with a mean of 6 days and 3 traditional axes: surgical complications, continence status 10 days after the operation & psycho-sexo-social adaptation. The aim of the work is to in the first stage and in the second stage, respectively. present an evidence-based metanalytic comparison of No complication is detected in the follow-up period ranging current outcomes of various surgical approaches applied in between 4-18 months . different centers on bladder exstrophy. Discussion: Single-stage flap urethroplasties are preferred Patients and method: Using Endnote X3® (© 2009 much than the graft urethroplasties in the correction of Thomson Reuters), a Pubmed search on the word primary hypospadias. On the other hand, grafts are much 'exstrophy' limited to 2000-2009 was done. This yielded 8 more commonly applied in two-stage operations. Our main cohorts with considerable case volume, each experience in a limited number of patients showed that the representing a different exstrophy center that were use of pediculated preputial mucosal flap to form the conventionally (luckily equally) split among the 2 main urethral plate in two-stage operations increases the success trends: 4 complete primary repair (CPRE) series from Lyon, rate of tubularization procedures in the second stage. We Indianapolis, john Hopkins & Boston and 4 planned think that we benefited from the known advantages of flap multistage repair (MSRE) series from Assiut, Cairo, Seattle applications in the hypospadias surgery in these patients. & Boston. Cosmetic and functional results seems successful in this Results & Discussion: Not all parameters were reported in small series with preliminary results. all 8 series. [2 tables & 2 graphs] Surgical outcomes of lower urinary tract: repair Penile Torsion: an Overlooked Anomaly With Anterior dehiscence/bladder prolapse at 2-16% in MSRE vs. 3% in Hypospadias. CPRE; bladder outlet stenosis & calculi at 1-51% & 5-24% Amr Zaki respectively after MSRE vs. 9% calculi in CPRE; bladder Ain Shams, Egypt carcinoma at 1% of 2/4 MSRE series & 0/4 in CPRE series . associated with bowel augments after longer follow-ups; Background/purpose: To identify the incidence of penile epidydimitis at 15% in 1/4 MSRE; urethral stricture at 2-6% torsion among patients with hypospadias, while using a & 3-6% in MSRE & CPRE respectively; hypospadias at 50- simple and objective method to measure the degree of 77% of neonatal CPRE repairs; VCF & UCF at 8-14% in rotation. Also, to compare 2 different techniques used for MSRE & 9-13% in CPRE; and male penile/glanular tissue correction of penile torsion (namely degloving and loss at 8% in 1/4 CPRE series. While, those of upper urinary repositioning of penile skin, and dorsal dartos flap rotation). tract: persistent VUR needing formal antireflux procedures Patients and method: From December 2007 to March at 5-91% of all MSRE and CPRE series; hydronephrosis at 2009, all boys presenting to our department for hypospadias 1-26% & 9-34% of all MSRE and CPRE series respectively repair (100 boys) were examined for associating penile & commonly coexisting in the same patient; renal calculi at torsion. The angle of penile rotation was measured on an 2% of 2/4 MSRE series commonly coexisting with upper

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EPSA 25th congress abstracts tract dilation & recurrent febrile UTI at 2-65% of MSRE 1. There is no existing ideal exstrophy repair as yet. series & at 20-28% of CPRE series; and DMSA renal 2. No unified long-term outcome parameters reported in scarring at 3% and 19% of MSRE & CPRE respectively. current series. Continence outcomes: current MSRE & CPRE series have 3. There is significant observer bias in all current exstrophy widely variable case volumes of 62-193 & 33-45 literature. respectively, variable durations (case burden/year) of 18-35 4. There are no prospective randomized trials with open- years (2.2-7.7/year) for MSRE & 6-19 years (2.1-7.5/y) for ended or defined end-points of exstrophy outcomes as CPRE & hence variable ranges of mean/median follow-up yet. intervals of 9¼-11 years/12½-17¾ for MSRE & 3¼/3½-5 5. Short & long-tem exstrophy outcomes should better be years for CPRE. Continence status: Expectedly, 77-98% of reported & interpreted related to the patient sex MSRE (older) patients were ‘evaluable’ for their continence (Gearhart, JU 2007-8). status compared to 59-100% of CPRE (younger) patients. However, the ‘lost-to-follow-up’ subgroups constituted 2- 10% of MSRE series compared to only 3% of CPRE cohort Persistent Hydroureteronephrosis in Posterior Urethral only. Although continence definitions across the selected Valve Patients. series were atypical, yet a ‘3-hour dry period daytime Sibel Tiryaki, Murat Alkan, Ibrahim Ulman, Ali Avanoglu, without nighttime wetness, with volitional voiding without Ege, Turkey CIC’ was a uniform index in 4/4 MSRE & 2/4 CPRE series (± night wetness) & ‘2-hour dry period daytime’ instead was Background/purpose: Persistent hydro-ureteronephrosis is the index in Seattle. a frequent long-term finding in posterior urethral valve (PUV) Continence mechanism: Regardless of the mechanism, patients despite rational contemporary treatment. Persistent normal anatomical continence was declared in 37-77% of upper tract dilatation is a concern during follow-up which MSRE series similar to 27-82% of CPRE series (MSRE ~ may or may not be accompanied by vesicoureteric reflux CPRE insignificantly), and non-anatomical continence was and parenchymal loss. We reviewed long term treatment achieved in 9-52% of MSRE series more than 0-27% of results of PUV patients to determine the implications of CPRE series (MSRE > CPRE significantly), while the persistent hydroureteronephrosis, and see if it alludes to any remaining 0-19% of MSRE series less than 0-47% of CPRE identifiable cause. series were incontinent or awaiting further surgery (MSRE < Patients and method: Persistent hydro-ureteronephrosis CPRE significantly). without vesicoureteral reflux was noted in 28 out of 59 Regardless of technique, initial closure rendered only 4-8% patients with PUV treated between 1998 and 2008. We of MSRE patients continent compared to 19-73% of CPRE reviewed 19 patients well documented with full work-up and patients (CPRE > MSRE significantly). Contrary to the long term follow-up. Six boys who had antireflux surgery traditional belief that only few ‘lucky’ females may achieve were included. All patients underwent serial urodynamic, continence with initial ‘bladder’ closure, even fewer ‘luckier’ ultrasonographic, and renal functional investigations males did achieve continence after epispadias closure if following valve ablation. Patients with hypercontractility done before BNR. Although BNR (YDL) was the main and/or low compliant small bladders were treated with mechanism of continence in all MSRE series at 29-72%, yet anticholinergics, and patients with significant postvoid it still remained a major continence surgery (YDL/Mitchell) residuals employed clean intermittent catheterization and/or after CPRE at 0-35% (MSRE > CPRE significantly). In urotherapy including timely voiding. contrast, bladder neck bulking thepary (BNB) using MPQ or Results: Initial urodynamic findings were normal in 3 boys. Deflux™ was responsible for only 0-5% of continent MSRE Low-compliant, small capacity bladder was found in one. compared to 0-14% of continent CPRE (CPRE > MSRE Nine boys had detrusor hyperactivity, whereas 6 had significantly). Tension free vaginal tape (TVT) was used to decompansated high-capacity bladders. Following medical achieve continence in selected older MSRE girls with treatment, hydronephrosis disappeared in only one patient. variable success, while AUS had a low safety profile in In 15, it improved, and in 3 it did not change. Three patients MSRE series and was abandoned in favor of bladder neck developed end-stage renal disease during follow-up. closure (BNC) and catheterizable reservoirs. Conclusion: The rate of persistent upper urinary tract Bladder augmentation (with various bowel segments) was dilatation after valve ablation is high. Urodynamic evaluation the 2nd major continence surgery in both MSRE series at 0- and treatment of bladder-sphincter dysfunction improves but 50% and CPRE series at 0-20% (MSRE > CPRE not totally alleviates the problem of persistent upper tract significantly), but invariably employing CIC (with partial or dilatation in PUV patients. The clinical significance and the absolute reliance) on the expense of volitional voiding. future of this probably residual stretching of the upper Finally, BNC ± 2ndry diversion was resorted to in 2-14% of urinary tract need to be elucidated. MSRE series compared to 0-7% of CPRE series (MSRE > CPRE significantly). Tunica Vaginalis as an Intermediate Layer in Difficult Regardless of the continence mechanism, CIC (urethral/ Hypospadias. Mitrofanoff) contributed a 9-67% and 10-80% towards Hisham safoury MSRE and CPRE continence respectively. In addition, 24- Ain-Shams ,Egypt 81% and 31-73% of MSRE and CPRE patients respectively needed surgery after BNR/CPR to achieve continence. Background/purpose: proximal and redo hypospadias Conclusion: have a high postoperative fistula rate. Using a covering

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EPSA 25th congress abstracts. intermediate layer has significantly reduced this problem. medical records of 175 boys with different types of Patients and methods: over the last 2 years, the tunica hypospadias, who underwent TIP urethroplasty, were vaginalis was used as an intermediate layer in 25 patients critically reviewed. Their age ranged from 9 to 36 months with difficult hypospadias. Thirteen patients with redo (mean age; 22.72 ± 7.75 months).The period of follow-up hypospadias and 12 patients with proximal penile was ranged from 7 to 60 months (mean 34.42 ± 15.41). hypospadias. Results: All families were happy with penile aesthetic Results: one patient (4%) had recurrent fistula, another appearance. The total number of boys with different types of patient had partial glandular disruption , 3 had scrotal hypospadias was 175 (145 1ry and 30 2ry). Out of 175 hematoma. In 22 patient the final outcome was very cases, the overall urethrocutaneous fistula rate was 11 satisfactory. (6.29%), and the overall rates for urethral stricture, meatal Conclusion: in selected patients using the tunica vaginalis stenosis and meatal regression were 5 (2.86%), 17 (9.71%), as an intermediate layer has markedly reduced the post- and 10 (5.71%), respectively. All cases of urethral stricture operative fistula rate, and allowed good quality penile skin and most cases of meatal stenosis 12 (6.86%) responded coverage. well to regular urethral dilatation. Meatoplasty was performed in only 5 (2.85%) cases (1 of 1ry and 4 of 2ry Modified Koyanagi Technique in Management of cases). Secondary surgery for fistula repair and glans Proximal Hypospadias. closure was successful in all patients. All children void with Adham El-Saied a single straight urinary stream in a forward direction, and Mansoura, Egypt. have a rounded glans with vertical slit-like terminal glanular meatus. The mean hospital stay was 4.6 days. Background/purpose: One stage urethroplasty with Conclusion: TIP urethroplasty with neourethral coverage parameatal foreskin flap (OUPF) applicable to all types of using a vascularized pedicle of dartos flap is versatile and hypospadias was first described by Tomohiko Koyanagi, simple operation in management of different types of however high complication rates were reported . Purpose: hypospadias. It has a good functional and cosmetic To analyze the results of a modification of the Koyanagi outcome. technique as a one-stage repair of proximal hypospadias. Patients and method: During the period of (March 2008 – March 2009), 30 patients underwent treatment of proximal Two Sites Vertical Meatoplasty in The Management of hypospadias using the modified Koyanagi technique. Patient Urethral Meatal Stenosis (A New Method). age at the time of surgery ranged from 6 to 24 months. In Alawadi Sayed, Ahmed Dawood all cases, the urethral opening was at or just proximal to the Aseer, Abha, KSA. penoscrotal junction. Follow up ranged from 3 months to 1 year. Background/purpose: Boys are frequently referred for Results: Primary success occurred in 27 cases (90%) with urethral meatal stenosie ( 5% of new outpatient cases). accepted cosmetic appearance. Complications occurred in 3 Meatal stenosis presents with straining, hesitancy and cases (10%). Urethrocutaneous fistula occurred in 2 cases intermittency. It may be acquired or congenital. Congenital (7%). Meatal recession occurred in 1 case (3%). There was is not common, it occurs in neonates with coronal and no incidence of meatal stenosis, urethral stricture, residual subcoronal hypospadias, otherwise is almost always chordee or complete flap necrosis. acquired after neonatal circumcision, repeated ! Conclusion The modified technique permits one-stage instrumentation or diaper amoniacal urethritis. Also repair of proximal hypospadias with low complication rates. recurrence after primary repair and in some cases of post hypospadias repair. Meatal stenosis is apparent after toilet training . Versatility of Tubularized Incised Plate Urethroplasty in Patients and Methods: A total of 120 patients were The Management of Different Types of Hypospadias: 5- included in this study, 30 patients were recurrent after Year Experience. meatotomy, 16 patients were post hypospadias repair Gamal Al-Saied , Ahmed Gamal and Diaa Mahdy ; stenosis , 74 new cases. The age ranged from 5 months to Al-Azhar Egypt ;Taif, KSA 12 years. I present a new method with simple technique . especially for recurrent cases and post hypospadias repair Background/purpose: The outcomes of urethroplasty in stenosis. The surgical technique : First site meatoplasty at the management of different types of hypospadias have the ventral web in the midline. A triangular part of the web continued to improve since the introduction of the (base up) is removed at 6 O\'clock. Second site meatoplasty tubularized incised plate (TIP) urethroplasty (Snodgrass is made at the dorsal end of urethra on straight line against method). The aim of this study was to evaluate the feasibility the first site at 12 O\'clock where vertical incision in urethra and applicability of TIP urethroplasty in the management of 2-3 mm in length from inside urethra till edge of meatus different types of hypospadias. which is sutured transversally, this make a wide meatus. Patients and Methods: This work was carried out at Al- Results : All 120 patients subjected to vertical two sites Azhar University Hospital, Cairo, Egypt in the period from meatoplasty voided spontaeously except 7 patients. January 2002 to December 2002 and King Abdul Aziz Spraying in 16 patients. Mild dysuria in13 patients. Follow Specialist Hospital, Taif, Saudi Arabia; in the period from up for 12 months showed good results without recurrence . January 2003 to January 2007 by the same authors. The Conclusion : This new technique is better alternative

Annals of Pediatric Surgery 62

EPSA 25th congress abstracts procedure especially in recurrent and post hypospadias group A, and 97% for group B). Complications consisted of repair meatal stenosis. No post operative diltation needed urethrocutaneous fistula in 3 boys (two in group A and one without recurrence. in group B), dehiscence in one boy (related to group A). Conclusion: Subcuticular uninterrupted suturing technique for hypospadias repair using TIP urethroplasty seems to TIP for Distal Penile Hypospadias: Do We Still Leave a hold a lower complication rate, when compared to the full Catheter? thickness uninterrupted suturing technique. Mohammed Youssef Alexandria, Egypt. Concealed Penis. Khalid Ahmed Ismail Background/purpose: In TIP repair for cases of distal Department of surgery, Tanta University, Egypt. penile hypospadias we use the urethral plate and routinely leave a catheter for 5-7 days .Herein, we report our Background/purpose: A concealed penis is defined as a experience with TIP repair for Distal penile hypospadias phallus of normal size buried in prepubic tissue (buried without leaving a catheter. penis), enclosed in scrotal tissue (Webbed penis), or Patients and Methods: In the period from 2006 to 2009, 36 trapped by Scar tissue after penile surgery. children with distal penile Hypospadias were operated upon (trapped penis). The aim of this study was to detect the in one tertiary centre in Alexandria and by one surgeon. The etiological factors, clinical presentation and outcome of age ranges from 1 year to 6 years. In all children, TIP surgical techniques to correct the anomaly of concealed procedure was used. The patients were divided into two penis. groups 18 patients each: Group (A): Urethral catheter was Patients and methods: From January 2003 to January left for a range of 5-7 days. Group (B) :No urethral catheter 2008, 20 patients with concealed penis were operated upon was left . Their ages ranged from 3 months to 15 years ( mean age Results: follow up ranges from 6 months to 4 years. We was 6 years and 8 months ) . there were 10 patients ( 50%) encountered 2 urethrocutaneous fistulas in group A and with buried penis , 2 of them had been circumcised prior to one fistula in group B whish were all repaired successfully. diagnosis , 7 patients ( 35 % ) with trapped penis , and all No urethral stricture no residual penile curvature. were complication of circumcision and 3 patients ( 15 % ) Conclusion: post operative catheterization after TIP repair had webbed penis. The common surgical option in most of in DPH is not mandatory. our cases includes complete penile . degloving , excising the scarring due to previous surgery , fixing the penile skin Hypospadias Repair: The Effects of Suturing Technique at the penopubic and penoscrotal angles and reconstructing on The Outcome of Tabularized Incised Plate (TIP) the penile skin . Urethroplasty. Results: Sixteen patients ( 80% ) showed an excellent Ahmed M Abdel Monem Ali Gafar, result as regards to the postoperative length cosmetic Sohag, Egypt. appearance of the penis and required no additional surgery . Residual redundant penile skin was present in 4 patients ( Background/purpose: The tubularized incised plate (TIP) 20% ) resulting in a bulky penis which was not acceptable urethroplasty or Snodgrass procedure has gained worldwide by them . Excision of the excess skin was done after 6 acceptance for distal hypospadias repair due to its low months. Five patients (25 %) presented with mild lymphatic complication rate, good cosmetic result, and technical stasis of distal shaft that spontaneously subsided within a simplicity. We compared the results of hypospadias repair few months, there was superficial infection in 2 cases (10%) using two modifications of the tabularized incised plate (TIP) responded to conservative treatment. All patients were urethroplasty; namely full thickness, uninterrupted sutures followed up for a mean period 28 months ( 1-5 years). and subcuticular uninterrupted sutures. The comparison Conclusion: concealed penis has a varied etiology and included the impact of that surgical modification on the requires a flexible surgical approach. Repair of concealed complication rate and outcome of the procedure. penis is a simple and effective outpatient procedure which Patients and methods: Fifty infants and children with alleviates the initial complaint and provides good cosmetic primary distal hypospadias were treated with the TIP and functional results with greater satisfaction to the procedure “Snodgrass technique”. In 23 patients patients and their parents. uninterrupted full thickness sutures were used (group A) and in the remaining 27 (group B), the sutures were subcuticular. All operations were performed by one surgeon Urethral Plate Characters and Its Impact on The and operative magnification, tissue handling, urethral Outcome of Tubularized Incised Plate Urethroplasty. stenting, penile bandage, and the size and type of suture Ahmed Gamal Eldin, M. Badr Eldin, Abdelgawad materials were the same for both groups. Patients were Menoufia, Egypt seen at follow-up visits by the end of the first, third, and sixth month postoperatively. The rate and type of complications of Since the emergence of TIP repair in 1994, it has been the each suturing technique were compared. place for extensive research and publications. The Results: Age ranged between 9 months and 7 years with a procedure is gaining much popularity and its indications are mean age of 25.3 months at time of repair. Mean follow up Progressively expanding.TIP urethroplasty can be used to was 4 months. Success rate was 92% for all cases (87% for repair proximal hypospadias in the absence of sever penile

63 Vol 6, No 1, October 2010

EPSA 25th congress abstracts. curvature, and If the incised urethral plate has a supple Conclusion: Variables for assessing the success of burn appearance (Snodgrass 2002) .TIP urethroplasty can wound therapy as need for surgery, wound infection rates, potentially be used for hypospadias redo. As previous eschar lysis success and mean hospital stay were not incision of the urethral plate is not considered a significantly different in both groups. Either CCA or VGE can contraindication, where the plate appears supple be used for reducing the overall need for surgery in deep- (Snodgrass 2002).TIP for distal hypospadias repair has a partial thickness burn wounds. VGE could be considered as low complication rate regardless of urethral plate first line therapy because of cost-effectiveness. configuration or width. Therefore, this procedure is potentially applicable in all cases of primary distal hypospadias (Snodgrass 2004).Urethral groove depth Extending Care for Patients With Cleft Lip and Palate appears to influence neourethral calibre. A shallow groove Through The Interdisciplinary Model: Emphazing The predisposes to a narrower neourethra and meatal stenosis Role of Maxillofacial Surgeon and Orthodontist (Part I). subsequently. While narrow urethral plate was associated Marwa Abd El- Wahab El-Kassaby, Fady Hussein Fahim: with fistula (Holland & Smith 2000). We evaluated the Cairo, Egypt. outcome of tip repair based on the morphology of the urethral plate is characterized as: flat, bifid or deeply Collaboration and understanding between different grooved specialties is mandatory in order to achieve optimal results Conclusion: A significantly higher fistula rate and narrow for patients with cleft lip and palate. Therefore; team work neo urethra in association with urethral plate width less than must be established through the interdisciplinary care model 8mm. Urethral plate character significantly affects the neo which is the currently the model of care for patients with urethral calibre however the effect on the fistula rate in is clefts and other facial anomalies according to the statistically insignificant .Redo cases has higher recommendation of the American Cleft Palate Craniofacial complication rate. The width and the character of the Association in November 2007. In this frame; the urethral plate doesn't significantly affect the outcome of tip collaboration of the Orthodontist and Maxillofacial surgeon is repair. of prime importance in teams caring for this category of patients. Therefore, the role of the Orthodontist and Pediatric Plastic Surgery Maxillofacial surgeon will be explained in different aspects in management of patients with clefts. The three main phases Triticium Vulgare to Collagennase: Comparison of of cooperation are first; after birth whenever naso- alveolar Wound Healing in Partial Thickness Burns. molding is required. Going through the second stage which Cisem Akyildiz, Sibel Tiryaki, Belce Candan, Ahmet Celik, is childhood where alveolar cleft bone grafting as well as Geylani Ozok, growth modification are needed and ending by the final Ege, Izmir,Turkey. stage which is during adolescence where late consequences of poor management during the two early Background/purpose: The primary goal to start the wound phases are manifested. In this phase every patient presents healing process in burn patients is removal of eschar. a set of problems that needs individualized plans such as Collagenase is an exogenous enzyme used for debridement missed alveolar cleft grafting, extensive malocclusions and and Triticum vulgare (wheat plant) extract stimulates the severe forms of maxillary deficiency. The main objective of growth of human endothelial cells. The aim of this study is this presentation is to high lighten the role of orthodontist comparing the effectiveness of Triticum Vulgare Extract and maxillofacial surgeon in interdisciplinary cleft teams. (VGE) and Collagenase Clostridiopeptidase A (CCA) on burn wound healing. Patients and Methods: Hospital records of one hundred Circular Excision and Purse String Closure of ninety two deep-partial thickness burn patients between Hemangioma: A Technique With Major Advantages years 2001-2007 were reviewed retrospectively. As the Over Lenticular Excision. comparison of the effects of VGE and CCA was the aim of Mohamed R Abdallah, Richard Azizkhan, Mansour the study, the patients who only had surgical treatment for Kabbash, Mohamed Elammary, Nabil Abo Eldahab, eschar were excluded from the study. For determining the Cincinnati, USA and Sohag, Egypt. success of therapy; length of hospital stay, complete removal of eschar duration, wound infection, cost and need Background/purpose: Hemangioma is a common tumor of for surgical excision were considered. infancy and its surgical excision may be a challenge for the Results: Sixty-seven patients were treated with VGE and pediatric surgeon. The traditional technique for surgical 126 were treated with CCA. Twenty three (35%) of the excision is lenticular excision and linear closure. However in patients with VGE and 42 (33%) of the patients with CCA some situation this may result in a long scar that can be had undergone excision. Treatment modality was changed cosmetically or functionally inappropriate and may have in 29 (44%) patients with VGE and in 63 (50%) patients with limitations in large defects. This study compares between CCA for any suspicion of infection. Mean hospital stay and the outcomes of lenticular excision and linear closure versus duration for removal of eschar were not significantly different circular excision and purse string closure for the treatment in both groups. The cost of therapy was found less in group of cutaneous hemangioma. VGE. Patients and methods: Sixty eight patients were included (47 in the retrospective and 21 in the prospective parts of

Annals of Pediatric Surgery 64

EPSA 25th congress abstracts the study). Thirty nine patients were treated by circular extensive aganglionosis) died before definitive surgery. The excision and purse string closure (Group 1), twenty seven remaining 22 patients were treated using straight endorectal were treated by lenticular excision and linear closure (group pull-through technique. An ileostomy was done initially in 19 2) and two patients were treated using a combined of the 22 patients, while one stage straight endorectal pull- technique (group3). Comparison included age at operation, through was done in 3. The main postoperative complication sex, phase and location of the lesion, indication for excision, included anastomotic leakage (n=2), recurrent enterocolitis lesion and scar measurements (length, width, width/length (n=6) , significant perianal excoriation (n=16), anal stricture ration) and parents' satisfaction with the results in each (n=2), and adhesive intestinal obstruction(n=1) . The follow group. up periods ranged from 9 month to 9 year. Sixteen of the Results: Lesion to scar length decreased by 46.9% in group the 22 patients developed bowel control few weeks to few 1, 38% in group 2 and 44% in group 3, while lesion to scar months after definitive surgery, while 6 still suffering from width decreased by 55% in group 1, 80% in group 2 and variable degrees of soiling (n=4) or frank anorectal 78.5% in group 3. Lesion and scar width length ration incontinence (n=2) decreased by 10.3% in group 1, 83.9% in group 2 and Conclusion The management of total colonic aganglionosis 90.9% in group 3. continued to be challenging. Considerable frequency of Conclusion: Circular excision and purse string closure is early complications should be expected and proper particularly suited for circular defects such as management should be always planned. The long term hemangiomas. It converts a circular lesion to a circular outcome after straight endorectal pull-through is defect that can be partially or completely closed using satisfactory . purse string closure by advancing the skin from the entire periphery of the wound and has better cosmetic results. Prospective Long Term Functional and Cosmetic Assessment of ASARP Vs. PASRP in Treatment of Pediatric Colorectal Surgery Intermediate Anorectal Anmalies in Girls. Sherif M K Shehata Total Colonic Aganglionosis: Outcome at Both Short Tanta, Egypt. and Long Term Follow Up. Amel Hashish, Hisham Fayad, Ashraf El-Attar A, Mohamed Background/Purpose: Vestibular fistula together with F Metwally, Abd El Motelb Effat, Essam Elhalaby, recto-vestibular constitutes the most common anorectal Tanta, Egypt. anomalies in females. The most widely described techniques for functional treatment were posterior sagittal Background/Purpose: The management of total colonic anorectoplasty (PSARP) and anterior sagittal anorectoplasty aganglionosis is a challenging problem. Various techniques (ASARP) techniques. In this study, prospective comparison were described with variable morbidity and mortality rates. of the functional and cosmetic results of both techniques The aim of this study was to review the short as well as the was performed along one decade. long-term results of straight endorectal pull-through Patients and Methods: In the period between August 1999 technique in the management of this group of patients and July 2008, thirty eight female infants with intermediate Patients and Methods: The medical records of 24 patients anorectal anomalies were randomly allocated to either with total colonic aganglionosis with variable lengths of group A that treated by the ASARP technique and group B small bowel involvement were retrospectively reviewed. that treated by PSARP technique in the pediatric surgery These patients were treated at Tanta University Hospital unit, Tanta University Hospital, Tanta, Egypt and other and affiliated hospitals from 1998 to 2009. Each patient was affiliated hospitals. Each group contains 10 cases of evaluated as regard to sex, age, symptoms and signs, rectovestibular fistula and 9 cases of vestibular anus. In all associated congenital anomalies, radiological investigations, cases, the procedure was performed without protective operative technique, any redo surgery, and outcome. Follow colostomy. 14 girls from each group reached the age of 30 up data were collected with particular emphasis on the months for functional assessment by both Templeton and growth development, enterocolitis, bowel function, and Holschneider scores. 18 cases passed the 55 months of late anorectal continence follow up for functional evaluation, but two –one from each Results: Of the 24 patients, 15 were males and 9 were group- lost. Median follow-up was 40.5 months (range 11- females. Four patients had a family history of Hirschsprung's 75 months). Both groups were compared for operative and disease. Eighteen patients (75%) presented in the neonatal postoperative results and the appropriate statistical test was period, twelve (50%) had full-blown picture of distal used whether T Student test or Fisher exact test where p intestinal obstruction. Six patients (25%) presented after the value at ≤ 0.05 was considered significant. first month of life although a clear history of bowel Results: The age of diagnosis (23 d in group A νs 21 d in dysfunction can be traced since birth. The length of group B) and operative age (70 d νs 70 d) were comparable. aganglionic segments were confined to the colon in 16 The same holds true for operative time without statistical patients ( 66.7 %) , while variable lengths of the small bowel significance. Operative vaginal wall opening reported 3 & 6 were involved in 8 (33.3%) patients. One patient had total times in both groups with p of 0.13 while post operative intestinal aganglionosis; the transition zone was located at wound infection reported 2 and 5 times respectively with p proximal jejunum in another one. Two patients (with of 0.11. The cosmetic results of the perineum were assessed at 6 months post operatively in all cases with

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EPSA 25th congress abstracts. arbitrary score ranged from 3 to 0. In ASARP group, higher of the rectal muscle strip ranged from 2 to 8 cm (mean: score of parental satisfaction with a median of 3 was 4.1cm). Distal end of the strips revealed aganglionosis in all recorded as compared to 2 in PSARP group with p value of cases but, normal ganglia were seen at the proximal end of 0.12. Only one case of posterior anal migration reported in the strip only in 13 (65 %) cases. Two of the remaining PSARP group. The first functional assessment was carried patients were treated with definitive surgery. Others was out for 14 cases from each group at median age of 33.5 underwent clinical observation. Average follow-up was 20 months νs 34 months where median of Templeton score months. Laxative treatment was only required in 9 patients was 4 νs 3.75 and Holschneider score was 11 νs 11 where during 3 months. Remaining patients are symptom-free. p were 0.13 and 0.39 respectively. For the 16 cases (8 from Conclusion: Myectomy is an effective and minimal invasive each group) late functional assessment was done for who treatment for SSHD. If the patient has anal hypertony, passed 55 months of age. Templeton score was 4 νs 4 with sfinctermyectomy can be performed. If the proximal end of p value of 0.17 despite the observation of higher score in the strip is aganglionic, definitive surgery can be cancelled ASARP group. The late Holschneider score was 12 νs 11 until resisted clinical findings. with p of 0.16. Conclusions: This prospective randomized study with the Adult Hirschsprung's Disease: What is The Best late functional assessment shows that ASARP is an optimal Management? technique for treatment of intermediate ARM in girls. Khalid A. Ismail, Mohamed H. Mazhar Ashour, Akram M. Excellent continence was achieved in all assessable cases. Elbatarny, Osama. H. El Khadrawy,Ali M. Turky, Perineal cosmetic results were superior to PSARP. Despite Mohammed F. Metwally, Hamdy Abdel Hady & Amal A. the observations that functional results at medium and late Hashish, follow up periods give higher scores in ASARP group as Tanta, Egypt. compared to PSARP group, no statistical significance could be reached. Bigger group of patients and longer follow up Background/Purpose: Although rare, adult Hirschsprung's are needed to validate the current results disease should be suspected in patients who have lifelong constipation. The purpose of this study was to find out the Myectomy and Sphincteromyectomy For Short-Segment best management strategy for Hirschsprung's disease (HD) Hirschsprung’s Disease. at this specific age group. Hasan Dogruyol, Kiristioglu I, Adıguzel U, Patients and Methods: This study included 15 adult Bursa, Turkey. patients (9 males and 6 females) with proven tissue diagnosis of HD. The diagnosis was confirmed by barium Myectomy/sphincteromyectomy (M/S) could be an useful enema and full-thickness rectal biopsy in all patients. Seven obtion of the surgical treatment for short-segment patients had anorectal manometry. These patients were Hirschsprung’s disease (SSHD). This study analyzed the treated between January 1995 and December 2008 at outcome of M/S in SSHD for demographic, clinical findings, Tanta University Hospital and affiliated hospitals. The results and follow-up after M/S. From 1997 to 2009, 20 clinical data, diagnostic tools, details of surgical children were treated with M/S for SSHD. They were management and outcome were analyzed. retrospectively screened on the basis of clinical history, Results: The patients' age ranged from 16-48 years (mean physical examination, preoperative barium enema (BE) 28±3 years). All patients presented with chronic constipation study, anorectal-manometry and rectal biopsy findings and requiring enemas, cathartics and multiple hospital follow-up. The study group included 13 boys and 7 girls with admissions for management. The aganglionic segments a mean age of 36 months (1 month to 10 years). The most were confined to the rectum in 6 patients and included the common symptom was chronic constipation without soiling distal part of sigmoid in nine. The definitive procedures (75 %). Others included abdominal distension with vomiting were: Primary Soave endorectal pull through (ERPT) (4 (20 %) and enterocolitis (5%). Delayed meconium passage patients), two-stage ERPT (6 patients), primary transanal was found in 8 (47 %) patients. ERPT (3 patients) and Duhamel retro rectal pull through (2 Physical examination findings; rectal and/or abdominal patients) after failed myectomy. Anastomotic leak occurred fecaloma in 9 (45%) abdominal distension in 4 (20%), in 2 patients (13.33%), anal stricture in one patient (6.66%), passage of gas and feces after rectal examination in 3 (15 cuff abscess in one patient (6.66%) and two patients %) patients. The remaining had normal physical (13.33%) suffered from partial incontinence improved by examination. Preoperative BE showed rectal dilatation in 19 conservative treatment. cases, while narrow segment was only detected in 10 Conclusion: Although rare, adult Hirschsprung's disease patients (53 %) with low cone position. Barium retention, must always be considered whenever a patient complains of more than 24 hours, was found in 17(85%) patients. severe chronic constipation. One stage ERPT either An anorectal manometry revealed lack of recto-anal conventional trans-abdominal or trans-anal approach is inhibitory reflex in 15 (89%) patients. Anal hypertony was feasible after prolonged bowel preparation but a two stage only found in 3 (17%) patients. The diagnosis of SSHD was approach is more technically easier and safer. proven histopathologically in all patients (preoperative rectal biopsy in 10 (50 %) patients, others perioperative frozen section biopsy). A simple myectomy was performed in all Lower Urinary Tract Dysfunction After Pull-Through patients except 3 cases who had anal hypertony. In these Procedure for Treatment of Children With cases sphincterotomy was added the myectomy. The length Hirschsprung's Disease.

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Mohamed A. Abdel Aziz, Sayed H. Abdalla, Ahmed Abdel We devised a modified technique of gasless laparoscopy in Ghafar and Samir H Gouda children at Al-Azhar University Hospital based on the Al-Azhar,Cairo, Egypt. concept of mechanical retraction of the abdominal wall for Gasless Laparoscopic Assisted Duhamell`s Procedure for Background/Purpose: Apart from the sequelae of (HD) in Children. Their mean age was 3 years (range=1-5) Hirschsprung's disease(HD) regarding the defecation Under direct vision and digital control an intraperitoneal abnormalities, some of these patients also suffer from retractor, which is attached to the arms of Abdominal Liver voiding dysfunction. retractor, was introduced into the abdominal cavity for Patients and method:The aim of this work is to assess and raising the abdominal wall. Then, a 5-mm telescope is define the effects of different 'pull through' procedures in 45 introduced through the same incision and the laparoscopic patients with HD on lower urinary tract function by means of procedure was started as usual. We used simple valveless urodynamic studies performed before and after surgery in trocars and some conventional instruments (Scissors, the form of cystometric bladder capacity (C.B.C),bladder Needle Holders, Alles Forceps). An unlimited suction can compliance, unstable detrusor contraction and residual be obtained without a loss of exposure. volume . Results: No technique-related complications occurred. The Results: All the urodynamic findings are recorded before exposure was excellent as gasless laparoscopy creates a and after Soave endo rectal pull through (15 patients), sufficient abdominal space. All cases were completed by Duhamel pull-through (15 patients),, and Trans anal pull- gasless laparoscopy without conversion. No intra-operative through (15 patients),. complications. The mean operative time was 65 minutes. Conclusions: In Hirschsprung's disease, neurovesical Conclusion: Gasless laparoscopic assisted Duhamell`s dysfunction may exist preoperatively and so the incidence of procedure for (HD) in children is a feasible, safe and postoperative changes in neurovesical function may appear effective alternative to the pneumoperitoneum technique. high. Children who present with urinary problems after The technique will be described in detail. surgery should be assessed urodynamically.

Transanal Endorectal Pull-through for Hirschsprung's Acute and Fatal Hyponatremia After Laparoscopic Disease During The First Month of Life. Anorectoplasty. Kamal Abd El-Elah Ahmed Elham Fares Mansoura, Egypt. Cairo, Egypt. Background/Purpose: Hirschsprung's disease (HD) is a Hyponatremia is being increasingly recognized as a common cause of bowel obstruction in the newborn period. complication of intra and post operative hypotonic fluid One-stage surgery for HD is well established and the results administration. Reported is a male patient with high are comparable or better than multistage surgery. The aim imperforate anus who had laparoscopic anorectoplasty. In of this study was to test for the feasibility and safety of the early post operative period he was fully conscious. He transanal endorectal pull-through (TEPT) for management collapsed 20 hours after the end of the operation and of HD during the neonatal period. developed sudden respiratory arrest. He was intubated Patients and Methods: twenty eight neonates having HD resuscitated. In the Intensive Care Unit course was were treated with TEPT at pediatric surgery unit, Mansoura complicated by recurrent seizures. His serum sodium University Children's Hospital (MUCH) during the period concentration was 120 mmol/L. He finally died after 48 from May 2007 to Jun 2009. 6 cases were in need for hours of surgery. The pathogenesis of hyponatremia and its concomitant laparotomy due to long segment disease. complication and management in such cases is discussed. Endorectal mucosectomy was started one cm. above dentate line and continued till the peritoneal reflection. The Gasless Laparoscopic Assisted Duhamell`s Procedure affected bowel was resected and colo-anal anastomosis for Hirschsprung`s Disease in Children. was performed with 4/0 absorbable sutures. Rafik Shalaby, Maged Ismael, Mohamad Abdel-Razik and Results: The mean operative time was 90±18 minutes. Abdel-Aziz Yehya . Blood transfusion was not needed. Oral feeding started 24- Al-Azhar, Cairo, Egypt. 48 hours postoperatively and the mean hospital stay was 3- 5 days. The commonest postoperative complication was Background/Purpose: Laparoscopy has gained wide perianal excoriations (64.3%), anastomotic leak occurred in acceptance as a treatment modality in a variety of colonic one case. 2 cases were in need for repeated dilatations and rectal disorders. Currently, most laparoscopic while 4 cases presented with postoperative enterocolitis procedures are performed using a carbon dioxide (CO2) (EC). pneumoperitoneum, which can lead to cardiopulmonary Conclusion: TEPT during the neonatal period is easy, loading and subsequent complications. The objective of this bloodless, without visible scar and with short intraoperative study was to determine the feasibility of gasless time and postoperative hospital stay. laparoscopic assisted Duhamell`s Procedure for Hirschsprung`s Disease in Children. Patients and Methods: Five males and 6 females with Hirschsprung`s disease (HD) were the material of this study.

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Pediatric Laparoscopy high scrotal , 9 cases : mid scrotal, and 7 cases low scrotal position, non atrophied. Color Doppler study showed Laparoscopic Gastric Sleeve in Children and adequate vascularity in all 23 cases. Adolescents. Conclusion: The technique of testicular traction for the Ayed Al Qahtani abdominal Testis is valid option in the treatment of Riyadh, KSA abdominal testis, can be applied simultaneously for the Background/purpose: The medical community is bilateral testis, and could provide an alternative for the struggling to develop an effective strategy for the treatment Fowler Stephens approach in the management of the of the growing epidemic of obesity in children and abdominal testis. adolescent . Bariatric surgery has gained increasing Laparoscopic Rectopexy for Persistent Complete Rectal acceptance in adolescents , however the ideal procedure is Prolapse on Pathophysiologic Basis. not yet determined. The aim of this study is to evaluate the Maged Ismail, Rafik Shalaby, Khaled Gabr, Abdel-Monaem safety and efficacy of laparoscopic sleeve gastrectomy Shams, Samir Gouda, Abdel-Aziz Yehya. (LSG) in children and adolescents. Al-Azhar, Egypt. Patients and Methods: We conducted a retrospective review of all children and adolescents who underwent LSG Background/purpose: Laparoscopic approach promises to Between February 2006 and January 2009 in our institution. become the gold standard for the management of complete We assessed surgical results, complications, excess weight persistent rectal prolapse (CPRP) in children. We present loss (EWL) and resolution of co-morbid conditions. our experience in the laparoscopic treatment of complete Results: fifty nine children and adolescents underwent LSG rectal prolapse in children on pathophysiological basis. (57% females). Mean age was 17 years (Range: 8 to 21 Patients and Methods: Forty patients presented with years). The median preoperative BMI was 51.1 kg/m2 (CPRP) have been operated upon laparoscopically at Al- (range, 35.5-85) and the mean follow up was 1 year Azhar University Hospitals. They were subjected to clinical (3months - 3 year) . EWL at 6 months was 64 % and 78% at examination, laboratory investigations, pre and 12 months. Preoperative co-morbidites were dyslipidemia postoperative EMG activities for anal sphincter and pelvic 43%, type 2 diabetes 5%, insulin resistance 50% arterial floor muscles. The pathophysiologic changes for each case hypertension 3.3 %, sleep apnea 6.7%. Among the 59 was identified and dealt with laparoscopically (laparoscopic cases, 5 had Prader Willi syndrome. Comorbidities resolved suture rectopexy, laparoscopic mesh rectopexy, or improved in 95% of cases. Complications included wound laparoscopic resection rectopexy and laparoscopic infection in 2 cases, and persistent gastroesopheageal levatorplasty) reflux in in 3. No leak or mortality was observed., All cases Results: Among the 40 children with (CPRP), 22 were continue their growth without malnutrition or metabolic males and 18 females. Their median age was 9 years derangements . (range 4-14). All cases (n=40) showed a redundant Conclusion: LSG is safe and effective in children and rectosigmoid junction. Additional laxity of the pelvic floor adolescents with low complication rate. was present in 32, recto-anal intussusception in 27. All procedures were completed laparoscopically. The median duration of surgery ranged from 60 to 120 according to the Medium Term Results for Laparoscopic Traction for The procedure. Median postoperative hospitalization was 3 days Abdominal Testis. (range 2-4). EMG studies showed statistically significant Sameh Shehata improvement during rest, minimal volition and squeezing in Alexandria, Egypt. all cases except those children with neuropathic lesions. Significant improvement of the continence score was Background/Purpose: To present the medium term results achieved in all cases. The only complications were post- for the laparoscopic traction for the abdominal testis. operative constipation and external colonic fistula which was Patients and methods: Cases with impalpable testis and controlled conservatively. There were no recurrences at 36 proved to have intra abdominal testis on laparoscopy were months follow-up. selected for testicular traction. Testicular traction was Conclusion: Laparoscopic management of (CPRP) on performed by passing traction stitch 2 cm above and medial pathophysiological basis is safe, effective, and is associated to the contralateral anterior superior iliac spine – through the with improved functional outcome. It saved the patient lower pole of the testis and back through the same point of multiple operations. entry and tied over a strip of gauze. A second laparoscopy is performed after 2 weeks to locate the testis intrascrotally. Follow up after 6 months for testis size and position and by Single Incision Laparoscopic Surgery (SILS): color Doppler study. Preliminary Single Center Experience. Results: twenty five testis were operated upon, 23 cases Sibel Tiryaki, Orkan Ergün, Ahmet Çelik, unilateral and one case bilateral. Age ranged between 1-5 Ege, Turkey. years with a mean of 2.3 years .follow up ranged between 6-18 months. Four testicles slipped traction , 2 in early Background/purpose: Single incision laparoscopic surgery cases ( converted to Fowler –Stephens) and one bilateral ( (SILS) is the newest aspect of minimally invasive surgery. completed traction successfully). Scrotal position : 7 cases : There have been recent reports that SILS is feasible also for children. In this paper, we would like to share our

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preliminary experience to establish the feasibility and tidal volume, O2 saturation, arterial blood gases (pH, PaCO2, effectiveness of SILS in children. PaO2, HCO3), hematocrit and intra-abdominal pressures. Patients and methods: A retrospective review of the Parameters were recorded at five moments: before CO2 operative database for patients operated using SILS at Ege insufflation, 15, 45, 60 minutes after insufflation in reverse University Department of Pediatric Surgery from March Trandelenburg position and 5 minutes after CO2 exsufflation 2009 to September 2009 was performed. Data regarding the in the supine position. operative performance were collected. Results: Ten patients were allocated in each groups. No Results: Our current experience with SILS consists of 25 postoperative complication related to the sickle cell disease patients, a small group with a relatively large spectrum of was observed and the post-operative hospital stay in two procedures. These included cholecystectomy (3), groups was similar. After insufflation, heart rate values were appendectomy (10), unroofing for ovarian cysts (5), similar in group1 and 2 were 95.1±12.8 and 94.2±18.77, unroofing for splenic cyst (2), gonadectomy (1), detorsion respectively. Mean arterial pressure (93.2±13.99), ETCO2 and ooferectomy (2) for ovarian torsion, splenectomy (1), (30.3±5.31) and regarding all other parameters, before and varicocelectomy (1). The mean operative time was 43 after CO2 insufflation and after CO2 exsufflation, there were minutes (range: 10-200 min). There were no conversions to insignificant changes in each group and between the two standard laparoscopic or open techniques. Only one wound groups. Intra-abdominal pressure changes have no effect on infection occurred after one appendectomy. There were no the hemodynamic parameters. periumbilical subcutaneous hematomas, hernias or any Conclusion: Laparoscopic cholecystectomy in children with other postoperative complications. Mean postoperative sickle cell disease is feasible and as safe as in NSCD hospital stay was 2.05 days (1-5 days). A circum-umbilical patients with good pre-operative management. skin incision from 3 to 9 o’clock position either from the superior or inferior aspect of umbilicus (determined by surgeon with respect to the main operative site) is used, and Laparoscopic Management of Chronic (Atypical) the fascia and peritoneum is cut with vertical incision Intestinal Malrotation. through “linea alba” which also enables removal of the Maged Ismail, Amen Abokifa, Rafik Shalaby, Abdel-Aziz organ without the need to enlarge or perform another Yehya, incision. SILS port (Covidien®) is placed through the Al–Azhar, Cairo, Egypt. incision to host the trocars, and self angulating instruments are used. Background/purpose: Laparoscopic procedure for Conclusion: To our experience, we think with the diagnosis and repair of malrotation has many advantages modifications of the technological devices and an over conventional surgical techniques, However, there have experienced laparoscopic surgeon, SILS can easily be been a number of small series and case reports describing performed also in children in every pediatric surgical the use of laparoscopy to diagnose and correct malrotation. procedure that can be performed with conventional Therefore, we present our experience with laparoscopic laparoscopic techniques. Problems like clashing of the management of atypical cases with chronic intestinal devices due to their proximity or loss of triangulation during malrotation. surgery can be solved with the surgeon’s experience in a Patients and Methods: Thirty children aged from 3 months short period of time. to 14 years were the materials of this study. They were 18 males and 12 females. They presented with recurrent attacks of acute abdominal pain and bilious vomiting. Wrong Evaluation of Effect of Pneumoperitoneum on diagnosis of familial Mediterranean fever was raised in most Hemodynamic Parameters During Laparoscopic of cases. The procedure was performed using three trocars Cholecystectomies in Children: A Prospective of 5 mm diameter placed at the supraumbilical ring and the Comparative Study With Sickle Cell Disease. right and left lower quadrants. A 5-mm 30 degree telescope Murat Alkan, Dilek Özcengiz, Serdar H İskit, Cemal was used. Parlakgümüş, Yasemin Güneş, Recep Tuncer, Ünal Results: All procedures were completed laparoscopically Zorludemir, Erbuğ Keskin, without conversion. Laparoscopic exploration revealed Adana, Turkey. chronic intestinal malrotation with several new unreported diagnostic laparoscopic data. The mean operative time was Purpose: to evaluate the difference of hemodynamic 70 minutes (range: 45-90). All patients were able to resume parameters during laparoscopic cholecystectomy in children oral intake on the first postoperative day. The study also will with or without sickle cell disease. present the different laparoscopic procedures for solving the Patients and Methods: Children with asymptomatic multiple pathologies present. Conclusion: Laparoscopy is cholelithiasis, recruited for elective laparoscopic helpful for the diagnosis and treatment of difficult cases cholecystectomy were allocated into two groups: children presenting with chronic or recurrent attacks of acute without sickle cell disease (group 1), and children with sickle abdominal pain in children. The technique will be described cell disease (group 2). All the patients with sickle cell in detail. disease had preoperative hematological preparation for the surgical procedure. Study parameters included: heart rate Laparoscopic Assisted Transumbilical Approach in per minute, mean blood pressure, peak inspiration pressure, Neonates and Infants. end-tidal carbondioxide concentration (PETCO2), expiratory Murat Alkan, Serdar H İskit, Gökhan Güler, Cemal

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Parlakgümüş, Recep Tuncer, Ünal Zorludemir, Erbuğ children. It resulted in reduction of operative time and Keskin excellent cosmetic results. Adana, Turkey. Minimally Invasive Surgery for Congenital Thymic Cysts Purpose: In this presentation, we aimed to share our in Children: a Report of 3 Cases. experience with transumblical laparoscopy assisted Nabil M. Dessouky approach (TULAP) to abdominal cystic lesions in children Cairo, Egypt. under one year of age. Patients and Methods: TULAP was the procedure of Background/purpose: Congenital thymic cysts are choice in all children with cystic abdominal mass under one considered extremely rare in children. They account for 3% year of age for the recent year in our unit. During the of all superior mediastinal masses. Approximately 150 operations after a semicircular infraumblical incision was cases of cervical thymic cysts have been reported in made, the abdomen was entered with a port. After literature usually as single case reports, 50% of them extend aspirating the liquid content the collapsed cyst was to the mediastinum. With review to the literature, no reports exteriorized through the port incision and remaining surgical have been documented to use the minimally invasive procedure was carried out extraperitoneally. approach for excision of such lesions in children. Results: There were 4 patients with 5 days – 9 months of Patients and Methods: Three children presented with age. Gonad spared cystectomy for 3 cases of ovarian cysts congenital thymic cysts were excised with video-assisted and resection and anastomosis for an ileal duplication cyst thoracoscopic approach. Their ages were 11 months, 2 and could be carried out with TULAP. 8 years. All of them were males. The cysts were on the Conclusion: Our initial results suggest that TULAP may be right-side in 2 patients. In two cases the cysts were cervico- a good alternative procedure with good cosmetic results and mediastinal . These were dissected thoracoscopically and technical simplicity in the management of intraabdominal then excision was completed through a small cystic lesions of neonates and infants. supraclavicular incision in the neck. In one case, the lesion was purely intra-thoracic with its total excision being achieved via thoracoscopy. The lesions were dissected Laparoscopic Hernia Repair in Infancy and Childhood; thoracoscopically from the great mediastinal vessels ( Evaluation of Different Techniques. superior vena cava and right atrium , left common carotid Rafik Shalaby, Maged Ismael, Khaled Gabr, Abdel Aziz artery…) with excision of the remaining part of the thymic Yehya, lobe . Al-Azhar, Cairo, Egypt. Results: Accidental intra-operative opening of the contralateral pleural space resulted in one case that Background/purpose: Laparoscopic hernia repair in necessitated the insertion of intercostal tube drainage. infancy and childhood is still debatable. There are many Histopathological examination of the cysts revealed fibrotic techniques available for laparoscopic hernia repair in wall with inflammatory cells and foci of cholesterine crystals children. The objective of this study is to evaluate the best surrounded by normal thymic tissues with Hassal’s technique for laparoscopic hernia repair in infancy and corpuscles. Follow-up of 6-18 months revealed no childhood. A randomized controlled study was carried out in recurrences. the Pediatric Surgery Unit of Al-Azhar University Hospitals, Conclusions: Thoracoscopy for thymic cyst can be used over two years period. safely to avoid scars of open surgery with rapid recovery of Patients and methods: One-hundred and fifty patients with the patients. It can assist the removal of cervical thymic congenital inguinal hernia were randomized into two groups cysts that extend into the mediastinum , thus eliminating the (n = 75) each group. Group A (n=75) was subjected to need for a second thoracotomy incision . intracorporeal insertion of purse-string suture using 2 needle holders. Group B (n=75) was subjected to laparoscopic hernia repair by Reverdin Needle for insertion of purse- Gasless Laparoscopic Cholecystectomy in Children. string suture. There were no significant differences in the Rafik Shalaby, Maged Ismael, Refaat Ibrahem and Abdel- age, sex, modes of presentation between the two groups. Aziz Yehya Inclusion criteria included; bilateral inguinal hernia, recurrent Al-Azhar, Cairo, Egypt. hernia, hernia in obese child, incarcerated hernia and hernia on one side with questionable other side. Exclusion criteria Background/purpose: Pneumoperitoneum as a necessary included; unilateral inguinal hernia, and hernia with step for laparoscopic procedures may be responsible for undescended testis. rare but specific complications and problems. Among them, Results: All cases were operated successfully without the most common is carbon dioxide retention, which conversion. There is significant statistical difference in the responds well to hyperventilation. The objective of this study operative time, recurrence rate and cosmetic results was to assess the feasibility of gasless laparoscopic between the two groups. While there were no significant cholecystectomy in children as an alternative method. statistical difference in the hospital stay, and post operative Patients and methods: We describe our early experience development of hydrocele. with gasless laparoscopic cholecystectomy in 8 children at Conclusion: Laparoscopic hernia repair by Reverdin Al-Azhar-University Hospitals. They were 5 females and 3 Needle is an effective line of hernia repair in infancy and males with a mean age of 8 years (range=4-12). Under

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EPSA 25th congress abstracts direct vision and digital control an intrapertoneal retractor is intra-operative complications were recorded. The mean introduced into the abdominal cavity. After raising the operative time was 45 minutes. The operative time was abdominal wall, 5-mm 30 degree scope was introduced relatively long in the first few cases, but decreased with the through the same access and the laparoscopic procedure is development of experience. It creates a sufficient abdominal started smoothly as in gaseous laparoscopy. We used space and good exposure. Furthermore, an unlimited simple valveless trocars and some conventional suction can be obtained without a loss of exposure. instruments. Conclusion: Compared to the traditional procedures with Results: The exposure was excellent and all cases were Co2 pneumoperitoneum, the results demonstrate potential completed by gasless laparoscopy without conversion. No advantages. The technique will be described in detail.

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