Afzal Sheikh

Cystic hygroma: An overview

Cystic hygromas are the cystic variety of lymphangioma, common locations being cervico-facial regions and axilla. Respiratory distress, recurrent infections or cosmetic reasons are the main indications of the treatment. The ideal treatment is complete surgical excision; however, there is a gradual conversion towards sclerosant therapy. This article reviews the current literature and discusses the various problems encountered during the management of these lesions.

Anorectal malformations in neonates.

BACKGROUND Anorectal malformations (ARM) are associated with congenital anomalies and other risk factors, yielding a poor prognosis, especially in neonatal life. OBJECTIVES This study was performed to identify the congenital anomalies as a factor of poor prognosis (mortality) in such patients. SETTINGS Department of Pediatric surgery, The Childrens Hospital and The Institute of Child Health, Lahore. DESIGN Prospective observational study, with statistical support. MATERIALS AND METHODS The information on the demography, clinical features, investigations, management performed, and outcome was entered in the designed proforma and analysed with the help of statistical software EpiInfo version 3.5.1. Statistical test: Chi-square test was used to determine statistical significance of the results. RESULTS Of 100 neonates with ARM, 77 were male and 23, female (3.4:1). The mean age at presentation was 3.4 days (range, 12 hrs to 28 days). In 60 patients (60%), the presentation was imperforate anus without a clinically identified fistula. In 28 patients (28%), associated anomalies were present. The common associated anomalies were urogenital (10%), cardiovascular (8%), and gastrointestinal (6%). Downs syndrome was present in 8 (8%) patients. A total of 15 (15%) deaths occurred in this study. In patients having associated congenital anomalies, 11 deaths occurred, whereas, 4 deaths were in patients without associated anomalies (P < 0.5). CONCLUSION The mortality is higher in neonates with ARM having associated congenital anomalies.

Management of biliary perforation in children

BACKGROUND To study the aetiology, management and outcome of biliary perforations in paediatric age group. PATIENTS AND METHODS In a retrospective study, the records of patients presented with biliary peritonitis due to biliary perforations, managed from March 2006 to July 2009, are reviewed. RESULTS Eight male patients with biliary peritonitis due to biliary perforation were managed. These patients were divided in two groups, A and B. Group A, (n = 3) patients, had common bile duct (CBD) perforation, and Group B (n=5) patients had gallbladder perforation. The presenting features were abdominal pain, fever, abdominal distension, vomiting, constipation, jaundice and signs of peritonism. The management of CBD perforations in Group A was by draining the site of perforation and biliary diversion (tube cholecystostomy). In Group B, the gallbladder perforations were managed by tube cholecystostomy in four patients and cholecystectomy in one patient, however, one patient had to be re-explored and cholecystectomy performed due to complete necrosis of gall bladder. There was no mortality in our series. All patients were asymptomatic on regular follow-up. CONCLUSION Early optimal management of biliary perforations remarkably improved the very high mortality and morbidity that characterised this condition in the past.

Decorative crystal balls causing intestinal perforation.

Crystal jelly balls are used for decorative purpose in homes and offices. They swell on contact with water. We managed a patient with a clinical diagnosis of acute abdomen. At surgery, there was fecal peritonitis and three ileal perforations caused by previously ingested decorative crystal balls.

Multiple associated anomalies in a single patient of duodenal atresia: a case report

BackgroundDuodenal atresia is a common cause of intestinal obstruction in neonates. It is associated with other congenital anomalies like Downs syndrome, annular pancreas etc.Case presentationWe present a case of a two days old male baby presented to us with bilious vomiting since birth. It was associated with Downs syndrome, Annular pancreas and Malrotation.ConclusionDuodenal atresia is associated with other congenital anomalies but more than one congenital anomalies in a single patient is very rare.

Congenital right hemidiaphragmatic agenesis.

Congenital diaphragmatic hernia is a congenital defect of the diaphragm through which intestine and other viscera herniate into the chest. In extreme form of diaphragmatic maldevelopment, there might be a complete agenesis of diaphragm. A 45-day old male infant was presented with fever, cough and respiratory distress for a week. Chest radiograph showed right-sided congenital diaphragmatic hernia. The patient underwent surgical exploration and found to have an unusual and large defect of right hemidiaphragm. The diaphragm was absent on anterior and lateral aspects of the chest wall and only a small rim of diaphragm was present on posterior aspect. The defect was identified as agenesis of right hemidiaphragm and successfully managed by suturing the posterior rim of diaphragm to the intercostal muscles and ribs. This report describes successful management of hemidiaphragmatic agenesis without incorporating a prosthetic material.

Laparoscopic management of 128 undescended testes: our experience.

BACKGROUND To describe different laparoscopic procedures in the management of impalpable undescended testes (UDT) and their outcome. Descriptive study. MATERIALS AND METHODS The medical records of all the patients, managed laparoscopically for impalpable UDT between January 2008 to March 2011 at the department of Pediatric surgery, the Childrens Hospital and The Institute of Child Health Lahore, Pakistan were reviewed for demography, history and clinical examination, investigations, operative notes, complication and outcome. RESULTS There were a total of 90 patients (128 testes) with impalpable UDT managed laparoscopically. The mean age of presentation was 4.25 years (SD±3.47). In 38 (42.2%) patients, UDT were bilateral, whereas in 33 (36.7%), these were right sided and in 19 (21%), these were left sided. Laparoscopic findings revealed 65 (50.8%) testes lying higher up in the abdomen, 26 (20.3%) testes at internal ring, vas and vessel going into the deep ring in 22 (17%) cases and 15 (11.7%) atrophied/vanishing testes. Laparoscopic 2-Stage Fowler-Stephen (FS) orchidopexy was performed in 65 testes, laparoscopic orchidopexy was performed in 26 testes, laparoscopy followed by inguinal exploration and orchidopexy in 19 testes (3 testes were atrophied) and orchidectomy was performed in 9 testes. There were three conversions to laparotomy, one for external iliac iatrogenic injury and two for adhesions of the testes with the intestine. During follow-up at 6 months, 2 patients had testicular atrophy and the parents of 5 patients where testes could be brought to the scrotum neck were worried for the location. CONCLUSION Laparoscopic management of impalpable UDT is an effective way of managing every kind of impalpable UDT. It is safe and its complications are very few.

Cystic hygroma of unusual sites: report of two cases.

Cystic hygroma is the cystic variety of lymphangiomas. Its common site is cervico-facial region, followed by axilla, superior mediastinum, mesentery and retroperitoneal region. Its occurrence in upper extremity is rarely reported, whereas its location at sternum has not been reported before. We report two cases of cystic hygroma occurring at unusual sites.

Surgical aspects of intestinal tuberculosis in children: Our experience

BACKGROUND Tuberculosis (TB) is a major health problem in resource-constrained countries. Intestinal TB is especially notorious as a number of cases have to be dealt surgically, which too have morbidity and mortality. This study was conducted to identify various presentations of intestinal TB necessitating surgical intervention, their management, complications, and outcome in our hospital. MATERIALS AND METHODS This was a retrospective study carried out at the Department of Paediatric Surgery, The Childrens Hospital and The Institute of Child Health Lahore, Pakistan, from December 2007 to January 2010. The information about the demography, clinical presentations, investigations, management performed, complications encountered, and outcome of patients with intestinal TB were reviewed. RESULTS There were a total of 18 patients with intestinal TB who were managed surgically during this period. Five were male and 13 female patients (M : F 1 : 2.6). Mean age of presentation was 8.3 years. Clinical presentations were acute peritonitis in 7 patients, pneumoperitoneum in 5 patients, complete intestinal obstruction in 4 patients, pain in right iliac fossa in 2 patients, and irreducible inguinal hernia in 1 patient. Four patients had concurrent pulmonary TB. Surgical interventions included primary repair of perforation in one, repair of perforation with diversion ileostomy in 8, and merely peritoneal drainage (haemodynamically unstable patients) in 3 patients. The post-operative complications were high output ileostomy in 3, faecal fistula in 1, wound dehiscence in 3, wound infection 5, and prolonged ileus in 1 patient. In three patients stoma was reversed during the same admission. There was one expiry in our study. CONCLUSION Acute peritonitis, intestinal obstruction and intestinal perforation are the main clinical presentations requiring surgical interventions. Optimal surgical strategy should be adopted to avoid such pitfalls in the management.

Different modalities used to treat concurrent lymphangioma of chest wall and scrotum

Lymphangiomas are congenital malformations of lymphatic system. The common sites are cervicofacial region and axilla, followed by rare sites such as tongue, retroperitoneum and mesentery. Scrotal and chest wall lymphangiomas are rare.[1] Lymphangioma usually presents as an isolated lesion, however, its occurrence at multiple sites in the same patient have been reported infrequently.[1,2] We report a case of concurrent lymphangioma of chest wall and scrotum which were managed with different treatment modalities.