Almoutaz A. Eltayeb

The role of surgery in management of necrotizing enterocolitis

OBJECTIVE Necrotizing enterocolitis (NEC) has become the most common gastrointestinal emergency among neonates and preterms admitted to the intensive care units. The aim of this study is to evaluate the surgical management of NEC as well as their outcome. PATIENTS AND METHODS Thirty five cases were included in this prospective study (10 full terms, 15 preterm and 10 infants) with the diagnosis of NEC. The severity of NEC episodes were determined according to Bells classification into group A (stage I 10 cases), Group B (stage II 17 cases) and group C (stage III 8 cases). Full history and clinical examination were taken. Radiological studies (abdominal plain X-ray and ultrasound), blood and stool cultures were done. RESULTS All risk factors such as sepsis, hypoxia, premature rupture of membrane (PROM) and eclampsia were statistically significantly higher among group C than group A. The commonest presenting symptom was abdominal distension followed by vomiting. All positive radiological signs were statistically significantly higher among both groups B&C than group A except for pneumopritonium sign. Medical treatment was started and complete clinical improvement was achieved in all cases of group A and in 2 cases from group B. The remaining 23 cases (15 cases from group B and the 8 cases of group C) failed to respond to the medical treatment and were operated upon. Resection anastomosis was done for 12 cases from group B while resection with stoma formation was done for 3 cases from group B and 8 cases from group C. The over all mortality was 11 cases out of 35 (31.4%). 5 cases from group B and 6 cases from group C. CONCLUSIONS Early diagnosis and intensive medical and surgical treatment with laparotomy and resection of the affected bowel were mandatory to minimize both morbidity and mortality from NEC. Primary anastomosis is the procedure of choice as long as the condition of the remaining bowel is satisfactory.

Supraumbilical Pyloromyotomy: A Comparative Study Between Intracavitary and Extracavitary Techniques

BACKGROUND Infantile hypertrophic pyloric stenosis (IHPS) is the most common cause of nonbilious vomiting in infancy, with an incidence of 1 to 3 per 1000 live births. Different approaches have been advocated for pyloromyotomy aiming to achieve better cosmetic results with least possible complications. Although many studies have shown that the umbilical pyloromyotomy is as safe as the traditional right upper quadrant approach with superior cosmetic results, still few studies reports high complication rates. The aim of this study was to assess intracavitary pyloromyotomy (ICP) in comparison with extracavitary pyloromyotomy (ECP) regarding the operative time, operative and postoperative complications, time to return to full oral feeding, and duration of hospital stay, as well as the final cosmetic results through supra umbilical skin incision. PATIENTS AND METHODS Forty patients with IHPS were admitted to Assiut University Children Hospital from January 2008 to June 2010 and operated through supra umbilical incision. They were randomly divided according to the surgical technique into 2 groups: ECP group (20 patients) and ICP group (20 patients). The evaluating parameters were: pyloric muscle thickness, operative time, operative and postoperative complications, time to return to full oral feeding, duration of hospital stay, and final cosmetic results. RESULTS There was no statistical significant difference between both groups regarding the patients age, weight, pyloric muscle thickness, and duration of hospital stay. No mortality was encountered among all patients. There was a statistical significant difference between both groups regarding the mean operative time and time to return to full oral feeding. During the follow-up period (ranged from 6 weeks to 8 weeks) all patients were gaining weight satisfactorily and the scar was barely visible. CONCLUSIONS ICP for pyloromyotomy is safe and can be done in large pyloric masses without wound extension. It gives best cosmetic results with minimal complications.

Evaluation of the role of dexamethasone in decreasing early recurrence of intussusception: Using ultrasound‐guided saline enema for reduction

Aim:  Intussusception is the most common abdominal emergency during early childhood. The current initial management by contrast enema or pneumatic reduction under fluoroscopy carries the risk of radiation. In case of recurrence, the repeated attempts for another reduction will also increase this risk, in addition to other risks of operative reduction, if needed. The aim of this study was to evaluate the effectiveness of ultrasound‐guided saline enema reduction (USGSER) in the diagnosis and treatment of intussusception, and to assess the value of using dexamethasone injection in preventing or minimizing the frequency of recurrence.

Cytomegalo virus as a possible risk factor for neonatal gastrointestinal surgical conditions.

The present work aims to evaluate the possible causal relationship between CMV infection and gastrointestinal surgical conditions in the neonates. 33 neonate operated on because of gastrointestinal surgical conditions in Assiut University Children Hospital. Detection of CMV IgG and IgM from both mother and newborn was done. Surgical specimen was taken for pathologic examination. Positive serological tests (CMV IgM) were found only in four neonates (3 males and one female). Maternal CMV IgM were positive only in two cases. All surgical specimens showed characteristic CMV nuclear inclusion bodies.

Topical treatment of major omphalocoele: Acacia nilotica versus povidone-iodine: A randomised controlled study.

Background: Conservative management for major omphalocoele with topical agents as escharotics therapy is well established in practice. Different agents have been used in the past, including mercurochrome and alcohol, proved later to be unsafe. The aim of this study is to evaluate the efficacy and safety of the application of Acacia nilotica paste compared to povidone-iodine solution as a primary non-surgical treatment of major omphalocoele. Patients and Methods: A double-blind, randomised study was conducted on 24 cases of major omphalocoele where they were randomly divided into two equal groups; Group A treated with topical application of A. nilotica paste and Group B treated with topical application of povidone-iodine solution. Cases with gastroschisis, ruptured major omphalocoele or minor omphalocoele were excluded from the study. The evaluating parameters were size of the fascial defect in cm, period of mechanical ventilation if needed, time required for full oral feeding tolerance, duration of hospital stay and any short- or long-term complications. Results: There was no statistical significant difference between both groups regarding their gestational or post-natal age, weight and the mean umbilical port defect. Patients from Group A tolerated full oral feeding earlier and had shorter total hospital stay duration than those from Group B, but without a statistical significant difference (P = 0.347 and 0.242, respectively). The overall mortality rate was 33.3% without a statistical significant difference between both groups (P = 0.667). Conclusions: Application of A. nilotica is a safe and effective treatment of major omphalocoele as it was associated with rapid full enteral feeding tolerance, short duration of hospital stay and low mortality rate.

The use of PROCEED mesh in ventral hernias: A pilot study on 22 cases

Background: The management of major omphalocoele and large incisional hernias is a common problem and constitutes a great challenge for paediatric surgeons. In most cases, the abdominal cavity is so small and does not allow immediate reduction. Prosthetic materials are becoming increasingly popular for such repair, but direct contact between the bowel and these synthetic materials carries the risk of adhesions and intestinal obstruction. The relatively new PROCEED mesh with absorbable layer in contact with the bowel and another polypropylene non-absorbable layer against the abdominal wall may not produce such adhesions. The aim of this study is to evaluate the feasibility and outcome of this relatively new prosthetic mesh for repair of ventral hernia . Patients and Methods: Between June 2009 and December 2012, a pilot study was conducted on 22 cases with large ventral hernias subjected to open surgical repair using PROCEED mesh. The inclusion criterion was cases with large ventral hernias (>4 cm). The evaluating parameters were all the early and late postoperative complications. Results: The defect size ranged from 5 to 12 cm. The early postoperative complication (≤1 month) was seroma discharged from the wound in four cases, while the late complications were recurrent herniation and stitch sinus that occurred in three cases. No manifestations of intestinal obstruction, enterocutaneous fistula or mortality were encountered in any of the 22 cases. Conclusion: The use of PROCEED composite mesh in ventral hernias is feasible and has minimal complication rates.

Button hole hernioplasty: A new technique for treatment of umblical hernia in cirrhotic patients. A prospective follow up study

BACKGROUND Surgical treatment of umbilical hernia in cirrhotic patients is still an interesting topic in many studies to achieve the best method of treatment. These patients are liable to many surgical and medical risks. AIMS to evaluate the surgical outcome as well as the postoperative course of Button hole hernioplasty as a simple, safe, and effective new technique for hernia repair in cirrhotic patients. METHODS Forty cirrhotic patients with uncomplicated umbilical hernia were included in this study through collaboration between Departments of General Surgery and Tropical Medicine and Gastroenterology, Assiut University Hospital, Assiut, during one year period. Patients were categorized according to the severity of liver cirrhosis into three groups (A, B, and C). Patients were subjected to an elective hernioplasty after adjustment of the disturbed medical and biochemical factors. RESULTS There was a significant difference in operative time, hospital stay, and prothrombine (time and concentration) among the three groups (p < 0.05). The three parameters were longest in group C when compared to the other two groups. No severe complications were recorded except in only one case. Also, no recurrence, no morbidities or deaths were recorded after 6 months follow-up. CONCLUSIONS Button hole hernioplasty is a new simple surgical technique for treatment of umbilical hernia in cirrhotic patients with no significant complications.

Single high scrotal incision orchidopexy for unilateral palpable testis: a randomised controlled study.

Background: Bianchi and Squire introduced single high trans-scrotal incision for mobilisation of palpable undescended testes to decrease the potential morbidity of the traditional inguinal approach. This incision has not gained widespread acceptance and there is still a considerable debate about its efficacy. This study evaluated the outcome of high single scrotal incision in comparison to the classic inguinal exploration for unilateral palpable testes regardless to its pre-operative location to assure its validity and safety. Patients and Methods: This was a randomised controlled study conducted on seventy males with palpable unilateral undescended testicles from November 2009 to October 2013. They were divided into two equal groups; group I had high single scrotal incision and group II had the classic inguinal approach. The comparative parameters between both groups were the operative time, intra-and post-operative complications, post-operative pain and scar. Results: There was statistical significant difference between both groups regarding the operative time (P < 0.001). The high scrotal approach (Group I) was not completed in three cases and were converted to the classic inguinal approach. No statistical significant difference between both groups regarding the post-operative complications. Conclusions: Single high scrotal incision orchidopexy for palpable undescended testis is safe, has shorter operative time but may not be suitable for proximally lying testis.

Oral propranolol versus cryotherapy in the management of cutaneous hemangioma in infants and children

Objective The aim of the study was to evaluate the efficacy, adverse effects, and success rate of oral propranolol versus liquid nitrogen oxide gas cryotherapy in the management of cutaneous hemangiomas in infants and children. Patients and methods A prospective study was conducted between March 2011 and May 2015 on 43 patients with cutaneous hemangioma treated either with oral propranolol (group A, 23 cases) or with liquid nitrogen (cryotherapy) (group B, 20 cases). The outcome of treatment was evaluated clinically and with serial photographs before starting treatment and monthly thereafter as regards the size and color of the lesion. Propranolol was given orally 2 mg/kg per day in two divided doses for 4-6 months. Cryotherapy settings were applied two to four times for a period of 2-6 months under inhalation anesthesia using sevoflurane. Results With propranolol, complete involution occurred in 78.2% of cases and good response in 17.3%. Regrowth of the lesion occurred after stopping propranolol in two cases; the parents of the children were instructed to continue the treatment for a further 3 months. With cryotherapy complete involution of the lesions occurred in 65% of cases. No recurrence was observed during the follow-up period. Hypopigmentation at the site of the treated area was evident in eight cases. Conclusion Oral propranolol could be considered a safe and effective treatment strategy for cutaneous hemangioma. Although inhalational anesthesia is needed for application of cryotherapy, it is a simple method for treatment of cutaneous hemangioma and has minimal side effects. However, a randomized controlled study on a large number of patients should be conducted.

Sphincter‐saving anorectoplasty for correction of anorectal malformations

Posterior sagittal anorectoplasty (PSARP) popularized by de Vries and Peña has become the preferred technique for surgical correction of anorectal malformations (ARM). Despite performing a technically perfect operation, it involves midline division of the sphincter with a subset of patients requiring significant lifelong bowel management for constipation or incontinence. Pratap et al. introduced sphincter‐saving anorectoplasty (SSARP) trying to spare the sphincter. The aim of this study is to preserve the neurophysiological function of the sphincter through SSARP in ARM patients and evaluate the outcome of these patients through this approach.