Patterns and Surgical Outcome of Pediatric Intestinal Obstruction in Pakistan

Background: Intestinal obstruction in children is a very common cause of admission in hospitals with usually a high mortality andmorbidity rate. There is a geographical variability in patterns of intestinal obstruction in pediatric population around the globe.Objectives: To evaluate patterns of presentation and surgical outcome of pediatric intestinal obstruction in Pakistan.Material and Methods: A prospective observational study with non-probability sampling technique was done in the departmentPediatric Surgery (East Surgical Unit), The Children's Hospital, Pakistan Institute of Medical Sciences (PIMS), Islamabad,Pakistan, from January to December 2017. Operated cases of intestinal obstruction from 1 day to 12 years were included. Age,patterns of presentation, sign and symptoms, surgical intervention, complications, outcome and correlation between variableswere studied.Results: Total cases were 316 (231 males, 85 females). Congenital Causes of intestinal obstruction in descending order wereAnorectal Malformations(75),Jejuno-Ileal Atresia(28), Hirschsprung Disease(27), Meckel's Diverticulum(17), DuodenalAtresia(16), Malrotation(12), Meconium Ileus(11), Midgut Volvulus(8), Mesenteric cyst(1) and Rectal Atresia(1).Acquired causeswere Intussusception(40), Perforated Appendix(20), Infantile Hypertrophic Pyloric Stenosis(14), Band Obstruction(12), BluntAbdominal Trauma(10), Obstructed Inguinal hernia (9), Worm infestation(9), Enteric Perforation(3), Necrotizing Enterocolitis(3).The overall mortality rate was 3.5% and postoperative complications rate was 40.8%. Statistically significant relationship wasfound between Age and post operative complications (P=0.048), Age and outcome (P=0.002) and between post operativecomplications and outcome (p<0.001).Conclusions: Causes of intestinal obstruction vary according to the age and geographical area. Accurate and timely diagnosis ofthe cause of intestinal obstruction along with prevention and treatment of sepsis can reduce morbidity and mortality.Key words: Intestinal obstruction; Children; Congenital; Acquired Causes; Neonate; Pakistan

LIMITATIONS OF CROSS TABLE PRONE LATERAL X-RAY/INVERTOGRAM IN DIAGNOSING OF TYPES OF ANORECTAL MALFORMATIONS

INTRODUCTION Anorectal malformation is the very common congenital malformation with the incidence of 1 in 5000 (1,2). The diagnosis is made on perineal examination which is further corroborated by cross table prone lateral x-ray or invertogram to find out the level of anorectal atresia. The cross table prone lateral x-ray is considered better investigation tool as compared to invertogram for demonstration of the level of rectal atresia in neonates. In prone cross table lateral x-ray, effect of gravity is negated, positioning of the baby is more comfortable and the rectal gas shadow is better delineated. AIM To evaluate the sensitivity and specificity of cross table prone lateral x-ray in labelling a patient of anorectal malformation as high or low. MATERIAL AND METHODS The study was conducted in retrospective manner. Radiological materials, clinical and operative records of the neonates with anorectal malformation operated in Department of Surgery, Pediatric Surgery unit, BRD Medical College over a period of 2 years (June 2017 to July 2019) were retrieved. Total 100 neonates with anorectal malformation were admitted in our hospital during this time frame. Out of these patients, colostomy was done in 79 patients, anoplasty was performed in 18 cases. Two patients underwent primary posterior sagittal anorectoplasty while 1 patient had ileostomy done. During this study, we came across four unusual cases of low anorectal malformation where the x-ray picture did not coincide with the clinical diagnosis. CONCLUSION Diagnosis of anorectal malformation is clinical but to diagnose the type of anorectal malformation it requires both clinical as well as radiological workup. In case of diagnostic dilemma, our clinical interpretation should lead the diagnosis as none of the x-ray modality has 100% sensitivity.

TREATMENT OF SEVERE RECTAL INJURY WITH DAMAGE TO THE EXTERNAL SPHINCTER IN CHILDREN

Material and methods. Over 30 years, under supervision there were 6 children of 3 and 18 years, with severe injuries of the rectum and anus. In the diagnosis there was used history, examination, catheterization of the bladder, ultrasound, vaginal and rectoscopy, x-ray diagnostic methods. Results and discussion. Two 3 and 6 years old girls were raped. All had damage not only to the perineum and vagina, but also to the vaginal-rectal septum, rectum, and sphincter. In one child, damage to the rectum and anus occurred during surgery for rectal atresia. Surgical intervention was performed by perineal access. In three adolescents, an injury to the pelvic organs with damage to the rectum, anus, and pelvic bones was a consequence of traffic accidents. Two of them died from traumatic brain injury. The author presents three clinical observations. Conclusion. Combined injuries of the rectum and sphincter are serious injuries. Signs of shock, internal bleeding, open and closed fractures may come to the fore. Assistance to injured children should be carried out in specialized institutions. The main method of the treatment of severe injuries of the sphincter of the rectum is the closure of the sphincter defect

Rectal Atresia and Congenital Hypothyroidism: An Association or Coincidence?

Rectal atresia is a rare anorectal malformation, and its association with other anomalies is even more rare. This study presents a unique case of co-twin in which the surviving newborn male underwent surgery due to rectal atresia. Newborn screening tests identified congenital hypothyroidism. The surgical treatment consisted of three stages and thyroid hormones were replaced.