Annals of Pediatric Surgery, Vol 2, No 1, January 2006, PP 53-76

2005 EPSA/ PAPSA Abstracts

Abstracts Presented at the 21st Annual International Meeting of Egyptian Pediatric Surgical Association (EPSA) In Collaboration with Pan African Pediatric Surgical Association (PAPSA)

November 14-18, 2005, Alexandria, Egypt

Alimentetarty Tract intermediate (n= 28) ARM. All patients underwent PSARP without a colostomy within the first 4 weeks of life at two major institutions

and affiliated hospitals and private sector during a 5-year period Anorectal Malformations: Recent Advances Concerning the from October 2000 through September 2005. The exclusion criteria Normal and Abnormal Anatomy of the Anus and Rectum. included: prematurity, associated major congenital anomalies, bad Michael R. Davies general condition, persistent coloaca in females and unfavorable Red Cross Children’s Hospital, University of Cape Town, South circumstances. Preoperative imaging was performed to assess the Africa severity of ARM and associated anomalies. Following preoperative assessment and preparation, all undergone the standard PSARP Background: Most anorectal malformations are of the approach. The meconium was evacuated during operation. communicating type. The opening of a fistula onto an internal Preoperative bowel prep was carried out through the fistula in surface is best considered to be ectopic anal opening. females with rectovestibular fistula. All patients were evaluated as Aim: Traditional anatomical concepts need to be challenged. The regard to operative details, postoperative complications, and bowel anal canal, the terminal part of the hindgut, remains difficult to function on short and long-term follow up, which ranged from 2 to define. The intrinsic structures of the rectal wall stretch nearly to the 60 months. skin, the anal canal being that part of it held within the external Results: Laparotomy was required for only one male patient with sphincter. This implies that the anal canal is a modified part of the rectovesical fistula. Twenty of the 22 females had rectovestibular rectum. fistula. Intraoperative complications included; opening the posterior Proposals: Congenital malformations involving the anal canal are wall of the vagina (n=6), injury of the seminal vesicle (n=1). classified as Rectal where the upper canal and rectum are involved; Postoperative complications included: Wound infection in 9 Anal where the lower canal, external genital and cutaneous patients, one of them required colostomy and 2 required secondary structures are perianally involved. In rectal malformations if a fistula suture. Postoperative anal stenosis occurred in five patients is present it is called a terminal channel; in anal malformations a secondary to parental noncompliance with the postoperative dilation terminal tract. This distinction is based on the anatomy of the fistula. regimen. One patient had anesthetic complications and died after 5 The sheet like muscle of the pelvic floor has been arbitrarily divided days without being weaned from mechanical assisted ventilation. into seemingly different muscles. This is of no importance to the All survived patients passed stool within 24-48 hours after operation surgeon. In practice, what can be visualised in the living by imaging and took full feeding by 72 hours. The average hospital stay was 8 techniques provides more guidance and insight into the nature of days. Twenty-five patients defecate spontaneously, 10 require the problem addressed. occasionally oral medication or rectal stimulation or enemas, and

the remaining 2 are maintained on bowel program. Eight of the 10

female who are older than 3 years of age are continent, while only 5 Primary Repair of High and Intermediate Anorectal of the 8 male patients older than 3 years are continent with Malformation in the Neonatal Period infrequent soiling. Essam Elhalaby, Hesham Elsafoury, Amel Hashish Conclusions: 1. One-stage repair of intermediate and high ARM is Departments of Pediatric Surgery, University of Tanta & Ain Shams technically feasible both in male and female neonates; 2. The University, Egypt safety of this approach depends on adherence to strict inclusion

criteria; 3. The early postoperative complications are acceptable Background/Purpose: The standard treatment of high and and can be managed successfully; 4.The functional results is intermediate anorectal malformation (ARM) is the staged approach, comparable or slightly better to those reported in patients which entails performing colostomy shortly after birth followed by undergone the standard staged technique; 5. this approach reduces posterior sagittal anorectoplasty ( PSARP) few weeks or months the risks found in multianesthesias and multioperations, and also later, and finally colostomy take down as a third stage. A growing decrease economic burdens of the patients and their parents. interest in one stage correction of ARM was noted recently. The aim

of this study was to investigate the feasibility, safety, and short-term

outcome of complete one-stage repair of high and intermediate Acquired Rectovaginal Fistula ARM in neonates. I Dube, B A Mbuwayesango Patients & Methods: This prospective study included 38 full-term Harare Central Hospital, Zimbabwe infants (22 females and 16 males) with either high (n=9) or

Abstracts Presented at the 21st Annual International Meeting of Egyptian Pediatric Surgical Association (EPSA) In Collaboration with Pan African Pediatric Surgical Association (PAPSA), November 14-18, 2005, Alexandria, Egypt

Abstracts Presented at EPSA/ PAPSA Joint Meeting, 14-18th November 2005, Alexandria, Egypt

Results: There were 9 term neonates, 13 infants and 28 children in Introduction: Congenital anorectal malformations are more this study. Mean anal canal length or High pressure zone was common in boys. Acquired anal conditions are rare in paediatric significantly varying with age in both patients and controls. Resting surgery. Acquired RVF is a rare complication of PSARP but now pressure of the anal canal in controls ranged from 23 mm Hg to being seen in HIV disease. 53mm of Hg but did not differ significantly in different age groups. Materials and Methods: This is an ongoing study to evaluate There was remarkably low resting pressure (mean of 20.50mm Hg) (acquired) RVF in children. Currently we have 9 patients. in post operative patients with ARM. Children with HD had high Results: Nine patients seen June 2004–July 2005, all patients were resting pressure (mean 44 mm Hg) in comparison with controls (P= female and indigenous Africans. Age range from 3 months to 17 .001). Neonates showed positive RAIR at smallest volumes of years. Mean time of noticing condition was 4 months. All children balloon. We used this modality in six neonates to diagnose HD and were clinically and nutritionally well at presentation. Mean Hb was we found that it was diagnostic in all. 10.5g.dL. On EUA minimal inflammation, sizable defects (3-5mm) Conclusion: Manometric anal canal length varies with age .Resting and clinically amenable to perineal or PSARP repair. pressure of the anal canal is variable but doesn’t significantly vary Conclusion: Acquired RVF increasingly being seen in paediatric with age in controls. Patients operated for ARM, however have low surgery in Sub-Saharan Africa. Surgically seen like easy lesions to resting pressure than controls. Anorectal manometry is reliable close but more information needed for optimal management of modality to diagnose HD. these cases.

Surgical Considerations in the Treatment of Constipation in Management of Anorectal Malformation Challenges Facing a Pediatric Patients Paediatric Surgeon in Tanzania Omar Abdulwahed, K.Hamamish, T.Sliman, S.Naasan Petronilla J. Ngiloi Aleppo University Hospital, Syria Department of Surgery Muhimbili National Hospital, Dar-Es-Salaam Tanzania. Introduction :The Constipation constitute a real social and medical problem in pediatric exercise especially when it affects children in Anorectal malformation is a worldwide problem, which plays a major school ages and when it is accompanied by soiling (or what is part of a general paediatric surgeon’s daily practice. It is one of the usually called incontinence),and when the affected patient is a girl. major challenges for any Paediatric surgeon who would like to keep Material and methods: 48 patients with non Hirschsbrung's pace with recent reconstructive advances. constipation problems were referred to the authors in the clinic and This retrospective study was done to assess the outcome of children the hospital during the period between November 2002 and who had Posterior Saggital Anorectal Plasty. (PSARP–Pena December 2004. All were referred by the pediatrician for the pullthrough) plus other minor form of reconstruction, and to highlight suspicion of H.D the mean age was (3 years), and the male /female the challenges facing a Paediatric surgeon in instituting bowel ratio was nearly equals. A new evaluation of these patients were management program in an African set up. considered and belong to the clinical examination. The patients A total of 99 patients with anorectal malformation were seen during were classified into 3 groups: 1- constipation with anal fissure. 2- the period of January 2003 to June 2005 (30 months). The age constipation with soiling 3-Constipation alone. Belong to this range varied from 7 months to 20 years. Peak age was 0 -2 years classification; a special treatment protocol was applied for each with 48.4% 0f the total admissions. Seventy five children had group, consisting essentially of conservative treatment in the anorecoplasty done (75.6%). The peak age was 2-3 years. Twenty beginning in all the patients and a surgical gest were applied in the two patients (29.3%) of the total number of patients were operated. absence of amelioration, except in soiled patients where all surgical The most disturbing complication was soiling. Eighteen patients of gests were withdrawn for medico-legal considerations. the 75 patients had soiling 24%. This was more prominent after the Results and conclusion :The majority of these patients have a age of 5 years. Bowel management programs like enemas and bowel good response on the alimentary regulation, and the stool washouts could only be done in hospital set up. Quality of life was evacuation training ,and the amelioration was evident within the first assessed in terms of school attendance. Out of the 18 children who month of treatment, when soiling is present the period of treatment had soiling only 2 were attending school. Sixteen hoped something and follow up is usually longer and must be continued for at least 3 else could be done. One of the patients was operated for a terminal months, in cases of anal fissure the constipation may persist even colostomy after the complete healing of the fissure which also indicate the necessity to continue the treatment for longer period. The internal sphincteromyectomy of Lyn was the final procedure of choice when Anorectal manometry at Ibn Sina Hospital, Kuwait the conservative treatment was failed. Saleema Al Ramadan, Sunil Kumar. Department of Pediatric Surgery, MOH, Ibn Sina Hospital, Kuwait. Intractable constipation in children revisited: Back-ground: We share our experience with anorectal manometry Sameh Shehata at our institute in pediatric population. Department of Pediatric Surgery, Alexandria Faculty of Medicine, Purpose: (1). To have our own normal values of parameters of Egypt. anorectal manometry (2). To know its usefulness for diagnosis of Hirschsprung’s disease (HD). (3) To evaluate the post operative Aim: To study the role of surgery in the management of intractable patients with anorectal malformation (ARM) and HD. constipation in children. Materials and methods: In this study we included 50 children with Materials and methods: Cases of intractable constipation with age ranged between 2 days to 12 years. 21 of them were controls failure of aggressive medical treatment for more than one year are while remaining 29 were the patients with constipation. Anorectal selected for this study. Hirschsprung's disease was excluded by manometry was done using water perfused system with radial 4 rectal biopsy. Barium enema was performed for all cases to assess channel rectal catheter with stationary pull technique. Results like the presence of megabowel. Follow up for at least one year for the length of high pressure zone, resting pressure (in mm of Hg) and stool frequency, the need for medications, and the presence of RAIR were analyzed. Comparisons were made between patients complications. and controls in respect to age groups and conditions. Results were Results: 12 cases were studied, 7 males and 5 females. Age statistically analyzed. ranged between 3 and 12 years with mean of 4.2 yrs. History since onset of symptoms ranged between 1 and 6 years with a mean of

54 Annals of Pediatric Surgery

Abstracts Presented at EPSA/ PAPSA Joint Meeting, 14-18th November 2005, Alexandria, Egypt

2.3 yrs. Stool frequency without treatment ranged between 2 and 8 after hospitalization. There were no deaths and anastomotic days with a mean of 4.2 days. Barium enema findings: Mega leakage, persistent stricture and cuff abscess did not develop in our rectum: 3, Mega sigmoid: 2, Mega rectum and mega sigmoid: 7 series. EMG mapping of the external anal sphincter showed a good Operation was preformed in the form of sigmoidectomy and resting and powerful squeezing pressure curve. plication of the rectum. Conclusion: Redo TEPT is a useful alternative procedure for Post operative stool frequency ranged between 3 times per day to persistent symptoms of H.D., and it appears to be safe and once every 3 days with a mean of 1.2 days. Parents' perception of effective. the result was classified into : Excellent: 7, improved : 3, Still constipated : 2. Adhesive intestinal obstruction occurred in 1 case, and incisional hernia in another one. Transanal swenson technique for treatment of Hirschsprung's Conclusion: A protocol for the management of cases of intractable disease. constipation in children include assessment by barium enema. The Ayman Ahmed El Boghdady presence of obvious megarectum and/or megasigmoid clearly Ain Shams University, Cairo, Egypt indicate the type of colonic inertia present and is markedly improved by sigmoid excision and plication of the rectum to reduce capacity. Background: Hirschsprung’s disease is a common cause of Cases without obvious megarectum and megasigmoid represent a intestinal obstruction in pediatric age. Several pull-through minority and probably will need further assessment by transit procedures have been used to treat this neurogenic form of bowel studies and defecography. obstruction. Objective: The aim of this study was to present the outcome of transanal one-stage Swenson pull-through procedure in the Long-term Outcome for Total Colonic Aganglionosis: King management of rectosigmoid Hirschsprung’s disease. Fahd Armed Forces Hospital Experience Patients and Methods: Between August 2003 and July 2004, 14 Enaam Raboei, Khalid Al-Harbi, Reijo Luoma children with biopsy-proven Hirschsprung’s disease underwent Department of Pediatric Surgery, King Fahd Armed Forces Hospital transanal one-stage Swenson pull-through procedure. The primary diagnosis in all the patients was rectosigmoid Hirschsprung’s Background/Purpose: Timing and optimal procedure in the disease. All children had their operations done without construction management of total colonic aganglionosis (TCA) is still of preoperative colostomy. Follow up period ranged from 3.5 months controversial. We present our experience using standard Duhamil’s to 15 months. procedure in this condition. Results: There were 9 boys (64.28%) and 5 girls (35.72%). The age Methods Chart review of all cases of Hirschsprung’s disease from at diagnosis ranged from 3 days to 3 years, the age at the time of November 1983 to December 2004 was conducted. All Patients surgery ranged from 3 months to 3 years, the weight at the time of with TCA and their parents were contacted personally to collect surgery ranged from 3.5Kg to 12 Kg. The length of aganglionic updated information on bowel habit and physical development. The segment resected ranged from 12 to 34 cm. The operating time, follow-up at present is 2, 7, 12, 12, 16, 16, and 21 years including taking frozen sections, ranged from 72 to 180 minutes. Results Eleven patients had TCA confirmed at laparotomy and Postoperative hospital stay ranged from 3 to 11 days. There were no diversion. Seven had definitive surgery during the first year of life. anastmotic leaks, wound infection, nor postoperative bowel The other four were as follows: two had Waardenburg syndrome obstruction. Two patients (14.28%) developed postoperative with lethal total aganglionosis, one had multiple other anomalies, enterocolitis. One Patient (7.14%) required a posterior internal and the last has mid jejunal involvement pending definitive sphincter myectomy despite repeated dilatations. All patients of the procedure. Familial incidence was apparent in two sets of siblings. study had less than 4 times bowel motions per day, 3 months after No immediate postoperative complications. All the children had surgery. Six patients developed perianal dermatitis that treated frequent loose motions during the first few postoperative years, conservatively within 3 months after surgery. Anastomotic which gradually improved. Several episodes of postoperative circumference could not be felt at digital examination, 3 months after enteritis occurred in two patients, one of which now has ileostomy surgery. Conclusion: A one-stage transanal Swenson pull-through performed elsewhere 3.5 years after the original pull through. procedure is a safe alternative to staged procedures for rectosigmoid Conclusions The long term results of standard Duahmel’s pull Hirschsprung’s disease. Careful long-term follow up is required to through for TCA is good in terms of continence; bowel motion; and assess continence and sexual function physical development.

Intestinal Transplantation in Children- UK Experience: 1993- Redo Transanal Endo Rectal Pull Through, A Priliminary Study. 2005 Programme Report Gobran TA, Ezzat A, Hassan ME, O'Neill, J. Gupte G, Kelly D, Mayer AD, Mirza D, Lloyd C, Clarke S, Sharif K, Department of Pediatric surgery, Zagazig University, Egypt. &, McKiernan P, DeVille deGoyet J, , Beath SV, Millar AJW. Vanderbilt University, Nashville, TN, USA Liver Unit Birmingham Children’s Hospital, and Hepatobiliary Unit, . Queen Elizabeth Hospital, Birmingham, United Kingdom. Purpose: The aim of this study is evaluation of the safety and efficacy of the redo transanal endorectal pull through (TEPT) for Introduction: Intestinal transplantation (ITx) in children was started patients with persistent symptoms after pull through for in the UK in 1993. Hirschsprung's disease (HD). Aim: To review the evolution of ITx over 12 years in children in UK. Methods: Seven children were included in the study, their ages Subjects & Methods: A retrospective review of 38 children ranged from 2.5 to 6 years (4 males and 3 females). They undergoing ITx. Results are presented in three separate eras presented with persistent obstructive symptoms after pull through which marked significant changes of practice (1993-1997- early for HD which was remediated with redo TEPT. Indications were experience; 1998-2001- introduction of reduced en-bloc surgical persistent constipation, anastomotic stricture unresponsive to reduction; 2002 –2005 introduction of basiliximab and regular dilatation and more than two attacks of enterocolitis. Epstein Barr Virus (EBV) PCR monitoring Results: Mean follow up period was 12 months (ranged from 8-16 Results: The indications for ITx were impaired venous access months). Obstructive symptoms were relieved in all patients with no (n=9), end stage liver disease (n=28), recurrent life threatening soiling throughout the period of follow up. Enterocolitis developed episodes of sepsis (n=1). Immune suppression protocols were from once in two patients who responded to conservative management 1993-2001 Tacrolimus + Azathioprine + Prednisolone (n=21), from

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Abstracts Presented at EPSA/ PAPSA Joint Meeting, 14-18th November 2005, Alexandria, Egypt

2002: Basiliximab + Tacrolimus + Prednisolone with Sirolimus/MMF Conclusion: We have shown that this simple procedure provides introduction after 4-6 weeks (n=17). considerable symptomatic relief and improves the quality of life of patients with this debilitating condition. 1993-1997 1998-2001 2002-2005 Early En-bloc Basiliximab era and EBV Fore-gut Pathology in HIV Positive Patients. PCR era R.A. Brown, L. Cook, E. Goddard, J. Ireland, H. Rode. Department of Paediatric Surgery & Paediatrics Red Cross War No. transplants 4 17 17 Memorial Children’s Hospital, University of Cape Town. Median age (years) 2.98 1.59 2.30 Median weight (kg) 12.85 9.36 11 Aim: To ascertain if there are upper gastrointestinal tract pathology Isolated-bowel 2 3 2 changes in children who are Human Immune Virus (HIV) positive. transplant (ISBT) Methods: Twelve children with HIV who presented to the Combined en-bloc liver 2 7 8 Gastrointestinal (GIT) Unit for upper GIT endoscopy were reviewed. and bowel (LSBT) Results: Five males and 7 females ranging in age from 4 to 133 Combined en-bloc 0 7 7 months (mean 49) were reviewed. Mean age at diagnosis of HIV reduced LSBT was 35 months, with the mean CD4 percentage 11.5% (range 1.3 – Waiting list deaths 9 2 6 21%). Two children were on antiretroviral therapy at the time of diagnosis. Presenting symptoms were vomiting (9), dysphagia (4), Post transplant 1 5 0 recurrent thrush (4), recurrent chest infections (3), GIT bleed (3). lymphoproliferative At endoscopy: 5 had oesophagitis/ulceration, 5 had gastritis, and 3 disease (PTLD) had duodenitis/duodenal ulcer Deaths from PTLD 1 2 0 Histology/microbiology showed: Cytomegalovirus (3), Candida (3), Median hospital stay 36 53 54 Cryptosporidium (1), H. pylori (1) Endoscopy changed medical (days) management in 75%. No.of deaths 4 10 6 Conclusion: Upper GIT endoscopy in HIV children with foregut Median follow-up in 7.4 21.78 9.8 symptoms is essential to identify the pathological process and months (1.14 - (1.21 - (0.5-45.4) changing flora and results in altered management in 75% of 76.4) 79.9) children. Conclusion: The advances in surgical practices and introduction of basiliximab and EBV PCR in tandem with increasing experience have resulted in continuing improvement in results of ITx. Outcome and Complications of Upper Gastrointestinal Endoscopy in Children. Ramy Waly Tubularised and button colostomy for colonic decompression Department of Pediatric Surgery, Alexandria Children and Students in African Degenerative Leiomyopathy hospital (Sporting). Health Insurance Authority, Alexandria, Egypt Lazarus, C, Chitnis, M; Breckon, V. Eastern Cape Paediatric Surgical Service, East London, South Africa Background and study aims: Upper gastrointestinal endoscopy is a well established technique worldwide. This study aims at Background: African Degenerative Leiomyopathy (DL), a assessment of the outcome and complications of upper progressive disorder affecting mainly the gastrointestinal tract and gastrointestinal endoscopy in diagnosis and treatment of upper seen only in African children of Southern, Central and Eastern gastrointestinal lesions in pediatric age, especially in infants. Africa, is characterized by smooth muscle degeneration and its Patients and methods: we used hard open-channel (3 cases) and replacement by fibrous tissue. DL presents in childhood with 9 mm caliber fiberoptic (17 cases) endoscopes in the diagnosis and features of chronic intestinal pseudo-obstruction such as chronic treatment of children with variety of upper gastrointestinal constipation, inability to evacuate flatus, gross gaseous abdominal complaints. The majority of our study cases were infants (10 cases, distension and malnutrition. Most patients die before reaching 50%). Three cases in our study were in the preschool age group adulthood. Operative interventions in this condition have provided (15%). Seven cases were in school age and adolescent age group no benefit. The use of laxatives, pro-kinetic agents, and regular (35%). The most common complaint was dysphagia (13 cases, decompressive bowel washouts are the mainstay of treatment. 65%), followed by vomiting, regurgitation and hematemesis in equal However, the repeated insertion of flatus tube for colonic deflation percentage for each of them (8 cases, 40%). We did laboratory and and irrigation is tiresome and difficult to maintain in practice. We radiological investigations when indicated. have used a catheterisable tubularised transverse colostomy and a Results: Endoscopically, we found esophageal stricture in 8 cases, button colostomy as a solution to these problems. reflux esophagitis in 3 cases, esophageal foreign body in 2 cases, Purpose: To describe our technique and discuss the outcome of esophagogastric varices in one case, three cases of gastritis, one the procedures case of antral mass, one case of esophagogastric varices, one case Patients and Methods: We have reviewed the records of 11 of prepyloric ulcer and one case of post caustic gastric outlet patients between the ages of 5 and 18 years who have undergone obstruction. As regard intervention endoscopy, we did esophageal the procedure. In the first 7 patients a tubularised colostomy was dilatation to 8 cases, endoscopic biopsy in 5 cases and esophageal created to provide a catheterisable conduit and in the last 4, a foreign body extraction in 2 cases. We did not encounter any post- button colostomy was placed. Follow up has been for a period of 1 endoscopy complications - other than minor complaints like – 6 years. discomfort and once or twice vomiting - except in one case which Results: A catheterisable conduit for intestinal deflation was was 6 month of age who had severe GERD and severe esophageal successfully created in 11 patients. All patients were able to use stricture and had 2 sessions of esophageal dilatation. After the 2nd the conduit to provide symptomatic relief by the gaseous session, she was manifested by progressive respiratory distress decompression of their colons and the provision of antegrade after 2 hours of the procedure. The condition worsened and the enemas. One patient who had a tubularised colostomy developed patient died after another 3 hours. a stomal stricture which required revision. A further patient died at Conclusion: Upper gastrointestinal endoscopy is a very useful home 6 months after his tubularised colostomy; the reason for technique in the diagnosis and treatment in children including the death is unknown.

56 Annals of Pediatric Surgery

Abstracts Presented at EPSA/ PAPSA Joint Meeting, 14-18th November 2005, Alexandria, Egypt

youngest age group but, on the other hand, carries more risk and Results: 59 children with paraoesophageal hernias were treated needs more training to avoid serious unexpected complications. during a 42-year period. Mean age at presentation was 23.4 months . (day 1 to 11years). Presenting complaints were recurrent chest infections (32), vomiting (24), symptomatic anaemia (20), Failure to Malrotation, Non-Fixation in Patients with Ileocolic thrive (18), and dyspahgia (6). 5 children were asymptomatic and Intussusception at a Major Referral Hospital the diagnosis was established when investigated for incidentally Mbuwayesango noted asymptomatic anaemia (3), scoliosis (2) and mumps (1). Harare Children’s Hospital, Harare, Zimbabwe Radiology typically showed cystic masses in the posterior mediastinum in the right lower chest and occasionally an air fluid Background: Intussusception is a very common paediatric surgical level with in or a dilated oesophagus. None presented with emergency. Ileocolic intussusception is by far the commonest form strangulation or haematemasis. All were operated on. Surgical in the infants. The cause in the majority of Intussusception is findings included a peritoneal lined sac, herniation through a idiopathic. widened diaphragmatic hiatus, containing stomach and at times Purpose: This study was carried out to find out if there is an transverse colon, spleen and small bowel. The hernial sac usually anatomic abnormality predisposing to infantile ileocolic occurred on the right. Principles of surgery included reduction of the Intussusception. contents, partial excision of the sac, crural approximation and a Materials and Methods: A consecutive case series observational fundoplication in 39 patients. No fundoplication was done in the study was carried out at Harare Children’s Hospital in Zimbabwe earlier years in 20 of whom 12 had recurrent reflux symptoms. Post between June 2000 and September 2005. A record was made on operative complications were bowel obstruction (6), intussuception whether the ascending and descending colon were fixed to the (3), dyspahgia (3) breakdown of the repair (3) and pneumothorax retroperitoneum. Also recorded was the age, sex, type of (1). There was one mortality due to pre operative aspiration. Intussusception and whether manual reduction was successful or Conclusion: Paraoesophageal hernias in children are uncommon otherwise. Analysis was done using simple proportional statistics. and most likely due to a congenital defect. It is associated with Results: A total of 56 patients were seen, 96% of them with considerable morbidity. Strangulation is not a feature. Principles of ileocolic intussusceptions. There were 37 boys and 19 girls with an repair are well established and should include an anti-reflux age range between 1 month and 8 years averaging 7 months. procedure. Diagnosis was clinical and all patients had laparotomy and attempted manual reduction. Only a third had successful manual . reduction and the rest required bowel resection. It was noted that Gastro esophageal Reflux in Nairobi the ascending and descending colon were intraperitoneal, or a James Ndungu mesentery, in all the patients with ileocolic intussusception. Nairobi, Kenya Ileocaecal rotation was complete but fixation to the retroperitoneum was absent. Objective: To determine the mode of presentation, investigations Conclusion: From these observations it may appear that non- and the outcome of management of patients presenting with gastro fixation of the colon to the retroperitoneum is a prerequisite for the esophageal reflux disease, as seen in Nairobi. development of ileocolic intussusception in infants. Design: This was a prospective study between 1997-2001. Settings: Private hospitals, which the author frequents, situated within the city of Nairobi. The physiological basis of GER treatment in children Subjects: All patients seen by the author who were suspected or Jose Boix Ochoa were subsequently proved to have gastro esophageal reflux Tordera- Barcelona disease. Over the past 35 years, the author have conducted laboratory Results: Twenty-two patients were included in the study. The and clinical investigations into the physiology and average age when initially evaluated fell into two groups. The non- pathophysiology of gastric oesophageal reflux and had operated group (N=9) averaged 5.8 months and the operated group experience with the management of this disorder in more than (N=13) averaged 24.1 months of age. The commonest presenting 3700 children. This has enabled the author to develop a symptoms were vomiting 72.2%, failure to thrive 59.1% and philosophy based on an understanding of the mechanisms of irritability/crying and fever 40.1%. The commonest investigations GER. and the derangements of these mechanisms. A carried out were contrast upper gastrointestinal studies, endoscopy therapeutic plan-medical and surgical-based on physiological and ultrasound respectively. The indications for surgery in order of principles has been developed and exposed by the author. frequency were 1- Gross reflux (89%); 2-Failure to thrive 83%; (3) Many of the concepts are so simple that they are very often Esophageal stricture (33.3%) ; 4 Failed conservative management forgotten. The purpose of the lecture is to highlight these (16.7%); 5- Urgent medical conditions (27.2%); 6- Respiratory concepts and present our point of views based in our infection or pneumonia (33%), Mortality has been low 8% (N=1). experience, clinical and laboratory researches and results. The Resumption of symptoms have occurred in 16% (N=2). author reviews the state of art of this pathology. Conclusion: GERD is not uncommon although its incidence is not known. Early recognition and institution of the appropriate treatment will avoid complications. Primary Paraoesophageal Hernia in Children. JS Karpelowsky, N Wieselthaler, H. Rode Department of Pediatric Surgery, Department of Radiology Red Surgical Experience in the First 100 Living Donor Liver Cross War Memorial Children’s Hospital Cape Town Transplantation Ahmed Darwish Background: Paraoesophageal hernias are uncommon in children Ain Shams University, Cairo, Egypt and are distinctively different from the more common sliding hiatus hernia and those following antireflux surgery in anatomy, pathology, Objective: To analyze the surgical experience in the first 100 living symptomatology, complications and management. We review a donor liver transplantation, including surgical techniques, surgical single institution’s experience with the above pathology. complications and correlation between technical particularities and Methods: Retrospective analysis of patient records outcome.

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Abstracts Presented at EPSA/ PAPSA Joint Meeting, 14-18th November 2005, Alexandria, Egypt

Methods: Between July 1993 and April 2002, a total of 100 children will discuss our experience with this technique and its short term received a left segmental liver graft from a living donor at Saint-Luc outcome. University clinics, Brussels. Presurgical evaluation in donors and recipients, analysis of the surgical technique and postoperative complications were reviewed. Non-Parasitic Liver Cyst in Children: Different Presentation Results: After a median follow-up period of 2526 days, no donor and Different Treatment Modalities. mortality was encountered, with a minimal morbidity and no long- Yaser Sad El Din term sequelae. At one and five years post-transplantation, the Department of Pediatric Surgery, Alexandria Faculty of Medicine, actuarial patient survival rates were 94% and 92%, the Egypt. corresponding figures being 92% and 89% for graft survival. The Objectives: Cystic diseases of the liver started to gain widespread incidences of portal vein and hepatic artery thromboses and of interest in recent decades. Although parasitic liver cysts biliary complications were 14%, 1%, and 27%, respectively. predominate especially in tropical regions, non-parasitic cysts Conclusion: Living related liver transplantation in children represent a real problem in both diagnosis and management.The constitutes an efficient therapy for liver failure to face the increase objective of this work is to study cases of symptomatic non-parasitic demand for liver grafts. Donor morbidity was kept to acceptable liver cysts in pediatric age group concerning their presentation, incidence, and surgical technique in the recipient needs to be methods of diagnosis and to highlight the different modalities used tailored to minimize postoperative complications for these uncommon lesions. Patients and Methods: Seven children with symptomatic liver cysts were reported in the last ten years. All patients were studied Meso-Portal Shunt Procedure for Extrahepatic Portal Vein concerning their clinical presentations and investigatory work-up, Occlusion. including serological tests to exclude hydatid disease of the liver. H. Rode, A. Numanoglu, M. McCulloch, E.A. Goddard, A.J.W. The different modalities of treatment were reported. Millar. Conclusions: Non-parasitic liver cysts in children are uncommon Department of Pediatric Surgery & Paediatrics, Red Cross War lesions. They should put in mind in our clinical practice. Different Memorial Children’s Hospital, University of Cape Town. modalities of treatment can be used for treatment.

Introduction: Extrahepatic portal vein thrombosis (EPVT) can cause severe bleeding from the gastro-intestinal tract (GIT). This Roux-en-Y hepaticojejunostomy versus Hepaticodudenostmy can present in an idiopathic form or following liver transplantation. for biliary reconstruction after excision of Choledochal cyst in Shunt surgery is indicated when the liver function is normal but children there is life-threatening bleeding from the GIT which could not be Amel Hashish, Essam Elhalaby controlled by medication or injection sclerotherapy of varices. Department of Pediatric Surgery, Faculty of Medicine, Tanta, Egypt Aim: Retrospective case review with assessment of outcome following this new technique of Meso-Rex bypass. Background/Purpose: Choledochal cyst is an important cause of Methods: Audit of children with EPVT and portal hypertension who surgically treated jaundice in infants and children. Primary cyst were considered for Meso-Rex bypass, with specific emphasis on excision combined with biliary reconstruction is the treatment of symptoms, investigations, type of shunt performed and outcome. choice for such cases. Roux-en-Y hepaticojejunostomy or Results: Seven children were considered possible candidates for a hepaticodudenostomy are most commonly used for reconstruction. Meso-Rex bypass. Four of them were found to be suitable for the The type of biliary reconstruction is usually based on the surgeon's Meso-Rex bypass of whom two had left lobe liver transplantation.. personal preference. This study was undertaken to evaluate Three patients had their Rex recess explored but no patent vein diagnostic tools, management options, and to compare the could be found. Two of these three patients had distal splenorenal operative feasibility and postoperative functional results of cases of shunt and one was found to be not suitable for a porta-systemic Roux-en-Y hepaticojejunostomy with hepaticodudenostomy on shunt. early and long-term follow up. Patients who had Meso-Rex bypass resolved their upper GIT Material& Methods: Twenty–seven patients were treated during bleeding, appetite improved, splenic size decreased and signs of the period from November 1993 through May 2005. All patients hypersplenism disappeared during the average follow-up of two were studied as regard to their clinical presentation, diagnostic years (six weeks – four years). tools, treatment modalities, and outcome. Conclusion: In suitable cases, establishing physiological portal Results: Nineteen patients were females and seven were males. vein flow into the liver prevents life-threatening intestinal bleeding Their ages at surgery ranged from 2 weeks to 13 years, 16 were and improves the general condition of children. There is a need to less than 6 months of age. Twenty-two patients had type I; five had investigate the intrahepatic portal system precisely by using IV, while none had type II, type III, or type V. The main presenting angiography to prevent unnecessary exploration of the Rex recess. clinical findings were jaundice alone (n=10), Jaundice and abdominal mass (n=11), and abdominal mass without jaundice (n=5). The classical triad of jaundice, mass and pain was noted in Initial Experience with Laparoscopic Kasai and Hepatico- only five patients. Abdominal ultrasonography proved to be the jejunostomy for Choledochal cyst: Technical Details and most useful diagnostic tool and was accurate in all except one Preliminary results patient. The patients were classified into two groups. Group I Aayed Al-Qahtani included 18 patients how had complete excision of the extra-hepatic Department of pediatric, King Saud University, Riaydh cysts and Rou-en-Y hepaticojejunostomy. Group II included nine patients how underwent complete cyst excision and The main role of laparoscopy in extrahepatic bile duct pathololgy hepaticoduodenostomy (9 patients). There were no major intra has been for diagnostic purposes. With increasing experience in operative or early postoperative complications such as biliary or various minimal access procedures intestinal leakage. Postoperative cholangitis occurred in 4 patients, In newborns and infants, we have found it safe and effective to 6 and 13, 18, 42 months after surgery. Adhesive bowel obstruction perform complicated laparoscopic reconstructive hepatobiliary occurred in one child in-group I (treated successfully by surgery in young infants.These include excision of choledochal cyst conservative management). One late mortality due to liver failure with hepatico-jejunostomy, and Kasai's portoenterostomy for biliary occurred 6 months after surgery in-group I in a patient with atresia. Excellent visualization in addition to the usual advantages preoperative severe liver cirrhosis. of MAS is the most important aspects of this technique. Herein, we

58 Annals of Pediatric Surgery

Abstracts Presented at EPSA/ PAPSA Joint Meeting, 14-18th November 2005, Alexandria, Egypt

Conclusions: The early diagnosis and treatment of choledochal Current strategy for treating cryptorchidism cysts are important to prevent complications of the disease. Total Faruk Hadziselimovic MD excision of choledochal cyst is usually feasible and is considered Kindertagesklinik Liestal Switzerland the most effective method of avoiding recurrent cholangitis and the late possibility of malignant changes. Both Roux-en-Y The transformation of gonocytes into Ad spermatogonia is crucial hepaticojejunostomy and hepaticoduodenostomy are effective for fertility. Unilaterally undescended testes have an inadequate techniques for biliary reconstruction following excision of the cyst adult stem cell pool that normally occurs at 2-3 months of age. with satisfactory early and long-term results. Cryptorchid boys, 8 or 9 months of age, with testes located either intra-abdominally or intracanalicular have critically low spermatogenic index; this suggests that surgical intervention is Pseudopancreatic Cyst Presenting As Obstructive Jaundice in appropriate before this age for cryptorchid testes in these high a 10 Years Old Girl. positions. The lack of Addark spermatogonia underscores the Nour El Kholi importance of a testicular biopsy at orchidopexy in order to identify Department of Pediatric Surgery, Alexandria Faculty of Medicine, those cryptorchid boys who would benefit from LH-RH treatment Egypt following the procedure since LH-RH analogs induce replication and . differentiation of germ cells that enhance the chance of fertility. Clinical data: Female patient 10 years old Born in Alexandria, Our current strategy for treating cryptorchidism is: 1. Begin Recent complaint of vomiting and epigastric colic, Jaundice ( treatment at 6 months of age: With LH-RH, 400 µg (3 times/day) for deepening), Failed medical treatment, Ultrasound scan of the 4 consecutive weeks. 2. For the non-responders: Switch to HCG, abdomen revealed a retro gastric cyst and mild dilatation of the 500 IU i.m./week for 3 consecutive weeks. 3. For the non- common bile duct., Barium meal confirmed a pseudo pancreatic responders: Orchidopexy, testicular biopsy; 4. Germ cell count cyst with a calcified wall, CT scan clenched the diagnosis <0.2/tubular x.s. and/or no Ad spermatogonia: LH-RH analog, 10 µg Management: Exploration through a transverse upper abdominal every other day for 6 months. muscle cutting incision revealed: A high well circumscribed firm wall calcified pseudo pancreatic cyst with a dimension of about 6 x 6 cm. It was attainable from above at the border of the lesser curvature Ambiguous Genitalia. Single Center Experience than from below from the lesser sac.The porta hepatic and the free Kamal Abd Elelah Aly, border of the lesser omentum was the seat of enlarged juicy Mansoura Universit, Egypt inflammatory lymph node mechanically compressing the common bile duct. Aspiration and de-roofing of the cyst (fluid kept for The aim of this work: was sex determination and surgical analysis ). Very delicate excision of the compressing lymph nodes correction of patients with ambiguous genitalia (AG) and freeing the common bile duct from compression. Patients and methods: The study included 27 patients with (AG) Pathology of the wall and lymph nodes revealed an inflammatory who were admitted at (MUCH) in the period from 2000-2004. process on to of an old trauma (though not referred to in the According to age of presentation, they were classified into 2 groups: history). Fluid analysis for cytology, bacteriology and chemistry group I: 24 infants complaining of (AG), group II: 3 patients aged denied any infection or pancreatic juice origin. from 15-17 years, 2 of them were male with under-verification, the Postoperative course was uneventful and the control ultrasound third one was reared as a female presented with bilateral inguinal scan proved free. swellings. Performed surgery was divided into exploratory surgery, Possible diagnosis is that of a traumatic hematoma with its sequels. excision of inappropriate tissues, feminizing or musculinizing genitoplasty. Results: the study found that 63% of cases were female Abdominal Malignancies in the Pediatric Age Group: The pseudohermarphrodite, 85% were male pseudohermarphrodite and Alexandria University Experience (1980-2000) 11.1% were true hermarphrodite while mixed gonadal dysgenesis Essam El Sahwi: was present in 7.4% of cases. Patient characteristics, biochemical Department of Pediatric Surgery, Alexandria Faculty of Medicine, changes, radiological findings, surgery performed and postoperative Egypt. complications, all were reviewed. Conclusion: Many aspects of AG are controversial and these 1277 cases of malignancies in the pediatric age group were recommendations may meet approval and disapproval. However, it received to the Alexandria Medical School in the period between is certain that the management is very complex and need to be 1980 and 2000. individualized as much as possible. Abdominal malignancy tumors constitute 420 cases (33% of the total cases). They are distributed as follows: nephroblastoma (35%), lymphoma (29%), neurobalstoma (26%) and Standardization of Surgical Management of Circumcision hepatoblastoma (4.3%), the percentage of the cases received in the Injuries same period. The clinical presentation investigation and pathology Osama K. Shaeer, Nabil El Desouky, Khaled El Desouky, Karam of these cases is discussed as well as the different lines of Khattab and Ahmad El Sadat treatment namely surgery, chemotherapy radiation was decided according to the stage of disease. As the number of the cases University of Cairo Children’s Specialized Hospital, Cairo, Egypt presenting in the third and fourth stage of the disease ranged Circumcision injuries are under rated regarding their incidence. between 12% and 44%, the only way of improving the survival was Methods for repair are not standardized. Most cases end up with to find a way for early detection of these hidden tumors. permanent mutilation and disfigurement. This work presents Therefore, a simple protocol of early detection in this age group is experience with management of circumcision injuries, and suggested and was recently adopted by one of the medical NGO standardization of surgical repair. foundation. In our opinion unless this protocol of early detection is Methods: Cases with circumcision injuries ranged from urethral established we wouldn't expect any improvement of the survival fistulation, subtotal or total amputation of the glans penis, loss of the rate whatever competent will be our receiving hospitals penile skin, to subtotal or total amputation of the penile shaft. The surgical procedure for each case is described, varying from re- Genitourinary Tract anastomosis of the glans, neo-glansplasty, fistula repair, penile skin coverage, and penile elongation.

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Results: All patients ended up with a cosmetically adequate penis, particularly induces the degree of penile curvature that influences with probable functional adequacy. the severity in this malformation. Conclusion: A penis, injured upon circumcision, can be salvaged with standardized techniques Review of One Hundred Cases of Hypospadias Seif ElIslam AbdulSalam, Mohamed Hobeldin What Makes a Man? Division of Pediatric Surgery - Shaikh Khalifa Medical City – UAE Amin Gohary, Abou Dabi, UAE Objective: To evaluate the results of our hypospadias repair surgery. Methods: A retrospective observational study. Files of all patients The story of sex determination started with Mendel in the 19th who had Hypospadias repair by one surgeon over 5 years were century and crystallized in the 1990 with the discovery of the SRY retrieved and analyzed with a view to evaluate results of surgery for gene. The journey that scientists have endured is a fascinating one. Hypospadias. For most patients who had penile or distal It has illuminated our understanding of how sex is assigned; which hypospadias Mathieu's repair, advancement or TIP (Tabularized has its repercussion on how we manage patients with intersex. It Incised Plate) urethroplasty were performed. Patients with severe also has its implication on the future of the human race.My chordee had Duckett Island flap urethroplasty as one stage presentation is to narrate the story of the discovery of ourselves as procedure. Patients having moderate chordee were subjected to the male and female and look for the implication of the recent finding on dorsal plication and only island urethroplasty Procedure. Some fertility and the future of the mankind. underwent meatotomy, GAP or two stage repairs.

Results: One hundred patients were operated on for hypospadias

repair in the study period and they were all included in the study. Modified Koyanagi Repair for Management of Moderate and The results of surgery were assessed by the number of satisfactory Severe Hypospadias repairs and the number of complications. Overall complication rate M.El Ghazaly Waly, Adham El Saied, Khaled Kandil and M. Sheir was 15 %, and the incidence of fistula formation was 5.7%. Highest Mansoura University – Egypt numbers of complications were seen in patients who had onlay or Duckett urethroplasty for proximal hypospadias with chordee Background: Koyanagi procedure is a one stage repair devised for Conclusion: Satisfactory functional and cosmetic results without correction of moderate and severe hypospadias utilizing a meatally complications were obtained in 85 % cases after one procedure and based yoke. It was modified by Emir et al (2000) thus allowing the after second procedure; it reached 98%. Overall complication rate urethral plate to be mobilized sufficiently to excise all chordee. was 15 % and was related to major procedures; however, it never Material: Thirty boys suffering from moderate or severe compromised the final outcome of the patient. When only distal hypospadias were admitted during the period from May, 2002 to forms are considered our complication rate was 7.5%. February, 2005. Their ages ranged between 15 months – 6 years. Results: We reported an overall complication rate of 40% (12 cases). Eight cases developed urethrocutaneos fistula, 1 case Comparison between Duckett and modified Asopa developed urethral stricture and 3 cases had retrusive meatus. (HodgsonXX) procedures of creating transverse preputial Conclusion: Modified Koyanagi procedure is highly applicable for island skin tube in proximal penile hypospadias. severe proximal hypospadias because it ensures enough skin for Hesham A Soliman, Ehab A El-Shafei the neourethra. The use of parameatal tissues and adjacent skin Ain Shams University, Cairo, Egypt flaps reduces tissue mobilization Purpose: Several vascularized island flap procedures have been described for the repair of severe proximal hypospadias with The use of spongiosoplasty in hypospadias repair. cordee. Modified Asopa (HodgsonXX) procedure employs an inner Sameh Shehata skin tube for the neourethra while providing simultaneous skin Department of Pediatric Surgery, Alexandria Faculty of Medicine, coverage to which it remains attached. In Duckett procedure, the Egypt. neourethra is dissected on its pedicle in an attempt to create two- blood supply, one for the neourethra and one for the preputial skin. Aim: Despite the numerous surgical procedures reported for The aim of our randomized prospective study was to differentiate hypospadias repair, little attention has been given to the precise between both techniques as regards duration of surgery and assessment of penile anatomy in this malformation. The aim of this achievement of the goals of hypospadias repair; release of cordee, study was to assess the effect of using the diverging corpus urethroplasty, and redistribution of skin coverage, in one operation, spongiosum as a second layer in hypospadias repair. with minimal morbidity. Material and methods: 52 cases of hypospadias were repaired Patients and methods: During the period between Jan 2003 and using the technique of preservation of the corpus spongiosum by May 2005, 20 patients with proximal penile hypospadias with careful degloving of the penis. No dartos intervenening layer was severe cordee, were randomly divided to perform either Duckett or used in any cases. Follow up for at least 6 months for complications modified Asopa procedure to create a transverse preputial island including fistula and strictures. skin tube. Patients below 8 months of age, and patients in need or Results: Fifty two cases of hypospadias were operated upon. Age received local or systemic hormonal treatment were excluded from ranged between 1 and 6 years with a mean of 3.2 yrs.The location the study. Our main concern in the follow up period that ranged of the meatus: Coronal: 10, Distal: 29, Proximal: 12 Complications from 5 months to 34 months was to assess the incidence of urethral encountered: Fistula: 4/52, Stenosis: 3/52, Repair disruption: 0/52 fistula, anastomotic stricture, diverticulum, meatal size and site, Conclusions: The abortive spongiosum is routinely obtainable with adequate skin coverage and residual cordee or torsion. careful penile degloving. This technique provides a vascular tissue Results: The mean operative time for the modified Asopa for coverage of the suture lines and reduces fistula formation. We procedure was 2hr, 10min, while in Duckett procedure it was 2hrs, describe the particular anatomy of the corpus spongiosum 50min.Superiority of modified Asopa technique was evident in the encountered, highlighting its relationships with the other features incidence of fistula, stricture and diverticulum formation, and observed in the different forms of this anomaly. It appears that the residual cordee. Skin necrosis was a major complication in patient level where the corpus spongiosum diverges into two limbs who underwent Duckett procedure (30%) with subsequent complete

60 Annals of Pediatric Surgery

Abstracts Presented at EPSA/ PAPSA Joint Meeting, 14-18th November 2005, Alexandria, Egypt

loss of the underlying tube in one patient. This has never been a On examination the baby had the scrotum on the suprapubic area complication in patients who underwent modified Asopa technique. with empty right scrotal compartment. The penis was found on the Conclusion: Based on these results we believe that modified perineum with perineal hypospadias where the urine comes from Asopa (Hodgson XX) procedure achieves excellent results when the anal dimple. This anal dimple was not communicating with the compared to Duckett technique for patients with proximal penile rectum. The child has rectal atresia and suffering also from hypospadias with severe cordee. esophageal atresia with tracheo-esophagial fistula. Unfortunately the child died on the same day of admission. We conclude that PST may represent only a part of a wide spectrum of anomalies resulting Simple Technique for Stent Fixation in Hypospadias Repair from major insult during early pregnancy. Treatment of the condition Khairi A requires an awareness of the association of other organ system Department of Pediatric surgeryt, Alexandria faculty of Medicine, anomalies. Egypt. Background/Purpose: Although many pediatric surgeons doing hypospadias repair do not leave urethral stent postoperatively, yet Surgical aspects of bladder augmentation and continent many others, and perhaps more than the first group, still do. We abdominal urinary wall stoma present a simple technique for stent fixation. Andrew B. Pinter Material and methods: from April 2002 till April 2004, 36 cases Pécs University Hungary have been treated for hypospadias by the same author. In procedures done for abnormal meatal site at/ or proximal to the Purpose: To introduce the most frequently applied surgical mid-glans (29 cases, 80.5%), a stent was left behind as a routine. techniques for bladder augmentation and creation of continent Fifteen boys (51.7%) had the stent draining in a urinary bag and 14 abdominal wall stomas. (48.2%) had been drained in their diapers. In all, the stent was fixed Material and Methods: Over the last 17 years 69 bladder by wrapping a small adhesive plaster piece (2x1 cm) around the augmentations and 46 continent (catheterisable) abdominal stomas stent just distal to the meatal orifice leaving a small mesentery of 10 were performed in the author’s institute. mm parallel to the stent and then passing a stitch of non-absorbable Results: The following alimentary tract segments were used for suture through this plaster mesentery, making sure it did not transfix augmentation: 34 large bowels (sigmoid colon or cecum and the stent, and then fasten the two suture ends together lightly ascending colon), 18 gastric segments and 17 small bowels (ileum). around the plaster. Lastly the two suture ends are tied to the For continent abdominal wall stomas, we used appendix (39 pts), glanular tension stitch applied at the start of the procedure. Then ureter (3 pts) small-bowel (Monti or Indiana-3 pts). In 3 patients the normal dressing is done. following a successful primary augmentation where we used 2 large Results: All the cases came to the follow-up clinic having no bowels and 1 gastric segment (2 – to 4 years) re-augmentation was problem related to stent fixation. No accidental in or out migration of required. Abdominal wall stomas had to be surgically revised either the stent had been observed. In cases where redressing was because of prolapse (3 pts) or difficult self-catheterisation (2 pts) or required before the stent had to be removed, dressing could be stricture (skin level or channel) (3 pts) or incontinence (2 pts). done easily without affecting the stent fixation. Two cases (6.8%) Conclusions: The GI segment used for augmentation should be had partial stent blockage that was related to the inside end of the long enough to ensure adequate capacity and low intravesical stent as proved after stent removal. pressure but not so large to foster electrolyte absorption. Conclusion: This simple technique for stent fixation in Detubularization of small or large bowel is obligatory. There is no hypospadias repair is an easy, cheap and suitable for any type of evidence based data which part of the alimentary tract should be dressing. used. Abdominal contint stoma without augmentation is usually not advised.Vesicoureteral reflux can spontaneously be solved following successful augmentation without antireflux plasty. Penoscrotal Transposition Success of augmentation mainly depends on the parenteral and Eltayeb.A M.D, Eltayeb .A.A MRCS, M.D, Ibrahim.A. M.D patient compliance and their close cooperation (regular ICC and Assiut university hospitals, Assiut, Egypt. bladder wash outs).

Penoscrotal transposition (PST) is a rare congenital anomaly of the external genitalia in which there is a partial or complete positional Antenatal Hydronephrosis exchange between the penis and scrotum. Concomitant Mohamed Eissa genitourinary abnormalities often life threatening in nature is University of Cairo Children’s Specialized Hospital, Cairo, Egypt frequently seen and major malformations involving other organ system may also be present. Chadha et al (1999) reported one Early relief of urinary tract obstruction is of utmost importance, case with PST and Kolligian et al (2000) reported 15 cases.Pinke et especially if the obstruction is in the developing kidney. Diagnosis of al (2001) reported the largest, single institution series of 53 patients hydronephrosis in utero is not difficult thanks to the wide use of 1 day to 30 years old with PST. They found a positive family history ultrasonografy which not only diagnosis obstruction, but also in 13%, abnormalities in other organs in 32%, hypospadias in 79% supplies enough data to predict the outcome and prognosis of the and chordee in 81%.Meguid et al (2003) reported 3 cases and ostruction, and a to put a plan for interference either ante or post Aslan et al (2005) reported another one. natal We report a 34 weeks newborn male (one of twin) with PST. There was no history of parental consanguinity but both parents are young. No family history of such anomaly. Laparoscopic Nephrectomy In Children No history of maternal medication or exposure to irradiation during Hisham El Safouri pregnancy. There is history of complicated pregnancy in the form of Ain Shams University, Cairo, Egypt pre-eclamptic toxemia. The child reached the neonatal ICU markedly cyanosed, bradycardic (HR 20/min) hypothermic and went Introduction: Children with multicystic and dysplastic kidneys into apnea with active resuscitation HR reached 140/min then the require nephrectomy to avoid future complication. The use of the baby was put on nasal O2 (3L/hr) where the O2 saturation was laparoscopy to remove these diseased kidneys has been feasible 70%. and has avoided large incisions for removal of usually small kidneys.

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Patients and methods: over a period of 3 years laparoscopic Experience with Bladder Exstrophy Complex in Kenya (Update) nephrectomy (LN) and nephroureterectomy (LNU), has been Safwat S. Andrawes performed for 18 patients with dysplastic and multicystic non- Gertrude’s Garden Children’s Hospital, Nairobi, Kenya functioning kidneys. Background: Bladder exstrophy is an uncommon pediatric surgical Results; the procedure was completed in all 18 patients via a condition. In developing countries its features and management transperitoneal approach with no conversion to the open technique. present unique challenges. The age ranged from 4 months to 15 years. Laparoscopic Methods: Medical records of all children operated for Bladder nephroureterectomy (LNU) was performed in 10 patients, while 8 Exstrophy, Epispadius and Cloacal Extrophy by the author between required LN. The operative time ranged from 40 to 90 min. There 1990 and 2005 were retrospectively reviewed. were no early postoperative complications. One patient later Results: There were 28 patients, only 50% of whom presented in developed an umbilical port site hernia. the first year of life. Several children had multiple previous Conclusion; Laparoscopic nephrectomy (LN) and unsuccessful repairs. The standard approach involved 3 stages: I: nephroureterectomy (LNU) in children are feasible and safe minimal bladder closure at presentation without iliac osteotomy; II: invasive technique. epispadias repair, 2 years after stage I; and III: continence procedure. Standard bladder neck reconstructions had limited success and were therefore replaced by a continent Mainz pouch II Nephrectomies in Children procedure (a modified ureterosigmodostomy) at the age of 5-6 years Soualili zinedine, Ait yahia.nedjar.Guettouchi. s Touabti were done for 3 cases. Two were followed for three years with good Faculte de medecine de setif, Algeria results. Follow-up was impaired by wide geographic distribution and accessibility, but short-term results were favorable The kidney insures the equilibrium of water and electrolytes it plays Conclusions: Despite specific challenges in developing countries, a very important role in the growth. Throughout a retrospective bladder exstrophy can be successfully treated in such settings.Their study of 60 cases and over a 10 years period a predominance of is a learning curve in managing these cases. More surgeons must nephrectomies at the boy is raised and a decrease is noted with be trained to address the significant need. Continence issues have age so we could define three varieties of nephrectomy etiologies to be revisited. the surgical removal of kidney for instance is more delicate in the case of tumoral pathology. A controlled plan for the remaining one is necessary this means that the applicable arguments are Augmentationcystoplasty with Extramural Subserous Tunnel absolutely necessary to achieve this gesture Ureteral Reimplantation in Children: Early Experience. Saad A, Youssef M, El-Metwally H, Mokhless I, and Hanno A. Department of pediatric Urology, University of Alexandria. Duhamel Procedure as a Continent Urinary Diversion for Complicated Bladder Exstrophy in Children Purpose: Evaluation of the use of extramural subserous tunnel Mohamed A Baky Fahmy ureteral reimplantation in children with small hypocompliant bladder Department of Pediatric Surgery Al Azher University, Cairo, Egypt and high grade reflux. Materials and methods: 5 cases of small hypocompliant bladder Introduction: Whatever the method and timing of surgery, a high with a mean age of 3 (range 2-6 years). All cases had bilateral proportion of children with bladder exstrophy will continue to suffer reflux G III at least and a small capacity high pressure native from urinary incontinence. They face the options of urinary bladder hindering reimplantation into it. In all cases augmentation diversion to an external stoma or construction of a neobladder from ileocystoplasty was done with bilateral subserous tunnel bowel. To our knowledge this is the first trial in a paediatric reimplantation of the ureters (10 units). In 2 cases an additional population of a Duhamel-Martin Rectal Pouch for continent urinary catheterizable stoma was done using the same technique for diversion. continence. Mean follow up period is 17 months (range 3-36). Materials and Methods: Three boys and one girl, 4-7 years of age, Results: In all cases bladder capacity and compliance are had several operations for bladder exstrophy commencing in the improved. Of 10 reimplanted ureteral units, one is refluxing (10%), neonatal period. All had good renal function and no other non is obstructed with empty bladder. anomalies, but were incontinent of urine and had a small contracted Conclusion: Bladder augmentation with subserous tunnel or prolapsed bladder. Following anorectal manometry, EMG, and a reimplantation is a valid option in cases of small hypocompliant barium enema they underwent urinary diversion to the rectum, with bladder and bilateral reflux to avoid reimplantation in the non insertion of both ureters in a subserosal tunnel in the rectal wall. healthy bladder. Using the Duhamel-Martin pullthrough technique the proximal colon was opened into the back of the anal canal, reducing the risks of Single Stage Repair of Bladder Exstrophy. Alexandria urine-faecal mix and hyperchloraemic acidosis associated with Experience in Redo Cases and Children Presenting at an Older ureterosigmoidostomy. Age Results: There were no major operative or postoperative Haytham Badawy, Ahmed Abd Elwahab, Shaaban Samir , Elsalmy complications. Follow-up from 6-18 months gave acceptable results Salah, Elrifai Alaa, youssef Mohammed, Ashraf Saad with no deterioration in renal function, no infection or Pediatric Urology, Department of Urology, University of Alexandria, hypercholermic acidosis. The children can hold up to 180 ml of Egypt urine and evacuate every of 3-4 hours. Nocturnal wetting occurs 6-8 times per month. Three children had postoperative diarrhea with Purpose: Evaluation of the possibility of achieving cosmetic and perianal skin excoriation, which ceased spontaneously in 2 cases functional closure with continence and preservation of renal function and was controlled with medication in the other. using single stage repair of exstrophy epispadias complex in older Conclusion: Four children achieved effective urinary continence by children and those with previous failed repair. ureteric diversion to the rectum, using the anal sphincter for both Material and methods: 15 children (12 boys, 3 girls) with classic urinary and faecal control. The proximal colon and anal canal were bladder exstrophy, of whom 8 children had previous failed repair anastomosed using the Duhamel-Martin pullthrough technique, and 7 children presented in older age. 6 boys and 3 girls were thereby reducing the risks of faecal-urine mix and hypercholaemic repaired using single stage Mitchell technique; remaining 6 boys acidosis associated with ureterosigmoidostomy. repaired using single stage closure with modified Cantwell Ransley technique for epispadias repair. The average age at repair was 8.6

62 Annals of Pediatric Surgery

Abstracts Presented at EPSA/ PAPSA Joint Meeting, 14-18th November 2005, Alexandria, Egypt

months (2-4). Anterior iliac osteotomy was performed in all children Superposed diphalia. Case report and hip spica was used for the immobilization. Nour El Kholi Results: We had one urethral stricture treated by endoscopic visual Department of Pediatric Surgery, Alexandria Faculty of Medicine, urethrotomy. Three penopubic fistulae closed spontaneously. Egypt. Vesicoureteral reflux encountered in 20 renal units but ureteral reimplantation was not performed in any child with good renal Male boy, Four years old - Born in Alexandria, Birth rank: 3rd of 4 growth. Average bladder capacity of 134 cc (110-160) was siblings (sole male). Presented with ambiguous super sized penis. encountered with 5 continent, 3 partially incontinent and 7 Advised by the pediatrician to wait for surgery. Normal dorsal penis incontinent children. Average follow up period is 2 years (1-3). with a ventral smaller penis. Urethra in the dorsal phallus. The small Conclusions: Single stage repair could be performed for children ventral phallus if devoid of urethra. Ventral prepuce is deficient. with previous failed repair and those presenting at an older age with Excision of the ventral small phallus. Coverage by Byars' flaps from satisfactory bladder and genital outcome achieving a good bladder the dorsal prepuce. capacity together with preservation of renal function. The impact of Review of the literature this technique concerning the continence rests to be determined in the long follow up period Spina Bifida in Kenya: Lessons from the First 500 Patients at Kijabe Correcting Penile Curvature without Shortening Hanneke Meester, Toos van‘t Veer, Dan Poenaru, Richard Osama K. Shaeer, Bransford Cairo University, Egypt BethanyKids at Kijabe Hospital

Introduction: Surgical correction of penile curvature starts with Background: Spina bifida is a serious and frequent condition in release of the tethering tissues (chordee), after which the penis is Kenya. Maternal folic acid deficiency has been shown to be re-assessed. If curvature still persists, it is corrected by shortening implicated in its aetiology, and studies have shown that folic acid the longer aspect of the tunica albuginea which results in a shorter supplementation leads to a marked reduction in the incidence of penis, or lengthening the shorter aspect by grafting which may this condition. We have undertaken an analysis of the children with result in graft contraction or erectile dysfunction due to venous leak. spina bifida treated at our institution, for the purpose of identifying Corporal rotation corrects ventral curvature in hypospadias patients useful features in their presentation and outcomes. by rotating the corpora cavernosa medially without the Methods: The medical records of all infants with spina bifida forementioned hazards. However, to this date, it could only be treated at AIC Kijabe Hospital and its “daughter” institution Bethany applied in hypospadias patients. Crippled Children’s Centre of Kenya (BCCCK) between January Aim: We report on the corporal rotation technique, customized for 1998 and October 2004 were reviewed. Data collected included the management of ventral curvature in patients without demographics, clinical features at presentation, treatment and hypospadias. outcomes. Data were entered and analyzed in an Excel Methods: Twelve adult patients with ventral congenital penile spreadsheet. curvature and a normally positioned meatus were operated upon Results: There were 500 patients, 230 female (46%) and 270 male with curvature ranging from 20 to 90 degrees. After releasing (54%). Their spinal defects were myelomeningoceles in 430 (86%), chordee, the neurovascular bundle is mobilized for a short distance meningoceles in 31 (6%), lipomeningoceles in 31 (6%), and other in (1-3 cm) at the point of maximum curvature. After testing, the 6 (1%). There was associated hydrocephalus in 306 patients (61%), corpora cavernosa are approximated to each other in the midline by with incidence varying from 0% in lipomeningoceles to 69% in suturing pairs of longitudinal parallel incisions, one incision in each myelomeningoceles. Orthopaedic co-morbidities were encountered corpus. In case the urethra is narrowed, minimal dissection is used in 102 patients (20%), tethered cord in 11 (2%), and other to develop the groove on either side of the corpus spongiosum conditions in 11 (2%). The motor level was found to be intact in 44 Results: All patients had full correction of the curvature. Erection, children (9%), thoracic in 189 (38%), lumbar in 133 (27%), and ejaculation and urination were normal. Only one patient with a 90 sacral in 44 (9%). In 32 children (6%) the level was asymmetric, degree curve had some hardly noticeable dimpling of the dorsal and in 51 it was not recorded (10%). shaft. Of the 500 children, 371 (74%) had their spinal defect closed at our Conclusion: Corporal rotation can be effectively and safely applied institution; in 5 children (1%) the defect had already scarred over, for correction of ventral or dorsal penile curvature in patients with 52 (10%) had their surgery elsewhere, and in 72 children (14%) the and without hypospadias. There is no risk of shortening to the penis information was not available. The median age of closure at our and minimal risk of injury to the neurovascular bundle. institution was 46 days (range 0 – 8 years). A ventriculoperitoneal shunt was inserted in 261 children (52%), at a median time of 14 days after the closure of the spina bifida. Urethroplasty in Children There were 90 deaths in the entire group (18%) at a mean follow-up Shaaban S, Youssef M, Saad A, El-Metwally H, El-Salmy S, Hanno of 17 months; 85 of these (94%) were among the A, and Mokhless I. myelomeningoceles. Up-to-date follow-up data is available on 180 Section of pediatric urology, Department of Urology, University of children (44% of those not known to have passed away). At the last Alexandria. follow-up visit, 126 (70%) were reported to be doing well, 17 (9%) “Fairly well”, and 37 (21%) not well. Purpose: Assessment of the different urethroplasty techniques Conclusions: Spina bifida presents as a spectrum of conditions used in the pediatric urology unit in children. with different characteristics as well as outcomes. Many children Materials and methods: twenty eight boys with post traumatic with spina bifida appear to be doing well after the closure of the urethral stricture indicated for urethroplasty. End to end defect. A multi-disciplinary, integrated program with thorough follow- anastomosis was done in 18 cases. Local skin flaps with different up is essential to improving the quality of life of these children. techniques were used in 10 cases. Preventive measures such as folic acid supplementation in all Results: twenty seven cases needed either no further management women of child-bearing age are critical to reducing the incidence of or endoscopic visual urethrotomy. One case needed re-do surgery. this serious condition. Conclusion: Urethroplasty is a successful treatment in urethral stricture in children when the proper technique is used

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Abstracts Presented at EPSA/ PAPSA Joint Meeting, 14-18th November 2005, Alexandria, Egypt

Urethral Duplication in Children Zakria Habib, Muhammad Awan, Al-Nassar Saleh Sameh A Hay; Alaa F Hamza; Tarek A Hasan; Amr Abdelhamid; King Faisal Hospital & Research Centre, Riyadh Saudi Arabia Hatem A Safaan; Ahmed A Darwish; Ehab A El-Shafei. Ain Shams University, Cairo, Egypt Background: Feasibility and safety of performing minimal invasive surgery (MIS) for pancreatic pathologies (Benign & Malignant) in Background: Duplication of the urethra is an uncommon anomaly. chidren. Urethral duplications are complex anomalies, and different Methods: This is retrospective analysis over a period of two years embryologic abnormalities are thought to be responsible for the between May 2003 to June 2005. A laparoscopic approach was many variations seen. Most duplication occurs in the same sagittal used to manage eight children for various pancreatic disorders. Age plane; that is, they occur one on top of the other. Less commonly, ranged from 3 months to 12 years with equal sex distribution. duplex urethras lie side by side. This is the usual finding in children Results: The laparoscopic procedure was completed in all except with a completely duplicated phallus. one. Operating time ranged from 150 to 600 minutes. The Patients & methods: We retrospectively reviewed the records of pathologies for these patients were Nisidoblastosis in 3, 12 male patients treated for urethral duplication in the last 10 years. Pancreatitis in 2 and malignant tumors in 2.There were no operative Age at presentation ranged from newborn to 8 years. Evaluation complications in these children. included ultrasound, voiding cystourethrography, retrograde Conclusions: This limited experience with laparoscopic pancreatic urethrography and endoscopy. surgery demonstrates its feasibility, safety and provide a way back Results: A blind ending duplicated urethra (type I) was present in 3 if further procedures are needed. patients, 2 independent urethras with separate origins from the bladder (type II A1) in 4, 2 urethras with common origin from the bladder (type II A2) in 4, and complete duplication of the bladder Laparoscopic anterior gastropexy for gastric volvulus in the and phallus (type III) in 1. pediatric population Conclusion: urethral duplication is a rare congenital anomaly with a Khalid Husein variable clinical presentation. Surgical management should be University of Cairo Children’s Specialized Hospital, Cairo, Egypt planned individually according to the anatomical findings of the abnormality Background: Gastric volvulus (Latin volvere, to roll) is rotation of

all or part of the stomach more than 180°, which may lead to a closed-loop obstruction and possible strangulation. First described Minimal Invasive Surgery in 1866 by Berti, gastric volvulus remains a rare clinical entity. Patients and methods: Three cases of gastric torsion presented to the department of pediatric surgery, Cairo University Pediatric Minimal Access Surgery in Neonates and Infants Hospital. The patients were investigated with respect to associated Aayed Al-Qahtani anomalies, radiological diagnosis, surgical treatment and prognosis. Department of pediatric, King Saud university, Riaydh All the patients were treated with a laparoscopic anterior Background Minimal access surgery (MAS) in small infants caries gastropexy. an important consideration. The tolerance of these small babies and Results: All the patients reported complete resolution of the the assumed physiological effect of MAS, in addition to the required symptoms following the procedure and were discharged, within 48 anesthetic and surgical skills have made it difficult to perform these hours of the surgery. types of procedures in many international centers. The present Conclusion: Laparoscopic anterior gastropexy offers a simple safe article will review our experience with MAS in neonates and infants solution to chronic torsion of the stomach in pediatric population in the first year of life. Methods: The medical records of all infants who underwent minimal access surgery over a period of three years were Laparoscopic Appendectomy: present status and what is new? retrospectively reviewed for demographic information, procedures, Turial S, Abdel-Aziz G., Kläger M., Hückstädt Th., Schier F. operative time, complications, outcomes and follow-up. Most of the Department of Pediatric Surgery, University Medical Centre Mainz, operations were performed with 3-mm instruments and scopes and Germany mean insufflation pressure of 10 mm Hg (range, 4-15mm Hg). Result 70 infants were included in this study. 19 girls and 51 boys. Introduction: Considerable controversy remains concerning the The weight ranged from 1.3 to 8.2 kg (mean 4.3 kg). The mean age preferred approach to appendectomy in children. In this series, we was 93 days (range 1 day to 12 months). 24 of these infants were analyze a last two-year experience with our technique and neonates (34%). Procedures performed included, repair of tracheo- Management of Appendectomy. esophageal fistula (TEF), lobectomy, repair of diaphragmatic or Material and Methods: Laparoscopic appendectomy is the hiatus hernias, pull-through for imperforated anus and standard technique for our patients since 2 years. A total number of Hirschsprung's disease plication of the diaphragm, Kasai's 173 patients were operated (71 children, aged 1 week to 14 years, procedure, excision of choledochal cyst, pyloromyotomy, ladd's median age 10.2 years) Out of these, 33 patients had undergone procedure and reduction of intussusceptions .There were two open surgery,134 had undergone laparoscopic appendectomy, 6 conversions, both in neonates with TEF. All patients tolerated the patients were converted to the open approach. Twenty eight procedure very well with lesser degrees in neonates undergoing patients had perforated appendicitis (16 lap. 3 converted and 9 thoracoscopic procedures. Two neonates had Postoperative open) pathologically, 91 patients had ulcerative phlegmonous hypothermia (<35 C) and one neonate had high Pco2 appendicitis (73 lap, 3 converted, 15 primary open).the other 54 postoperatively. There was one mortality and no morbidities. The were either catarrhal or chronic appendicitis follow-up ranged from 1 month to 3 years (mean 19 months). Results: Median operative time in the laparoscopic group was 45 Conclusion: MAS in neonates and infants are safe and well minutes (35-190). Post operative stay: lap: 3, 4 days, open: 5, 4 tolerated. Intraoperative monitoring of end-tidal Co2 and core days temperature are essential in avoiding unwanted effects of Complications: 5 patients had persistent abdominal pain, 3 performing these procedures especially in neonates. patients had prolonged ileus after open appendectomy, 2 patients had umbilical abscesses (following laparoscopic resection of a perforated appendix) and 3 patients sustained intraperitoneal Minimal Invasive Surgery (MIS) For Pancreatic Pathologies in collection. Patients had undergone conversion due to inexperienced Children. surgeon, loss of the appendix in the abdominal cavity after

64 Annals of Pediatric Surgery

Abstracts Presented at EPSA/ PAPSA Joint Meeting, 14-18th November 2005, Alexandria, Egypt

resection, very big appendix to be extracted via the trocar, or Mohamed Hobeldin, Azzam Alzobie, instrument failure Division of Pediatric Surgery & Pediatric Oncology - Shaikh Khalifa Conclusion scientifically speaking, it is not still well settled if Medical City – UAE laparoscopy appendectomy is really better or associated with a rapid post-operative recovery as our subjective impression may A two year old boy presented with chest infection. Investigation suggest. The rapidity of postoperative recovery is more related to showed left apical mass, tumor markers were checked and tru-cut the underlying pathology, the surgical manipulation and the needle biopsy was done. The biopsy was diagnostic of thoracic presence or absence of associated peritonitis. Neuroblastoma. Preoperative chemotherapy was given followed by As a rule, laparoscopy has an advantage as a diagnostic tool Thoracoscopic excision of the tumor. A case presentation with especially in experienced hands. Generally speaking in experienced review of the literature. hands, even the most difficult cases of appendicitis can be handled laparoscopically with good results and with minimum risks. Laparoscopic repair of an inguinal hernia associated with crossed testicular ectopia in an infant: Case Report Laparoscopic repair of type VI hiatal hernia in Children Mohamed M Elbarbary, Ayman Hussein Mohamed M Elbarbary, Ahmed E. Fares University of Cairo Children’s Specialized Hospital, Cairo, Egypt University of Cairo Children’s Specialized Hospital, Cairo, Egypt Background: Giant hiatal hernia is defined as herniation of the Background: The usual presentation of crossed testicular ectopia bowel (eg, spleen, colon or omentum) through the oesophageal is that of inguinal hernia with contralateral absent testis. hiatus together with the stomach. It is a rarely reported clinical form Material and methods: We report on a 10-month-old infant with of hiatal hernia in childhood. Clinical presentation of children with crossed testicular ectopia, which presented as inguinal hernia. this problem is nonspecific and usually consists of persistent Diagnosis was made preoperatively. vomiting, hematemesis or a more life threatening complications like Results and conclusion: Laparoscopic herniotomy with transseptal gastric volvulus or splenic infraction. Although technically orchidopexy of the ectopic gonad to the opposite hemiscrotum was challenging, laparoscopic repair of giant hiatal hernia has been done. The child remained asymptomatic 1 year postoperatively reported before.

Material and methods: We present giant type IV hiatal hernia in two girls. A 6 year old female child was referred to our section after Laparoscopic management of recurrent inguinal hernia in being diagnosed of having right sided diaphragmatic hernia. The children diagnosis was suspected on a plain chest x-ray done for the Salmai Turial, Gaber Abdel-Aziz, Katrin Wolf, Felix Schier diagnosis of repeated chest infection and abnormality in the contour Department of Pediatric Surgery, University Medical Centre Mainz, of the chest. She had already a CT scan done that confirmed the Germany presence of both a gastric shadow together with bowel loops in the right chest cavity and fluoroscopy showed non paradoxical Introduction: In the literature there is increasing number of reports movement of the right copula. Right thoracoscopic repair was concerning the laparoscopic management of congenital inguinal attempted. At the beginning of the procedure a hernial sac was hernia. We report in the following study the possibilities of seen coming out from the posterior mediastinum. The procedure application of laparoscopy in cases of recurrent hernias following was abandoned when examination of the right diaphragmatic laparoscopic or open repair. copula proved to be intact. An upper gastrointestinal contrast study Material and Methods: The study includes 16 recurrent hernias in confirmed the presence of a giant mixed type hiatal hernia 15 children (age 4 months. to 18 years, median age 5, 4 years) Out containing the stomach, small and large bowel. The second 7 of these, 11 patients were recurrences after laparoscopic repair and month old girl presented with recurrent attacks of vomiting and 5 were recurrences after open herniotomy. hematemesis. Upper endoscopy and upper gastrointestinal series The recurrence was almost always on the medial side in the confirmed the presence of volvulated stomach in the chest. laparoscopic recurrent group. Three out of the other 5 patients Laparoscopic repair was attempted. (recurrent hernias after open surgery) had unfamiliar forms of Results: Laparoscopic repair was completed successfully in both hernias; direct and femoral. In one patient, we had to convert and to cases. The stomach was reduced in the abdomen after dissection perform an open inguinal exploration. of the hernial sac. The Crura were approximated primarily with no Results: Median operative time was insignificantly longer prosthetic material using four 2-0 non-absorbable sutures (two compared to the primary laparoscopic herniotomy. The behind and two in front of the esophagus). The procedure was postoperative management was not different. We had neither intra complete after Nissen’s fundoplication was performed. Operative nor postoperative complications. time was 180 and 150 minutes in the first and second case Conclusion: In our opinion, Laparoscopic re-do herniotomy is respectively. No significant intraoperative events or retention of easier, more cosmetic and has a low complication rate in carbon dioxide were noted. They were kept for first one comparison to open re-do surgery. Laparoscopy provides new postoperative day in a pediatric intensive case facility. An aspects of inguinal recurrent hernias and allows for type-specific intraperitoneal drain was inserted near the repair and was removed repair .There is essentially no big difference in the technique of once oral intake was established on the second postoperative day. laparoscopic redo herniotomy whether the previous repair was open Both were discharged from the hospital on the third postoperative or laparoscopically done day. Both remain asymptomatic 9 months postoperatively.

Conclusion: Although giant hiatal hernias in children have only been very rarely reported, this clinical condition may mimic other Does Laparoscopy Have A Real Role In The Management of chest pathologies. The dissection was difficult, but by sticking to the Non-Palpable Testis? Analysis of Single Center Experience with diaphragmatic crura during dissection proved an effective and safe 125 Children technique to free the esophagus and stomach. Laparoscopic repair Haytham Badawy, Hanno Ahmed, Mokhless Ibrahim, Shaaban of a giant hiatal hernia is feasible with an excellent postoperative Samir, Elsalmy Salah, Elrifai Alaa , Youssef Mohammed, Ashraf course. Saad, Assem Akram, Alaa El-Ghonemi

Pediatric Urology, Department of Urology, University of Alexandria,

Egypt&. Hôpital Robert Debré Pediatric Surgery and Urology Paris Thoracoscopic Excision of Neuroblastoma FRANCE

Vol 2, No. (1), Jannuary. 2006 65

Abstracts Presented at EPSA/ PAPSA Joint Meeting, 14-18th November 2005, Alexandria, Egypt

Objective: The management of non palpable testis (NPT) remains brought about a significant change in the surgical repair of these controversial. The real benefit of laparoscopy over the open surgery diaphragmatic conditions. Thoracoscopic approach for is yet questionable. We analyzed our series of NPT operated by diaphragmatic hernias has been performed in adults but experience laparoscopy over a period of 7 years to determine its exact role. in children remains limited being performed in only a few centers Patients and methods: From 1997 to 2004, 125 children (146 throughout the world. NPT) with a mean age of 41 months (7-264) have been operated Material and Methods: Cases with congenital diaphragmatic using laparoscopy. Twenty one (16.8%) children had bilateral NPT, defects presented over a period of 18 months had undergone an while 104 (83.2%) children had unilateral NPT. Fifty three (36.3%) attempt at minimally invasive surgical repair. Candidates for NPT were on the RT side and 93(63.7%) were on the LT side. laparoscopic correction were children having mild symptoms with Results: The testicular location by laparoscopy is intra-abdominal good respiratory and haemodynamic conditions. in 72 (50%), intracanalicular in 24(16%), vanishing testis syndrome Results: The study included 22 cases with congenital (VTS) in 43 (29%), true testicular agenesis in 7 (5%). Primary diaphragmatic defects: six Morgagni hernias with a large part of the laparoscopic orchidopexy was performed for 24 testes. The position liver herniating into the sternocostal hiatus (Larry hernia) in 2 cases; of the testes after orchidopexy is intrascrotal in 23 (95%) (5 at the six Bochdalek hernias (five of them were left-sided); seven cases of neck of the scrotum, 18 at the bottom of the scrotum) and 1 (5%) at esophageal hiatus hernia, one of these was a large hernia of the the pubic tubercle. 18 (75%) testes are normal in size while 6(25%) mixed sliding/ paraesophageal type and three cases of testes are smaller than the normal side with no testicular atrophy. diaphragmatic eventration, two of them were right-sided. Multiple stage fowler Stephens orchidopexy has been performed to Thoracoscopic repair was performed for three cases of Bochdalek 37 testes. The position of the testes after orchidopexy is intrascrotal hernias (all of them were left-sided) and for all 3 cases of in 35 (94.5) (8 at the neck of the scrotum, 27 at the bottom of the diaphragmatic eventration. Their ages varied between 3 days – 48 scrotum) and 2 (4.5%) at the pubic tubercle. Twenty six (70%) are months with a mean of 8.6 months. Four newborns were operated normal in size, 9 (24%) are small and 2 (6%) are atrophic with a upon: a case of Morgagni, 2 cases of Bochdalek and a case of mean follow up of 10 months (1-48). Laparoscopic orchiectomy was eventration. Thoracoscopic repair was adopted in 3 of them (2 performed for 2 atrophic testes. Bochdalek and an eventration). Minimally invasive surgical repair Conclusion: laparoscopic orchidopexy has a satisfactory outcome was successful in all cases except in one case of Larry hernia, concerning the final position of the testis and the testicular viability. which was converted to open surgery. Dacron mesh was only used Orchiectomy for atrophic testes can be performed easily by in the case of Morgagni-Larry hernia. Nissen fundoplication was laparoscopy. Laparoscopy permits the diagnosis of true testicular performed for all hiatal hernias. Injury to the pleura occurred in one agenesis with certainty. In VTS, it permits the differentiation case of hiatus hernia and a port site hernia in another case. between intra-abdominal and intracanalicular types hence Occasional vomiting resulted following repair of a case of hiatus alleviating the need to perform unsatisfactory inguinal exploration hernia; this was managed conservatively. There was no recurrence with a follow-up period of 3 -16 months. Conclusion: Under specific conditions, minimally invasive surgery Thoracoscopic Surgery for Pulmonary Sequestration in can be an effective and more advantageous alternative to Children. laparotomy for congenital diaphragmatic defects in children. Pascal de LAGAUSIE*, Jean Christophe DUBUS**, Guillaume Thoracoscopic repair appears to have easy access in cases of GORINCOUR***, Florence NICOLAS ****, Jean Michel GUYS* Bochdalek hernias and in diaphragmatic eventration. It results in Department of Pediatric Surgery (*), Pediatric Pneumology (**), better respiratory function. A longer follow-up period is needed for Pediatric Radiology (***) and Pediatric Anesthesiology (****). Hôpital evaluation of the technique. la Timone, AP-HM, France

Background: the aim of this report is to assess the technique and Laparoscopic pyloromyotomy versus circumumbilical outcome of thoracoscopic pulmonary sequestration resection in umblical approach children. Tamer Yasin Methods: from May 2001 to June 2005, 9 consecutive patients with University of Cairo Children’s Specialized Hospital, Cairo, Egypt a prenatal diagnosis of pulmonary sequestration underwent thoracoscopic lung malformation resection. Single lung ventilation Background: Ramstedt pyloromyotomy through a right upper was used in all. The aberrant artery was identified, isolated and quadrant (RUQ) transverse incision has been the traditional controlled with endo-ligature. Lower thoracoscopic lobectomy was treatment for hypertrophic pyloric stenosis. Recently, laparoscopic then performed. Follow up ranged from 4 to 62 months. (LAP) and circumumbilical (UMB) approaches have been Results: Over the 9 patients, only one had a preoperative attempt introduced as alternative methods to improve cosmesis, but of embolization. Mean age at surgery was 10 months (range 4-44). concerns about greater operative times, costs, and complications Seven lesions were on the left lower lobe and 2 were in the right remain. This study compares the three operative techniques and lower lobe. Seven infants were operated successfully by examines their advantages and complication rates. thoracoscopic approach. Two had conversion. Mean operative time Study design: We performed a prospective study of patients was 155 minutes. Average hospital stay was 3.4 days. There were undergoing pyloromyotomy at Cairo University Pediatric Hospital, no postoperative complications. between January 2004 and June 2005. Conclusions: Thoracoscopic approach for pulmonary Results: 25 patients underwent pyloromyotomy by LAP (n =9), sequestration is technically feasible. Early resection obviates the RUQ (n = 8), or UMB (n = 8). Complication rate, time to add risk of infection. Rather than using stapling devices or clips, elective feeding, incidence of emesis, and postoperative length of stay did aberrant artery ligature is a safe procedure. Cosmetic result after not differ considerably among groups. Two LAP patients were thoracoscopic procedure is excellent. converted to RUQ Mucosal perforation occurred in three patients each in the RUQ and UMB groups, but none in the LAP group. Operative times were considerably less for LAP (25 - 9minutes) Thoracoscopic versus Laparoscopic Repair of Congenital than for RUQ (32- minutes) and UMB (42-2 minutes) (p0.05,) Diaphragmatic Defects in Children. Conclusions: Advantages of LAP include a shorter mean operative Nabil El Douski time without higher complications or costs. UMB is associated with University of Cairo Children’s Specialized Hospital, Cairo, Egypt the greatest mean operative time and costs. Laparoscopic Background: Surgical procedures are frequently performed on the pyloromyotomy is a safe and effective approach to the treatment of diaphragm in children. The development of video-assisted surgery hypertrophic pyloric stenosis

66 Annals of Pediatric Surgery

Abstracts Presented at EPSA/ PAPSA Joint Meeting, 14-18th November 2005, Alexandria, Egypt

Minimal Access Surgery in the Treatment of Abscesses Cantrell. All patients were approached via the abdomen. In 16 Mohamed Hobeldin, Seifelislam Abdulsalam patients, a sac was found. Operative repair with prosthetic material Division of Pediatric Surgery - Shaikh Khalifa Medical City - UAE was required in 7 patients only (primary tissue repair in 32, and 3 Retrospective review of all soft tissue abscess cases presented to refused surgery). Eight patients required post-operative ventilation SKMC and treated by the auther over a period of 4½ years. These and there were 5 significant complications (pneumonia in 3, jejunal cases were abscesses at different sites and were treated using a perforation in 1 and adhesive obstruction 6 years later in 1). There new concept of minimal access technique. Results are evaluated, were 2 deaths. Mean hospital stay was 11 days (4-27 days). principals of the technique are presented and advantages and Conclusion: Patients with CDH who present late usually present disadvantages of the new method are discussed as emergencies with respiratory complaints and gastrointestinal problems. Early surgical repair is associated with minimal mortality and morbidity.

Thorax Congenital Cystic Malformations of the Lung in Children Surgical Interventions for Broncheictatic Changes of the Lungs Nabil Desouky, Sherif Kaddah in the Pediatric Age Group University of Cairo Children’s Specialized Hospital, Cairo, Egypt Talal Al-Malki Taif University- -College of Medicine & Medical Sciences, Taif, KSA Background/ Purpose: Congenital cystic malformations of the lung (CCLM) are rare and vary considerably in their embryology, Objective: To see the effect of “custom-designed” surgical presentation, management and outcome. The aim of this study was resection of some severely damaged parts of the lungs in children to report the series of these anomalies detected at the New with bronchiectasis for children. Children’s Hospital of Cairo University, comparing the data with the Design: All children with bronchiectasis – post lipoid pneumonia or current literature and clarify the controversies about their diagnosis idiopathic – who failed to respond to medical treatment had surgical and management. removal of most affected parts of their lungs. Methods: Children who had CCLM presenting with variable Subjects and settings: Nine children aged between 7 and 12 degrees of respiratory distress were diagnosed and managed in the years with lipoid bronchiectasis were referred to pediatric surgical Pediatric Critical Care and Surgical Units over a period of 10years, service for surgical treatment. The study was at Asir Central between 1995 and 2005. Radiological studies included both chest Hospital Abha, a referral hospital in Asir region of Saudi Arabia and x-ray and computed tomographic scan (CT scan). Ultrasonography a Teaching Hospital for College of Medicine and Health Sciences, was performed in some cases. Intensive respiratory management King Khalid University and Al-Hada Military Hospital at Taif. and control of infection- if present- was initiated and once stabilized, Main outcome measures: There was an improvement in the Surgical management was performed. Extracorporeal membrane quality of lives of all the children. oxygenation (ECMO) support was not available in the hospital. Results: There was no surgical mortality. Apart from mild cough, all Histopathological evaluation was performed for most of the lesions. the preoperative symptoms of the children disappeared. Two Pulmonary function tests were only done for 5 patients to assess children died more than 6 months post- operatively due to the them postoperatively. Follow up period ranged between six months extent of the original disease. and 5 years Conclusion: Surgical resection designed to remove the most Results: Forty children consisting of 29 boys (46 %) and 34 girls affected parts of the lungs in diffuse-type bronchiectasis is (54 %) having CCLM were diagnosed and managed. Their ages recommended when there is failure of medical treatment. ranged from two days to nine years. Ten cases (16 %) presented in the neonatal period 42 cases (67 %) during infancy and 11 cases (17 %) in childhood. There were 34 patients (54 %) of congenital Congenital Diaphragmatic Hernia Presenting After 28 Days lobar overinflation (CLO), 20 patients (32 %) of bronchogenic cysts M.H. Sheik-Gafoor, AS Shaik, GP Hadley, NC Campbell (BC), 5 cases (8 %) of congenital cystic adenomatoid malformation University of KwaZulu-Natal, South Africa (CAM) and 4 cases (6 %) of pulmonary sequestration (PS). Respiratory distress of varying degrees was the presenting Objectives: To review the clinical presentation, management and symptom in 55 cases (88 %), while recurrent chest infections surgical intervention in patients with congenital diaphragmatic occurred in 8 cases of B C (12 %).The right lung was affected in hernia who present beyond the neonatal period. Design: 32cases (51%), while the left lung was affected in 30 cases (48 %); Prospective cohort study of all patients with congenital these included only one patient with CLO, the lung was affected diaphragmatic hernia (CDH) presenting after 28 days of age, to the bilaterally and a mediastinal form of BC. Generally, the upper lobes Department of Paediatric Surgery, University of KwaZulu-Natal, were the mostly affected lobes (n=39) the right one in 19 and the Durban, between January 1989 and June 2005. left in 20 .This was followed by the lower lobes (n=20), ten for each Patients: Children greater than 28 days and less than 12 years of side, while the right middle lobe was affected in 5 cases. age with congenital diaphragmatic hernia were reviewed. Lobectomy was performed in 58 cases while isolated resection of Demographic data, clinical presentation, radiological findings, the cyst was done in one patient where the cyst was attached to the operative findings and outcome were recorded. whole lung. Total pneumonectomy was performed in 2 cases. Results: Forty-two patients out of 84 with CDH met the inclusion Conservative management was done successfully in 2 patients. criteria of the study. The median age at presentation was 10.4 The postoperative pulmonary function tests revealed 20 % months (1-48 months) and 29 were males. The majority presented reduction of the functional residual capacity with low compliance. as emergencies (n=30). Respiratory signs alone were the Recurrence of the cyst occurred in one patient. The mortality rate commonest presenting feature in 25 patients and combined with was 8 % (n = 8), three of these died preoperatively. gastrointestinal complaints in a further 7 patients. Seven patients Conclusions: This review showed that CAM and PS were not presented with gastrointestinal complaints only and 2 were common lesions as compared to other series. Respiratory distress asymptomatic. Associated anomalies were present in 10 patients. of varying degrees is the most common presenting symptom. C T The diagnosis was made in all with a chest x-ray. Ten patients also scan is a diagnostic postnatal imaging modality especially if x-ray is had a contrast meal. In 24 patients the hernia was a left sided not confirmative, ultrasonography can be used antenatally. defect, right sided in 9 and bilateral in 2. Three patients had Mechanical ventilation was a risk factor and this should be Morgagni hernias, 3 para-oesophageal and 1 a Pentalogy of considered in planning for management. Lobectomy is the surgical

Vol 2, No. (1), Jannuary. 2006 67

Abstracts Presented at EPSA/ PAPSA Joint Meeting, 14-18th November 2005, Alexandria, Egypt procedure of choice for most of the lesions. Further studies are Departments of Pediatric Surgery, Pediatrics, Radiology, and needed to assess the applicability of thoracoscopy in management Anatomopathology, Aleppo University Hospital. Aleppo-Syria of these conditions and the late functional effects of surgical Ewing sarcomas, although are rare malignant tumors in children, management of these lesions in children. their dominant localization is in the femoral bone, the other osseous localizations are less frequent. The Use of Hernial Sac for Abdominal Wall Repair In Difficult We report a case of 4years old child in whom the parents noticed a CDH Cases recent and progressive appearance of tumefaction in the right side Hisham Elsafory of the thoracic wall. Ain Shams University, Cairo, Egypt The plane X-rays, CT scan, show a solid mass of 8.5 cm in the right middle thoracic wall in continuity with the right middle pulmonary Abstract: Introduction: In patients with congenital diaphragmatic lobe and partial destruction of the fifth rib with subcutaneous hernias, abdominal wall closure may be difficult. Reckless closure bombing accompanied by moderate hydrothorax and right lobar may cause abdominal compartment syndrome. The use of a mesh atelectasia. in abdominal wall closure may significantly increase the costs, in Surgical and aspiration's biopsies were realized under general addition to the other hazards of using a mesh. Direct skin closure anesthesia, this will reveal a malignant Ewing Sarcoma in this may cause some difficulty in subsequent muscle closure, due to the Tumor. The management began by course of chemotherapy over developed adhesions between the bowel, liver and skin. Patients about 2 months, where a new clinical and radiological evaluation and methods: over the last 14 months, 5 patients underwent CDH will show the diminution and limitation of the tumor mass. The repair with anterior abdominal wall repair using the CDH sac to skeletal scintigraphy will confirm the absence of metastases and the cover the abdominal contents before skin closure. The abdominal limitation of the tumor mass in the right thoracic wall. muscles where not closed. Results: four patients survived, while A complete surgical resection of the tumor mass with central one patient died in the early postoperative period. Two patients resection of the 4th ,fifth, and sixth ribs with complete dissection required further surgery for ventral hernia repair. One patient from the lobar tissues the parietal gap was closed by muscular flaps required surgery for correction of adhesive small bowel obstruction; from the neighboring muscles. he had a simultaneous closure of the abdominal wall. The last The histopathology will prove the Ewing's nature of the tumor with a patient has an unrecognizable ventral hernia that will not require free margins tumor resection. The thoracic drainage was left for 3 further surgery. Conclusion: the use of the CDH sac in closure of days and the patient will leave the hospital on the fifth day. A the abdominal wall instead of direct skin closure over the abdominal complementary chemotherapist course is realized. Fourteen contents may facilitate subsequent proper muscle closure. months follow up shows the absence of recurrence with good clinical findings.

State of the Art of Modified Nuss Funnel Chest Repair; Prospective Study of 424 Adolescents Extralobar Pulmonary Sequestration Associated with Congenital Klaus Schaarschmidt Diaphragmatic Hernia Helios Center for Pediatric and Adolescent Surgery Berlin-, Essam Elhalaby, Amel Hashish, Fersan Salam Germany Departments of Pediatric Surgery, and Pathology, University of Tanta, Egypt Background/Purpose: Thoracoscopic Nuss repair has a significant complication rate: 8-24% bar dislocations, cardiac/aortic, Background/ Purpose: Extralobar pulmonary sequestration (EPS) diaphragmatic and hepatic injuries and soft tissue problems. To is a rare congenital anomaly characterized by nonfunctioning reduce these problems we modified indication and technique embryonic pulmonary tissue that has no communication with the following all patients prospectively. normal tracheobronchial tree. The association of EPS and Methods: 4/2000-9/05 Nuss repairs were performed in 424 congenital diaphragmatic hernia (CDH) has been considered very adolescents and young adults (11-41 years, mean 17.4 years ± 6.1 rare with only few cases reported in the English literature. The aim years; 67 females) using HDTV-monitors., and bilateral 30° lens of this study is to report two new cases and to highlight the and thoracic epidural. We applied our own modification management of this association. (submuscular extrapleural bars, fixed by 8-12 thoracoscopically Patients& Methods: Two male patients aged 6 and 12 weeks placed pericostal sutures, JPS 2002/JPS 2005) on principle we presented with recurrent chest infection and respiratory distress. don’t operate before puberty and leave bars beyond the termination Chest X- rays and contrast upper gastrointestinal studies confirmed of growth. 284 (67%) patients had asymmetry, 146 patients got two the herniation of bowel loops in the left hemithoraax in the first or three bars and in the recent 324 patients the bar(s) was (were) patient and on the right side in the second. A 10 ×8 cm mass placed extrapleurally located in the abdomen and partially protruded in the chest through Results: Mean Follow up was 35.5 ± 9.5 months (2 - 66 months) a left diaphragmatic defect was discovered only during exploration and all children were followed prospectively at three monthly in the first patient. Initially, the mass was looking as if it is a part of intervals and yearly intervals after bar removal. There were four the left loop of liver but with a clear plane of dissection. The mass rethoracoscopies one for late hemorrhage after two month one for has a large well defend infradiaphragmatic blood supply directly spontaneous pneumothorax after four months and two for persisting from the abdominal aorta. After reduction of the other herniated pleural seroma all effectively dealing with the respective problem. loops of bowel, excision of the mass, and repair of the left CDH was There was no major complication one early pericarditis and not a done successfully. single bar dislocation. In 192 patients, the bars were removed The second child has a right CDH with a distinct sac. After without problems with 173 excellent, 17 good and two fair results, reduction of the herniated loops of bowel and excision of the hernial which underwent subsequent, redo Nuss. sac a 3 ×5 cm intrathoracic mass was noted just lateral to the Conclusions: Modified Nuss is a safe and reproducible technique mediastinum at lower part of the chest cavity. The mass was and despite selecting the difficult adolescent patients, has reduced completely separate from lung tissue and has an ill-defined blood complication significantly below reported rates. supply. Excision was done followed by repair of the diaphragmatic defect. The histopathplogical examination confirmed the presence of pulmonary tissue in both excised masses. Both infants recovered uneventfully and continued to be asymptomatic at one-year follow Ewing Sarcoma in the Right Thoracic Wall up. Omar Abdulwahed, K.Khanji, I.Otaba, M.Sharaf, MN.Akil.

68 Annals of Pediatric Surgery

Abstracts Presented at EPSA/ PAPSA Joint Meeting, 14-18th November 2005, Alexandria, Egypt

Conclusions: 1. Every pediatric surgeon should be aware with the esophageal FBs were extracted, 4 had already passed into the association of EPS and CDH, which may be more common than stomach by the time of procedures, and one had negative generally thought 2. A high index of suspicion for associated esophagoscopy. The most common site of FBs impaction was in anomalies should be maintained during the management of patients the upper esophagus (55% radiologically and 51% by with CDH. . oesophagoscopy). McGill forceps was used to extract 6 FBs, the rest were extracted using rigid esophagoscopy. There were no

complications related neither to the procedure nor to the FB

themselves. Long Gap Esophageal Atresia: An Australian experience Conclusions: The rigid esophagoscopy was successful in Saud Al-Shanafey, John Harvey extracting all esophageal foreign bodies that required this Children’s Hospital at Westmead, Sydney, Australia procedure. It proves to be safe and efficacious. We have found

good correlation between radiological and esophagoscopic Introduction: The diagnosis of Long gap esophageal atresia localization of the se FBs. Furthermore, we re-emphasize the (LGEA) may preclude immediate primary anastomosis; however importance of repeating the radiological evaluation just before going both the definition of LGEA and its management vary widely. We to the operating room to avoid unnecessary procedures. reviewed our experience with this entity over a period of 10 years.

Methods: Retrospectively, charts of patients managed for

esophageal atresia (EA) were reviewed over the period from 1991 Post Corrosive Esophageal Injury in Children; Routine to 2001.Oesophageal Atresia was defined as ‘Long Gap’ when it Dilatation or Dilatation When Symptoms Arise? was considered that primary anastomosis was not possible due to Mohammed Aly Youssef the length of the gap between the upper and lower segments. Alexandria hospital for sick children –Sporting, Alexandria Demographic and clinical data were collected and analyzed.

Results: 103 patients with EA were managed over that period, 17 Introduction: Esophageal injury due to ingestion of corrosive (16%) of them were defined as LGEA. There were 10 males and 7 substances occurs predominantly in the pediatric patient population females with mean gap of 5 cm (SD 1cm). 8 patients (47%) had and remains a significant problem. The signs and symptoms may tracheoesophageal fistula (5 distal, 2 proximal, and 1 both). 16 vary from minimal erythema to severe respiratory distress and the patients had gastrostomy tube insertion at a mean age of 4 days. 6 degree of injury could be mild, moderate or severe. patients had esophagostomy at a mean age of 27 days. 13 patients Aim of the work: The aim of this study was to define a protocol to had EA repair at a mean age of 146 days. 7 patients had delayed deal with cases of post corrosive esophageal injury in children primary repair, 3 of them had Gough flap and 2 had myotomies. 5 Patients The patients were divided into to two groups; group A 95 patients had gastric tube interposition and 1 had gastric pull up. 4 patients whose files were studied retrospectively and to whom patients died before repair and 2 after repair secondary to routine dilatation of the esophagus was done, and Group B 27 associated anomalies. 6 patients had complications post repair cases whom were classified into mild, moderate and severe cases including anastomotic leak (2), anastomotic stricture that needed with esophagoscopy and dilatation was done only to the revision (1), bilateral pneumothoraces (1), aspiration pneumonia symptomatic patients. (1), and voice hoarseness (1). Results: 15 % only of the patients of the severe type of injury Conclusions: LGEA represents a surgical challenge. Mortality rate needed dilatation. is high secondary to associated anomalies. Delayed repair seems Conclusion and recommendation: Only a small percent of the appropriate with use of native esophagus if possible. Replacement cases of post corrosive esophageal injury need dilatation which procedures reserved for patients in whom the later option failed. should be done after diagnostic esophagoscopy and only for the

symptomatic cases

Rigid Esophagoscopy and Esophageal Foreign Bodies in

Pediatric Patient Abdulmonem Abdulmonem Gado, Aayed Al-Qahtani, Neonatal Surgery Abdulrahman Al-Bassam, Haytham Esmat Eltantawi Department of Pediatric Surgery, King Khalid University Hospital, Surgical Procedures Performed In Neonatal Intensive Care Unit Riyadh, KSA (NICU): Feasibility and Safety Abdulmonem Gado, Abdulrahman Al-Bassam Department of Pediatric Surgery King Khalid University Background/Purpose: Most complications of pediatric foreign Critically ill neonates who require surgery are routinely transferred bodies (FB) ingestion are due to esophageal impaction. Since this to operating room (OR). Transferring unstable ill neonate to and impaction may lead to significant morbidity (and even mortality) from OR can cause significant problems and morbidity. These removal of impacted esophageal foreign bodies is mandatory. include to name a few, wasting of valuable time, potential for Rigid esophagoscopy is one of the most commonly used means of endotracheal tube or intravenous line disconnection, transfer esophageal foreign body extraction. We conducted this study to hypothermia, discontinuation of monitoring, incompatibility between evaluate the diagnostic and therapeutic outcomes of this procedure equipment in the OR and the NICU. In view these considerations, in pediatric patients. in 1999 at KKUH we started to operate on those critically ill Methods: We conducted a retrospective review of all pediatric neonates in the NICU. Various procedures have been performed patients who were diagnosed to have esophageal FBs and ranging from minor ones like central lines, peritoneal dialysis underwent rigid esophagoscopy from 1995 to 2005. Clinical catheter insertion to major procedures such as laparotomy, bowel presentations, radiographic and esophagoscopic findings were resection, stomas formation, repair of congenital diaphragmatic obtained. hernia, repair of abdominal wall defect, PDA ligation, etc… We Results: Forty-six patients were included, 24 males and 22 report our experience with 36 neonates whose surgical procedures females. The mean age was 4.4 years (range, 8 months to 12 were performed within the NICU. Advantages and disadvantages of years). The most common symptom was drooping of saliva 71% such approach are discussed. Experience of others who adopted which was combined with other symptoms in most of the patients the same approach will be mentioned. Conclusions and (vomiting, respiratory distress and dysphagia). Underlying recommendation on the feasibility and safety of performing surgery predisposing conditions were found in 17% of cases. 45 FB (97%) in NICU will be given. were visualized radiologically, 51% of them were coins. 41

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Abstracts Presented at EPSA/ PAPSA Joint Meeting, 14-18th November 2005, Alexandria, Egypt

The Management of Gastroschisis in a Limited Resource The baby was maintained on NPO, NGT&TPN from that time, Environment with a very slow adaptation process for her short bowel Mbuwayesango syndrome. On 10th day of operation she passed stool & she had Zambia gastric residues, for that she is on NPO & TPN. To the best of our knowledge, this is the first described gastroschisis with Background: Gastroschisis is a well-known neonatal emergency associated anomalies treated & surviving in Palestine. throughout the world. It is associated with a very high mortality in limited resource environments. Purpose: This study was carried out to review a new method of Surgical Problems in Down's syndrome in the Neonatal Period treatment of gastroschisis that may result in reduced mortality. Ashraf Ibrahim, Talal A Al-Malki Materials and Methods: A consecutive case series review was Khamis Mushait Military Hospital), Taif University-College of employed. Data was collected including the age, birth weight, Medicine& Medical Sciences, KSA grade of peel, time to complete bowel reduction, time to closure of abdominal wall, time to complete oral feeding, complications and Objective: To study Down's syndrome associated congenital outcome of neonates with gastroschisis. The data was analysed anomalies and to observe the fate of those anomalies management using simple proportional statistics. Subjects and settings: Over eight years a total of 38 Down’s Results: A total of 17 patients were treated with a survival rate of syndrome babies were admitted to the NICU / Aseer Central 65%. The average time to complete bowel reduction was 3 days. Hospital, KSA for a variety of medical/surgical problems related to Conclusion: It appears that this new method of treatment of their accompanying congenital anomalies. 33 / 38 were full terms gastroschisis in a limited resource environment may be associated and at the time of the study only 12 were proved genetically and the with a higher survival rate. rest later. Imperforate anus was observed in 13, duodenal obstruction in 8 and Hirschsprung’s disease in 7. necrotizing enterocolitis in 3. Some anomalies presented in combinations

Results: Surgical and medical management were offered according Intestinal Diaphragms: Experience with Membrane Excision to the anomalies, despite that management overall mortality were 6 Saber M Waheeb, Mohamed A Abouheba, / 38 (3 medical & 3 surgical). Shatby Hospital for Sick Children, Alexandria University, Egypt. Conclusion: Although this is a small study but it brings to attention

that Down’s syndrome newborns may present with a variety of other Background: Intestinal diaphragms are easy to diagnose. We associated anomalies which may be of detrimental effect if not present our experience with diaphragm excision as opposed to diagnosed early and managed promptly and correctly. bypass surgery in 16 consecutive cases.

Purpose: Case series report of neonatal intestinal diaphragm

Material & Methods: 16 cases of single small bowel diaphragms Unusual Presentations of Duodenal Obstruction are included with exclusion of multiple diaphragms & other types of Ahmed A. Gani Gomaa, Mohamed A. Baky Fahmy MD, FRCS atresia. Proximal entrotomy was done with delivery of the Pediatric Surgery Dept El Galaa Teaching Hospital diaphragm & its excision with hemostatic suturing was done in all cases. No tube bypassed the excised diaphragm before closure Background: Duodenal obstruction may be caused by atresia, without drains. All cases were followed up for 6 months. stenosis, duodenal diaphragm or web, congenital bands, intestinal Results: Eight Duodenal (50%), 2 jejunal (12.5%), 4 ileal (25%) & 4 malrotation, annular pancreas, preduodenal portal vein, and colonic (25%) diaphragms were reported. 4 cases had Down's duodenal duplication. Duodenal atresia and stenosis is a frequent syndrome (25%) & 2 had VSD (12.5%). All neonates presented in st cause of congenital, intestinal obstruction. the 1 week of life. No proximal ectatic pouches were noticed in any Aim of the work: This work aiming is to study the clinical of the cases, therefore there was no need for bowel resection. No presentation, investigations and management of patients with leakage was recorded & no injury to duodenal ampulla was duodenal obstruction presentations to detect unusual one. detected. All cases opened their bowel 3-5 days postoperatively. All rd Material and Methods: This study includes 30 patients with cases started oral feeding on the 3 post-operative day, 12 of them duodenal obstruction diagnosed and treated in pediatric surgery (75%) tolerated full feeds within 48 hours, while 4 cases (25%) department in El Galaa teaching hospital, Cairo, Egypt. They are of required 7-8 days to reach full feeds. different age ranges, pathology and different presentations. Some Conclusion: In our experience, diaphragm excision represents an of them diagnosed antenatally and the others later on. easy technique with operative risk of leakage & shorter hospital stay Results: This study included 30 babies with duodenal obstruction. compared to bypass surgery (duodenoduodenostomy in duodenal There were 19 girls and 11 boys. 18 (60%) patients were premature diaphragms). No need for TAT tube & babies tolerated feeding (gestational age < 37weeks) and 5 (28%) had Down’s syndrome. quickly. We believe that it is easy to perform & easy to teach junior Ten (30%) babies had associated congenital anomalies. Five surgeons in-training. patients (16.6%) had an unusual presentation, pathology and

different age of presentation.

Conclusion: Duodenal obstruction may be associated unusual Gastroschisis with Associated Anomalies in a Premature Baby presentations and different age of presentation, and that type of Taiser Milhem patients need a special attention for their proper management. Hebron, Palestine.

A 2140 Gr, 34 GW was born to a 21 years old primipara Predoudenal portal vein not causing duodenal obstruction palestenian female .she arrived to pediatric surgery hospital th associated with intestinal malrotation: A case report after 16 hours with Gastroschisis & Duodenal atresia (4 part) & Abd Elmoniem shams Jejunal atresia with 70 cm. Of ileum were found. Small intestine Pediatric surgery, Azhar Univeresty, Cairo were one mass adhesive to each other, the colon was straight, very narrow & short Duodenostomy & primary closure Abstract: preduodenal portal vein is a rare anomaly described in performed. TPN started. On the fifth postoperative day second only 82 patients in the literature In few patients, the preduodenal operation was performed. Seperation of the small intestine from portal vein was the direct cause of duodenal obstruction, in this each other, checking of the patency of the short bowel & colon, case ,the patient has a preduodenal portal vein not causing then Duodeno-Ileostomy (End to Oblique) anastomosis done.

70 Annals of Pediatric Surgery

Abstracts Presented at EPSA/ PAPSA Joint Meeting, 14-18th November 2005, Alexandria, Egypt

duodenal obstruction ,associated with intestinal malrotation { Ladd’s involvement of pediatric surgeons gives the best outcome. bands} However, adult surgeons could have good results as well, if they become aware that children are not just small adults. Pediatric Trauma

A Potentially Fatal & Strange Penetrating Injury, In a Fortunate

Child: A Case Report. Scotchcart Injuries in Zimbabwe Khaled Saad Ashour, Dube, Harare Central Hospital Department of Pediatric Surgery, Alexandria Faculty of Medicine, G I Muguti, Medical School Department of Surgery Egypt. S Rusakaniko, Medical School Department of Community Medicine

Introduction: Although children are more prone to all sorts of Introduction: Scotchcarts are a common mode of transport in trauma, sharp penetrating injuries are less common than blunt some communities and over the past years there has been an trauma, being merely recorded in child abuse. This can be ascribed increase in scotchcart injuries from observations of hospital records. to the less availability of sharp objects among children population, Most of the cards are home made and usually drawn by either cattle as well as the highly recorded road traffic accidents, which bring or donkeys. about prevalence of blunt injuries. Nevertheless, penetrating injuries Aims of the Study: To determine the types of injuries sustained in in children are potentially fatal especially in the neck and chest. scotchcart injuries and the case fatality rate. Patient: A five-year old male child was presented to the pediatric Results: One hundred and one patients were seen. Age range emergency center, Alexandria University with a sickle “Sharp, was 3-80 years with a median age of 16 years. Seventy-two curved, and serrated knife”, transfixing the right side of his neck, percent of patients were males. Sixty-one percent of the patients with the site of entrance anterior, and that of exit posterior. presented with painful limbs, 7.8% abdominal pain with 8.5% having However, consciousness was retained and vital signs were stable. had loss of consciousness. The mean Revised Trauma Score was Results: Immediate surgery was performed to determine the 7. The mean Revised Trauma Score for those who died was 2.833. relation of the sickle to the important structures of the neck, and the Case fatality rate was 4%. possibility of removal without much injury to tissue. Surprisingly Conclusions: Scotchcart injuries generally cause minor injuries enough, the sickle took a very strange course in the child’s neck, with only a minority having severe injuries needing hospitalisation. being lateral to the trachea, and medial to the carotid sheath, as if it Mortality associated with these injuries is low but more information pushed the sheath laterally to protect it. Moreover, the thyroid gland is needed to fully appreciate these injuries. as well as the right recurrent laryngeal nerve was preserved. The

child was dismissed on postoperative day three. Conclusion: Although apparently fatal, this kind of trauma could be Blunt Abdominal Trauma In Children With Solid Organs exceptionally safe. However, the chance to have the same course Injuries; Experience In 24 Cases by any transfixing injury is nil. Ahmed khairi , El-Kholi N , Tolba M

Department of pediatric surgery, Alexandria, Dallahhospital Riyadh, KSA Surgical Infection Background/ Purpose: Multiple traumas are the leading cause of mortality and morbidity in children. Although operative management was the preferred method of treating blunt abdominal trauma (BAT) Surgical Ramifications in HIV / AIDS in Children in the past, recent literature and practice recommend a non-surgical H. Rode, A. Numanoglu, J. Karpelowsky approach for most pediatric solid organs injuries. We present our Department of Paediatric Surgery, Red Cross War Memorial experience in managing such cases. Children’s Hospital, University of Cape Town. Methods: The study retrospectively analyzes the data of children with (BAT) and proven solid organs injuries that had been managed Aids in Africa has become a full-blown pandemic and is on its way by the authors over a period of 4 year. to becoming the single greatest threat to human security on the Results: From December 2000 through December 2004, 24 continent. It presents with either prodromal symptoms, a protracted children with (BAT) and solid organs injuries were managed. The illness or a rapidly developing fulminating disease. Effective HIV mechanism of injury was road traffic accidents (RTA) in 19 cases management has broadened the scope of treatment options and (79%), sport-related in 4 (17%) and falling from a height in 1(4%). surgical procedures are increasingly becoming more common. The spleen was injured in 13 children (54%); the liver in 12 children HIV positive children have similar complications as non-infected (50%), the kidneys in 3 (13%), and the adrenal glands in 2 (8%). children with the same pathology. A structured surgical approach is Other systems involved were head injuries in 13 cases (53%), chest utilized in children with Aids. Alternative diagnosis should be in 11 (46%), extremities in 8 (33%), spinal in 4 (17%) and pelvis in 2 contemplated, and a higher morbidity and mortality must be (8%). Thirteen cases were treated conservatively (53%), and 11 expected. Emergency surgery is often done for diagnostic cases operatively (47%). Operations targeting the spleen (total= 6) purposes or to treat bowel obstructions, haemorrhage, perforations were splenectomy in 3 (50%), partial splenectomy in 2 (33%) and or a variety of opportunistic infections. splenorraphy in 1 (17%). In one of the cases who underwent In clinical practice, infants and children often present with splenectomy, left-sided diaphragmatic tear was repaired during the septicaemia, abscesses, skin necrosis, eye conditions, same procedure. Those targeting the liver (total = 6) were suturing condylomata, localized or widespread tuberculosis, candida, herpes tears in 4 (67%) (With splenectomy in 1) and perihepatic packing in infections, CMV infections, malignancies i.e. non-Hodgkin’s 2 (33%). The mean time of hospital stay was 6.5 days. Four lymphoma, leiomyosarcoma, Kaposi sarcoma or lymphoproliferative children (17%) died from their injuries; (2) due to severe chest disorders. injuries, (1) due to spinal fracture, and (1) due to severe liver injury In addition, the GIT may be involved with a diversity of pathology with massive hemoperitoneum (1). varying from stomatitis, esophageal disease, malignancy, infections Conclusions: Children with blunt solid abdominal organs injuries and perineal diseases. can be treated successfully without surgery if the decision is based CONCLUSION: Surgery has become routine in children with HIV. on their hemodynamic status and response to resuscitation. Surgical diseases are modified by HIV and require innovative Managing these cases in pediatric trauma centers with the modifications in approach and techniques. An increase in morbidity

Vol 2, No. (1), Jannuary. 2006 71

Abstracts Presented at EPSA/ PAPSA Joint Meeting, 14-18th November 2005, Alexandria, Egypt and mortality in category B & C is seen. There are many fecal incontinence (1 pt), intestinal obstruction (2 pts), nerve injury unresolved problems which will be addressed as we gain more (1 pt), thorax deformity (4 pts), and scar formation resulting in experience with this disease. psychological problems (12 pts). Chemotherapy alone (41 patients) resulted in side-effects in 19 patients. Radio and chemotherapy in combination (23 patients) Antibiotic Policy of Pediatric Surgery Unit in Kuwait. resulted in side-effects in 20 patients. Fifteen patients did not Saleema Al Ramadan, Eman Mokkadas, Sunil Kumar, Ali Askanai receive adjuvant therapy. The most serious late side-effects were Department of Pediatric Surgery Ibn Sina Hospital Kuwait 24 spinal deformities (half of them severe), breast underdevelopment, muscular deformity, renal damage. Height and Purpose: To establish our own antibiotic policy in department of weight gain decreased (p<0.01 and p<0.05, respectively) in the first pediatric surgery in Kuwait since 1995-96. To prevent abuse of 8-10 years of the follow-up and accelerated significantly (p<0.05 antibiotics to control resistant organisms and nosocomial infections. and <0.05, respectively) in the second half of the follow-up. Methods: Review of antibiotic policy is done on yearly basis in Infertility, due to the shortage of follow-up time (21-26 years), collaboration with our Microbiologist. Results of all cultures (blood, permits only limited analysis. urine, swabs, drain sites, tip of catheters and endotracheal tubes) in Conclusions: Whenever possible surgical excision should be the neonatal and pediatric wards, intensive care units and surgical treatment of choice. No routine aggressive chemotherapy is theaters were obtained. The laboratory results of isolates are indicated. Radiation therapy frequently resulting in long-term tabulated according to organisms, source, and sensitivity patterns. musculo-sceletal morbidity should be avoided. Catch-up somatic Results are analyzed and discussed in joint meeting of Pediatric development occurred in the second part of the follow-up. surgery, Microbiology and infection control units. Results: During year 1995-96 empirical therapy for septicemia was ampicillin, gentamycin and metronidazole. Review of all cultures Management of Hepatoblastoma and Hepatocellular Carcinoma revealed increased resistance of gram negative bacteria to in Children: ampicillin and gentamycin hence in 1997 the policy was changed to Millar AJW cefuroxime amikacin and metronidazole but after few months of use Liver Unit and HPB and Transplant Surgery, Birmingham Children’s of cefuroxine we had serratia outbreak in neonatal ICU and ward. Hospital, Birmingham, UK There were 6 neonates infected with serratia 4 of them died and 2 recovered. That was the reason to shift the policy to cefotaxime, Primary malignant liver tumours represent less than 2% of all amikacin and metronidazole as triple regimen in 1997-1998. In childhood cancer with an incidence of 1-1.5 per million children per 1999 we switched to pipracillin – tazobactum and amikacin for year. Hepatoblastoma (HPBL) and hepatocellular carcinoma (HCC) neonatal septicemia, but for pediatric cases we retained cefotaxime, are the tumours most frequently seen. The ratio of HPBL to HCC amikacin and metronidazole. In 2001 we continued with previous varies around the world from 6:1 in the USA to 1.6:1 in developing policy but recommendation for life threatening septicemia was to countries. HPBL differs from HCC in many respects. More than start imepenum and meropenum immediately. We were quite happy 80% of liver tumours in children less than 15 years are HPBL with with this policy until 2004 when our review showed increased multi an associated genetic influence occurring in about 50% of cases. drug resistant gram–ve bacteria (Pseudomonas and Klebsiella) with Other associations include low birth weight, Beckwith-Wiedeman high mortality. Incidence of ESBL organisms was increased and this syndrome and familial polyposis coli and are thought to be due to was attributed to use of cefotaxime hence it was completely inactivation of the APC tumour suppressor gene in about 80% of stopped. 2005 protocol was to use piperacillin-tazobactum and cases. HCC is seen predominantly in older boys and aetiology is amikacin patients in neonatal ward, ICU and pediatric ward. We associated with environmental factors and co-existing liver disease introduced Augmentin (Amoxycillin with clavilunic acid) for with the incidence being 100 times more common in HBV carriers in urological septicemia. endemic areas. There is also an increased risk in HCV and HIV Conclusion: Regularly updated antibiotic policy protocol is an ideal infection. Only about one third have cirrhosis of the liver as measure to control antibiotic misuse and control noso-comial opposed to adults where 70-90% has cirrhosis. Presentation is not infections and reduce mortality and morbidity secondary to dissimilar with an upper abdominal mass, evidence of malignant septicemia. malaise and metastases but HPBL presents much earlier in life, usually in the under 3 year old age group. Also the genetic associations would be evident. Pediatric Oncology The management of HPBL has been well developed, predominantly through the SIOP studies with a well defined disease assessment system of pre-treatment extent of disease staging into four Long-term follow-up of cancer in neonates and infants. categories. According to the SIOP system, all patients will have National survey of 142 patients pre-operative chemotherapy using predominantly the Andrew B. Pinter Adriamycin/Cisplatinum chemotherapy protocols and surgical Pécs University HUNGARY excision of the tumour two thirds way through the treatment programme. The aim is surgical ablation of the tumour. If this Purpose: To analyse the complications of surgery and adjuvant cannot be achieved through surgical resection due to multifocality chemo and radiotherapy, somatic development, fertility, mortality or involvement of portal veins then total tumour resection, i.e and survival rate. hepatectomy with transplantation is indicated provided there is no Material and Methods: From 1975 through 1983, the data of 142 residual tumour evident outside the liver after chemotherapy. The patients under the age of one year operated on for solid malignant outcome of transplantation as primary treatment is currently tumours were analysed. The follow-up period ranged from 21 to 29 considerably better than as rescue treatment for local recurrence years (mean 23). Investigations were based on the Hungarian after resection. Thus criteria for transplant would be: unresectable Tumour Registry, personal interviews with the patients and their tumour, complete removal obtained only by total hepatectomy, ie no parents, and detailed questionnaires. extrahepatic disease, chemotherapy sensitive and clearance of Results: Fifty-one patients died, 79 survived. Of the 79, 48 had extrahepatic metastases. abdominal and 31 extra-abdominal tumours (35 neuroblastomas, 21 In a Birmingham, UK series of 53 patients seen since 1990, 49 are renal tumours, 15 soft tissue sarcomas, 5 gonadal tumours, 2 alive and diseases free (92% survival). Of these 34/35 undergoing sacrococcygeal carcinomas and 1 hepatic tumour). Side effects of resection are alive (97%), 13/16 undergoing transplant are alive surgical intervention were partial urinary incontinence (2 pts), partial (81%), 50% undergoing resection and then transplant are alive and

72 Annals of Pediatric Surgery

Abstracts Presented at EPSA/ PAPSA Joint Meeting, 14-18th November 2005, Alexandria, Egypt

2 patients died due to unresectable tumour, both pre-transplant. of malignant tumours in children is 39.8%, which is much lower than The challenge is to recognize the tumour with poor prognosis early that in the Western countries, which are over 605 nowadays. (mixed, anaplastic, and macrotrabecular histology with multifocality Conclusion: Survival in developing countries is much lower than in and vascular invasion) and perhaps apply more aggressive developed countries. This is attributed mainly to delayed chemotherapy and surgery. presentation, which is due to lack of awareness and delayed Hepatocellular carcinoma is relatively rare in developed countries diagnosis with subsequent delayed treatment. and opportunities for resection are uncommon. In developing countries, most present with extensive disease and metastases, not amenable to treatment. In a few cases of either the fibrolamellar A Rare Case of Teratoma of Lingual Origin type with localised disease, seen in older children, or in those Irfan Serdar Arda, ustafa Celik, Hampar Akkaya, Akgun Hicsonmez patients being monitored for metabolic disease eg tyrosinaemia, Department of Pediatric Surgery Baskent University, either resection or transplantation is an option. In the Birmingham series 6/11 survive but in a multicentre South African study only Introduction: A rare case of lingual teratoma which caused 5/68 (7%) survived. Clearly the challenge here is prevention postnatal respiratory arrest is presented. through universal HBV vaccination along with early recognition and Case Report: Three-hour-old male patient had been examined due treatment in those with localized disease in an otherwise healthy to postnatal respiratory distress and was referred to our center liver. following an oral mass had been detected. He was brought with cardiopulmonary arrest and cardiopulmonary rescuscitation (CPR) had been applied during transportation. Physical examination Hypertension in African Children with Renal Tumours revealed a polypoid solid mass with a diameter of 2 cm originating GP Hadley, M Mars, AS Shaik, MH Sheik-Gafoor from posterior tongue which was obstructing the oropharynx. The University of KwaZulu-Natal mass was exteriorized and the patient was entubation. The mass was totally excised after the patient’s general condition improved, at Patients: 45 children with renal tumours (43 Wilms, 2 mesoblastic 1 day of age. No problem was experienced during post-operative nephromas) were admitted during the period 2002-2004. Of these, period and the patient was discharged. Histologically the excision 25 patients (56%) had elevated blood pressure (BP) on admission material was detected to have keratinized squamous epithelium, and had serum renin estimation as part of their work-up. One follicular sebaceous and eccrine skin inclusions, dermal patient presented with a stroke and four others had seizures and components in stroma, mucous glands, mature adipose tissue, altered level of consciousness indicative of hypertensive smooth and striated muscle tissue and neural structures. The mass encephalopathy. Intracranial bleeding, cerebral atrophy, was reported to be teratoma. hydrocephalus and left ventricular hypertrophy were identified as Discussion: Tongue is an unusual location for teratoma. Less than secondary pathological changes. Hypertension was defined as a 1-2% of all teratomas have an oral location. Only 17 lingual sustained rise above the 95th percentile for age and height, and this teratoma cases have ever been reported. The biggest problem was not substantiated in four of the inception cohort. All patients caused by teratoma of head and neck region is respiratory distress with malignant disease were offered neoadjuvant chemotherapy. due to mass effect. Deaths of that reason in the first hours of life Symptomatic patients and those with a poor response to primary have been reported. Securing the airway is the priority. Lingual therapy were offered antihypertensive drugs. teratoma is generally benign and totally cured after surgical Results: There was poor correlation between serum renin and level excision. of hypertension (r2=0.1292). Neither BP nor serum renin correlated with tumour mass. During the period of pre-operative treatment BP Castleman’s Disease – Increased Incidence in Developing (MAP) decreased independent of the use of 9.5) (p 32.1 – 86.8 Countries? antihypertensive drugs (mean 111.3 >0.0093). Surgery was 15.1) R.A. Brown, A. Numanoglu, H. Rode, A.J.W. Millar (p=0.04) 7.6 – 82.5 associated with a further decrease in BP Department of Paediatric Surgery Red Cross War Memorial (mean 85.4 though this failed to reach significance. No patient Children’s Hospital, University of Cape Town required long term anti-hypertensive following surgery. There was no dominant histological appearance in the resected specimens. Aim: To assess the incidence of Castleman’s Disease over the One patient died of hypertension-related heart failure during period 1983 – 2003. neoadjuvant therapy. Method: Histologically confirmed cases of Castleman’s Disease Conclusion: Hypertension is common amongst African patients were reviewed. and causes significant morbidity and mortality. Not all hypertension Clinical material: Castleman’s Disease (C.D.) – giant lymph node was associated with hyper-renin anemia. During neoadjuvant hyperplasia – is uncommon in children with only 12 paediatric cases chemotherapy hypertension improved or and without specific reported up to 1990. Seventeen children at our institution have had antihypertensive therapy. It seems reasonable to avoid specific histologically confirmed C.D. with an average age of 6.2 years (2- medication in asymptomatic patients until the BP response to 11). Thirteen presented with peripheral lymphadenopathy and two neoadjuvant chemotherapy can be assessed. had abdominal masses. Treatment consisted of surgical excision in 9 and biopsy in 8. Histology showed hyaline vascular change in 6, plasma cells in 5 and elements of both in 6. Of importance were Pediatric Oncology: General Principles and Survival Problems four associated malignancies – 3 Kaposi sarcomas and one in Developing Countries. lymphoma of the stomach. The plasma cell variant was present in Yaser Sad El Din ¾ with associated malignancies. There were no surgical Department of Pediatric Surgery, Alexandria Faculty of Medicine, complications or recurrences at follow-up. Egypt. Conclusion: An increasing incidence of Castleman’s Disease has been documented at our institution. Immune deficiencies and Background: Cancer in children is the most common cause of infective agents (Human Herpes Virus Type 6) have been death in developing countries after malnutrion, infectious diseases implicated in this increase. and accidents. The study showed that survival in the early seventies compared to the late eighties, Survivsal rate improved from 36% to 60% in USA and from 33% to 58% in UK. In the reported series of 20 years study in Alexandria University, the overall 5years survival

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Abstracts Presented at EPSA/ PAPSA Joint Meeting, 14-18th November 2005, Alexandria, Egypt

the advanced age of mothers, consanguinity, paternal age and Miscellneous maternal medications

Risk Factors Associated With Pediatric Surgical Deaths at a Parathyroidectomy Experiences In Children With Secondary Government Referral Hospital in the Gambia) Hyperparathyroidism RM Auro, B Sanno-Duanda, SW Bickler Irfan Serdar Arda , Ibrahim Otgun, Arzu Gencoglu, Ibrahim Department of Surgery, Royal Victoria Hospital, Banjul, the Gambia Sanlialp, Ozlem Ozen, L. Hakan Guney, Aynur Ozen, Ender Division of Pediatric Surgery, University of California, San Diego, CA Fakioglu, Akgun Hicsonmez USA Background: Little is known about factors that contribute to poor Introduction: Secondary hyperparathyroidism (SHPT) is outcomes in pediatric surgical patients in sub-Saharan Africa. characterized by high parathyroid hormone (PTH) levels due to low Purpose: To identify factors associated with pediatric surgical levels of ionized calcium in chronic renal failure (CRF) cases. This deaths at a government referral hospital in sub-Saharan Africa. rare condition is the most common reason for parathyroidectomy Material and methods: Multivariate analysis of children aged- (PT) in childhood. Besides high PTH levels, ultrasonograpy (USG) under fifteen years who were admitted to the surgical ward at the and scintigraphy (SC) are frequently used diagnostic tools. Royal Victoria Hospital in Banjul, The Gambia during a 29-month Scintigraphy with Tc-99m sestamibi (SSC) during PT makes the period. Children who died were compared to children who survived operation easier. during the specified timeframe with respect to their admission Patients and Method: In our clinic, four cases (2 boys, 2 girls) diagnosis, age, sex and area of residence. under follow-up for CRF have been operated due to HPT, between Results: There were 89 deaths in 1655 pediatric surgical admission 1998-2005. Ages varied between 6 and 16 years. High blood for an overall mortality rate of 5.3%. After controlling for all variables phosphorus, alkaline phosphatase and PTH levels were detected in in logistic regression model, the odds for in-hospital mortality were all cases. USG and SC revealed doubtful lesions for adenoma highest in children aged less than one year (OR 2.9, p-value .0005), and/or hyperplasia. Medical treatment and alcohol ablasion applied those admitted with a diagnosis of burns (OR 5.2, p-value <.0001), to 2 cases were not beneficial. Subtotal PT was performed in 2 and residence outside the Greater Banjul Area (OR 6.6, p-value cases and total PT in the other 2, with implantation of almost 40 mg .01). Female sex was associated with an increased risk of death. of tissue into the sternocleidomastoid muscle. Intraoperative SSC However, the finding was not statistically significant (p-value .065). was performed in 1 case. Conclusions: Admission diagnosis, age and distance from the Results: Histopathological analysis of all cases revealed hospital are the major factors associated with in-hospital deaths in parathyroid hyperplasia. In early post-operative period, PTH levels pediatric surgical patients at the Royal Victoria Hospital in Banjul, were found to be high in subtotally parathyroidectomized cases, The Gambia. Additional studies are needed to better delineate why normal in totally parathyroidectomized and implanted cases. these categories of patients have an increased risk of death and to Intraoperative SSC use has been detected to be beneficial in develop strategies to reduce the mortality of these groups of finding the parathyroid glands more easily and in a shorter time children. period. Discussion: PT ceases the symptoms in unresponsive SHPT cases to medical treatment. Total PT and implantation with Dysmorphogenesis, Clinical Study intraoperative SC should be the preferred surgical method in these Mohamed A Osman, Mohmoud M Mostafa, Ahmed E Essa, patients. Assiut, Egypt

Introduction: Dysmorphology describes the study of human A combined femoral and canal of Nuck hernia in a young congenital defects or abnormalities of body structure that originate female: Case report. before birth, dysmorphic anomalies can occur in any part of the body Heba Ali Elbadry and most arise during the first 3 months of intrauterine life. Some of Department of Pediatric Surgery, Alexandria Faculty of Medicine, these anomalies are negligible or have only cosmetic significance, Egypt. but about 3% of all children are born with a serious structural defect that interferes with normal body function and can lead to lifelong Objectives: Femoral hernia is a rare type of fascial defect, which is handicap or even early death. encountered mainly in females. Muscle weakness, obesity, and Aim: To evaluate the prevalence, pattern of clinically detectable pelvis over tilt are the main predisposing factors in older females. congenital anomalies among neonates, infants and children However, in children these factors are lacking, and thus the admitted to Assiut University Hospital. occurrence of such variety in young children is exceedingly rare. Result: During a period of one and half years from January 2003 to Furthermore, a concurrent hernia of canal of Nuck renders these June 2004, a total 9700 cases were admitted to AUH, 620 of them cases more peculiar. have a congenital malformation. They are segregated into 222 Patient and Method: A seven year-old female child presented with neonates, 269 infants and 129 children: 119 babies have GIT left irreducible femoral hernia. Infrainguinal transverse incision was anomalies, 129 have cardiac anomalies, 75 have CNS anomalies done, reduction of the contents (ileal loop), double securing of the and 86 with urogenital anomalies. The results spotlight that the femoral canal (transfixion & occlusion of the ring). During femoral incidence of dysmorphogenesis is high with father’s age less than ring attack from within the inguinal canal, surprisingly ipsilateral 40 years old age. The incidence of dysmorphogenesis is increased canal of Nuck hernia was found. It was dealt with accordingly. directly with number of pregnancies. The prematurity doesn’t have Result: The child was discharged free on the next day; no adverse effect on the incidence of congenital anomalies. The postoperative mishap was detected during the follow-up period. incidence increased among babies came from rural area. It is Conclusions: Femoral hernia does not necessarily indicate inversely related to the maternal age showing low incidence with underlying acquired fascial weakness. A congenital defect could be age ≤ 20 years old and high with age 20-35 years old. accused, especially if combined with congenital inguinal hernia, in Conclusion: the study provides basic information about the which case, the condition can be attributed to a common congenital magnitude and spectrum of dysmorphogenesis in our community. fascial defect. The main predisposing factors in our study were multiparty, family history of congenital and rural residence. This study may support Furlow Palatoplasty: A Preliminary Study

74 Annals of Pediatric Surgery

Abstracts Presented at EPSA/ PAPSA Joint Meeting, 14-18th November 2005, Alexandria, Egypt

Mahmoud Fawzy ElBestar, Mamdouh Aboul Hassan, Purpose: Assessment of the effect and safety of the A- adrenergic ENT department, pediatric surgery department, Cairo University blocking agent (Doxazocin) in the management of non neurogenic bladder out let obstruction in children Double opposing Z plasty palatoplasty has been introduced by Materials and methods: 12 boys with non-neurogenic neurogenic Furlow in the 1980s for repair of cleft palate. The procedure bladder dysfunction causing bilateral hydronephrosis and DSD. All depends on the geometrical properties of the Z plasty in achieving children were treated with a starting dose of Doxazocin 0.5 mg at both palatal lengthening and restoration of a muscular sling. This bedtime. The dose was increased by 0.5 mg every 2 weeks until study was performed on 20 patients with cleft palate in an attempt either full response is achieved or side effects ensued. Mean age to assess the technical aspects of this procedure. The study was was 5 years (range 3-11 Y) and mean follow up period is 30 months conducted at Cairo University Children Hospital during the period (range 12-36). from September 1st, 2003 till August 31st, 2004. The overall Results: 4 cases improved on treatment with a dose of 4 mg /day success rate was 80%. Gain in length ranged from 2 mm to 6 mm and treatment is discontinued after 6 months with no need for with an average gain of 3.85 mm. Average operative time was 2 recontinuing therapy. 4 cases improved with relapse after stoppage hours and 31 minutes. No medical or surgical complications were of the drug and treated with BOTOX injection. 2 cases failed to encountered. The average follow up period was 6.1 months. respond to a dose of 6 mg/ day and side effects started to appear Flexible nasopharyngoscopy showed the results of velopharyngeal and treatment was shifted to BOTOX injection. 2 cases lost the competence after surgery to be above average. In conclusion, the follow up. double opposing Z plasty (Furlow) palatoplasty is a technically Conclusion: A-adrenergic blocking agent (Doxazocin) may be a challenging procedure, however, can attain excellent results as the valid option in the treatment of bladder outlet obstruction due to learning curve rises. Endoscopic assessment of the velopharyngeal non-neurogenic neurogenic dysfunction in children. Safety is valve might be an indicator of adequate function; however, the final guaranteed to doses up to 5 mg/day. The poor permanent success functional outcome can only be assessed by speech analysis. rate gives BOTOX the upper hand in the management of these Speech analysis of patients included in this study will be done once cases with a single injection to the bladder neck. their ages allow. This study is considered to be a preliminary step in assessment of Furlow palatoplasty (technical aspect) before recommending it as the standard of care in cleft palate repair Nasogastric tube after abdominal surgery in children. Is it necessary? Ashraf Elatar, Hesham Elmotaher, Ahmed Nofal, Ahmed Gaber, Essam Elhalaby Dr Wael Moustafa Prize Competion Session for Department of Pediatric Surgery, Tanta University

Junior Staff Background Purpose:.The prophylactic use of flexible nasogastric (NG) tubes after abdominal operations was introduced during the Defects in the Testosterone Biosynthetic Pathway in Boys with past century. It became so prevalent that it had been variously Hypospadias described up to 2002 as ‘the standard of care’, ‘common practice’ Mosbeh Amin Abdo, Hesham abd el Kader, M. Hatem Sherif and ‘routine’. However, outside the pediatric age group, this Ain Shams University, Cairo, Egypt “routine” use was critically challenged through several studies and a recent meta-analysis concluded that those who do not avoid routine Development of the male external genitalia depends on adequate NG insertion should preferably do so. Although the same principles testosterone production in early gestation. Therefore the enzymes apply, such studies in the pediatric age group are scarce. necessary for testosterone synthesis must be assembled and fully Patients and methods: This prospective study comprised 110 functional in the correct sequence between 8 and 10 weeks of children who underwent various major abdominal procedures in gestation if the urethral meatus is to advance completely to the tip Tanta university hospitals in the period between December 2002 of the penis. In theory, any deficiency of these enzymes will prevent and December 2003. Patients were equally randomized into two the completion of this process. groups: “Tube” and No tube”. Exclusion criteria included bowel Patients and methods: The work was conducted on 30 patients obstruction, perforations and intestinal atresia. Various with anterior penile hypospadias that were divided in two groups postoperative outcomes were compared, however, three end points according to the age range. Furthermore 15 patients were taken as were primary looked at: the incidence of nausea and vomiting controls. Patients and controls lab investigations mainly comprised: (PONV), the incidence of severe distension as well as the Hormonal assay: With the patients fasting, blood sample was occurrence of pulmonary complications. obtained in the early morning and then spun down in separate Results: In the “No tube” group, a significantly lesser incidence of tubes. The frozen plasma was sent to laboratory for determination pulmonary complications was met (9.1% versus 20% in the “Tube” of serum concentration of 17-hydroxy progesterone, dehydro- group). Eleven percent received an NG for severe abdominal epiandrosterone (D.H.E.A.) and androstenedione. The precursor to distension or repeated vomiting and a higher incidence, yet product ratio was then calculated before and after stimulation. statistically insignificant, of PONV was found in comparison to the From the results obtained we concluded that a high incidence of 3β- “Tube “group (12.7% versus 7.2% respectively). hydroxy steroid dehydrogenase and 17, 20-lyase enzymes Conclusions: Our study could not justify the routine use of deficiency was found in boys with hypospadias and that nasogastric decompression following major abdominal procedures hypospadias is the result of fetal Endocrinopathy. in children. An even higher complication rate has been noticed with this strategy. A selective insertion approach is advised.

Evaluation of the Use of Á- Blocker (Doxazocin) In the Management of Non-Neurogenic Bladder Outlet Obstruction in The intra-operative application of the vacuum chest wall lifter Children during Nuss repair for pectus excavatum Youssef M, Saad A, El-Metwally H, Assem A, Hanno A, and Gaber Abdel-Aziz, Salmai Turial, Thomas Hücksadt, Felix Schier Mokhless I. University Medical Center.Mainz, Germany Section of pediatric urology, Department of Urology, University of Alexandria.

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Purpose: This report describes the authors’ experience using a Abdulmonem Gado, Saquib Mallick, Abdulrahman Al-Bassam, vacuum to pull the abnormal chest wall outward in patients with Haytham Esmat Eltantawi pectus excavatum. Department of Pediatric Surgery, King Khalid University Hospital, Methods: A suction cup was used to create a vacuum at the chest Riyadh, KSA wall. A patient-activated hand pump was used to reduce pressure up to 15% below atmospheric pressure. The device was used by 60 Background: Although laparoscopic appendectomy for patients (56 males, 4 females), aged 6.1 to 34.9 years (median, uncomplicated appendicitis is feasible and safe, its application to 14.8 years), for a minimum of 30 minutes, twice a day, up to 5 complicated appendicitis is controversial. Recent studies have hours per day (median, 90 minutes). Patient progress was reported an increased risk of intra-abdominal abscess formation documented using photography, radiography, and plaster casts of following laparoscopic appendectomy for perforated appendicitis. the defect. In 14 children, this method was used during the Nuss Objective: We conducted a retrospective analysis to assess the procedure to enlarge the retrosternal space for safer passage of the feasibility of laparoscopic appendectomy in the cases of introducer. complicated appendicitis (Appendicular mass perforated appendix Results: Follow-up occurred between 2 and 18 months (median, 10 with localized or generalized pus) months). Computed tomographic scans showed that the device Materials/Methods: A retrospective study of the children who lifted the sternum and ribs within 1 to 2 minutes; this was confirmed underwent laparoscopic appendectomy for complicated appendicitis thoracoscopically during the Nuss procedure. The suction cup in KKUH, Riyadh, Saudi Arabia from January 1998 to April 2005. enlarged the retrosternal space for safer passage of the introducer. Results: 46 children aged 3 to 15 years underwent laparoscopic Initially, the sternum sank back after few minutes. After 1 month, an appendectomy for complicated appendicitis. The average duration elevation of 1 cm was noted in 85% of the patients. After 5 months, of symptoms was 3 days. The average operating time was 70 the sternum was lifted to a normal level in 12 patients (20%) when minutes; average length of hospitalization was 5 days. Post evaluated immediately after using the suction cup. All patients operative narcotic analgesic requirement was minimal. Morbidity exhibited moderate subcutaneous hematoma, although the skin rate was 8.6%. The morbidity included 3 patients (6.5%) developed was not injured. One patient suffered from transient paraesthesis in wound infection, 1 patient (2.2%) developed haematoma at the the right arm and leg. Two patients experienced orthostatic umbilical port site. There was no conversion to open and no post disturbances during the first application of the suction cup. There operative intra abdominal collection. were no other complications. Conclusions: Laparoscopic appendectomy is feasible for

complicated appendicitis; it does not increase the incidence of

complications in the hands of experienced laparoscopic surgeon Hegar-guided circular myotomy in long-gap esophageal atresia:

Revival of an old technique

Saber M Waheeb, Mohamed A Abouheba, Urethral Substitution Using Vein Graft for Hypospadias Repair Shatby Hospital for Sick Children, Alexandria University, Egypt. El-Sadat A., Shaeer O.K.Z.,

University of Cairo Children’s Specialized Hospital, Cairo, Egypt Background: Circular myotomy is a well-known technique to repair long-gap TEF. Complications associated with this procedure have Objectives: Complex hypospadias surgery requires abundant and led to its abandoning by many pediatric surgeons who prefer spiral stretchable tissues for urethroplasty. Genital skin is ideal for this myotomy or traction-lengthening procedures. purpose but is often unavailable in re-do cases. Extragenital tissues Purpose: We describe the use of a Hegar dilator inserted inside the have their drawbacks such as the limited length of buccal and upper pouch to ease the circular myotomy & perform a mucosal bladder mucosa, and contracture of skin grafts. Tubularization and pull-through to overcome the long-gap esophageal atresia. on-lay techniques comprise one or two longitudinal suture lines that Materials & Methods: We describe 10 cases of neonates with are the source of complications. long-gap (>2.5cm) type III EA&TEF (commonest). Using an extra- Aim of the Work: We investigate the possibility of using saphenous pleural approach, after ligating the distal fistula, the anesthetist vein graft for constructing a long, wide, stretchable and inserts a 10 or 12 Hegar trans-orally to dilate the upper pouch & to pretubularized neo-urethra that is not compromised by the ease the circular myotomy down to mucosa. The sero-muscular cuff longitudinal suture line. is then peeled to perform a mucosal pull-through to lengthen the Patients and Methods: A male patient with proximal hypospadias upper pouch to bridge the gap. Then the upper pouch is then for which surgical correction had failed was operated upon. The pierced at the tip & a full-thickness anastomosis is done in the usual patient had a penoscrotal meatus and was circumcised. Saphenous way around a naso-gastric tube. An extrapleural drain was inserted vein graft is passed through a tunnel that is created on the ventral in all cases. No gastrostomy was done in any case. All cases were aspect of the penis, and is anastomosed to the urethra proximally followed up for 6 months. rd and the distal opening of the tunnel at the tip of the penis. Results: NG feeding was started on 3 pop day. No leakage was Results: After 12 months, the patient had a forward stream, no reported. 3 cases required esophageal dilation up to 1 year posto- dilatation of the neourethra and no penile curvature upon morning peratively. 8 cases suffered from GER, but are still managed erection (as reported by the parents). conservatively 6 months after the procedure. Conclusion: This initial experience with saphenous vein Conclusion: Using a Hegar to stretch the upper pouch makes urethroplasty shows that the technique is feasible and may provide circular myotomy easier compared to the softer Nelaton catheter. It a reliable and practical alternative to the current techniques. also allows a proper mucosal pull-through that can bridge truly long gaps. It may be a good tool to avoid esophageal replacement in long-gap TEF. We believe that using a Hegar-dilator revives the Conchal cartilage graft in closure of cleft palate fistula: A long abandoned Levaditi's myotomy. Novel Technique

Nader Elmeligy - Ehab Zayed , -Walid Mostafa

Tanta University, Tanta, Egypt Laparoscopic Appendectomy for Complicated Appendicitis, Is

It Safe? Background: Despite the improvement in cleft palate surgery and even in the best of hands, a fistula may develop in the palate following operative repair. Residual oronasal fistulae remain a frustrating problem because of the high incidence of failure in the secondary closure that ranges between 33 and

76 Annals of Pediatric Surgery

Abstracts Presented at EPSA/ PAPSA Joint Meeting, 14-18th November 2005, Alexandria, Egypt

37%. No single operative approach consistently yielded harvested, setteled into the pocket and sutured to the successful results. mucoperiosteum. Purpose: the purpose of this study is to report our initial Results: Among 23 included patients, 6 cases were males and 17 experienceusing a new technique (conchal cartilage graft)in the were females. 16 cases had no previous trials to close the fistula, management of cleft palate fistula. Matuso (1990) reportedits use in while 5 cases had one trial and two cases had two trials. Site of the a single patient, Ohsumi (1993) confirmed its usefulness through fistula was the hard palate in 14 cases and the junction of hard and animal experiments and clinical application. soft palate in 9 cases. The fistula was small in size (<3mm) in 11 Patients and methods: This series included 23 patients suffering cases, medium (3-5mm) in 8 cases and large (>5mm) in 4 cases. from palatal fistulae following cleft palate repair who were admitted Patients were followed up for at least 3 months. Recurrence to Pediatric division of Plastic and Reconsrtuctive Surgery Unit, occurred in 4 cases, two of them were small non functioning Tanta University Hospital in the period between June 2003 and May fistulae. Recurrence was probably due to unsatisfactory formation 2005. Free conchal cartilage graft was used in the repair. The of the pocket or too small grafted conchal cartilage palatal mucoperiosteum was dissected for 3-4 mm from fistula Conclusion: This technique is easy, simple and reasonably margin creating a pocket, then a conchal cartilage graft was successful. It can be performed as a day case procedure. It involves little tissue dissection and minimizing growth disturbances

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