Dr. Ahmed Elrouby, MD - Alexandria University - Lecturer

Dr. Ahmed Elrouby

MD

Alexandria University

Lecturer

Alexandria , Alexandria | Egypt

Main Specialties: Pediatric Surgery

Additional Specialties: Pediatric surgery

ORCID logohttps://orcid.org/0000-0002-7339-0244

Dr. Ahmed Elrouby, MD - Alexandria University - Lecturer

Dr. Ahmed Elrouby

MD

Introduction

Primary Affiliation: Alexandria University - Alexandria , Alexandria , Egypt

Specialties:

Additional Specialties:

Research Interests:

Education

Jul 2015
Alexandria University
Doctorate Degree

Publications

13Publications

37Reads

23Profile Views

Anterior sagittal anorectoplasty as a technique for the repair of female anorectal malformations: A twenty two-years-single-center experience.

J Pediatr Surg 2020 Mar 24;55(3):393-396. Epub 2019 Apr 24.

Pediatric Surgery Department, Alexandria University, Egypt. Electronic address:

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http://dx.doi.org/10.1016/j.jpedsurg.2019.04.008DOI Listing
March 2020
8 Reads
1.311 Impact Factor

Fatal Course of a Male Newborn with Double Duodenal Atresia.

European J Pediatr Surg Rep 2020 Jan 7;8(1):e7-e9. Epub 2020 Feb 7.

Department of Pediatric Surgery, Faculty of Medicine, Alexandria University, Alexandria, Egypt.

Multiple point duodenal atresia is an extremely rare condition with atretic segments in either two or three sites of the duodenum. We report a newborn male patient who presented to our institution with bilious vomiting, nonpassage of meconium, mild abdominal distension, and a palpable epigastric abdominal mass ?1?×?1?cm. A faint double bubble was found on abdominal X-ray. On exploratory laparotomy, a duodenal cyst due to double duodenal atresia was found and a typical diamond-shaped duodeno-duodenostomy was created. A postoperative contrast study revealed passage of the contrast media into distal intestine. However, the patient died 2 weeks later due to uncontrolled sepsis and pneumonia. Despite the fact that multiple-point duodenal atresia is a rare condition, it should be considered as a differential diagnosis to avoid missed pathology.

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http://dx.doi.org/10.1055/s-0039-3400488DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7007303PMC
January 2020

Duplication cyst of the cecum; a rare cause of intestinal obstruction in infants

MOJ Clin Med Case Rep. 2020;10(1):1‒3.

MOJ Clinical & Medical Case Reports

Submit Manuscript | http://medcraveonline.com

Introduction

Although, it was said that Calder was the first to report similar lesions in 1733; the term (duplication of the alimentary tract) was introduced by Ladd in 1930s.1 Duplications of the GIT can affect any part of the alimentary tract from the oesophagus to the anus and always develop on the mesenteric border. Ileal and jejuna duplications are the commonest encountered duplications. On the other hand, cecal duplications are very rare subtype with an incidence of only 3 %.2 We report a case of 4- months old female patient who were presented to our department with a classical picture of intestinal obstruction. She had been urgently explored with a duplication cyst of the cecum being detected.

Case Report

A full-term four months old female with normal antenatal scans who was born by spontaneous vaginal delivery without any reported perinatal morbidities was presented to our department with a classical picture of intestinal obstruction in the form of vomiting, abdominal distention and non-passage of stool.

Her parents told us that the condition started with non-bilious vomiting since 2 days which progressed to bilious vomiting with increased frequency along with progressive abdominal distension and obstipation. They claimed that the baby was previously well without any history of intermittent colicky abdominal pain, passage of bloody stool nor any previous similar attacks of bilious vomiting.

Systemic examination revealed that the patient was dehydrated, lethargic and tachycardic. Urgent resuscitation with I.V. normal Saline (10mg/kg) was then started with marvellous improvement of her general condition. The nasogastric tube drained 100ml of bilious suction. Chest examination showed equal bilateral air entry with no adventitious sounds. There was no obvious spinal nor other associated congenital anomalies.

Local abdominal examination revealed marked abdominal distension with dilated veins and visible bowel loops without any sign of peritonitis. Normal groin examination with no obvious hernias with empty rectum on digital rectal examination. Normally located anus with normally looking perineum were also noticed.

Laboratory investigations revealed average values except for slight hypokalaemia which was corrected pre-operatively.

Standing abdominal X-ray showed marked abdominal distension with multiple air-fluid levels suggesting distal ileal obstruction, with no obvious masses or free air under the diaphragm. (Figure 1).

Figure 1 PXR abdomen standing showing multiple air fluid levels.

Urgent US abdomen revealed a well-defined fluid filled thick walled cystic structure at the right hypochondrial region measuring about 3 cm×2.5cm with marked proximal small bowel dilation.

Owing to the marked abdominal distention; laparoscopy was not feasible and the decision was to proceed with lower midline exploratory laparotomy. Exploration revealed a cystic lesion on the mesenteric side of the cecum. (Figure 2).

The small intestinal loops were distended with collapsed large gut. There was complete intestinal obstruction at the level of the cyst as shown by failure of the passage of the intestinal contents distal to the cyst using manual milking. The posterior wall of the cyst shared a common wall with the cecum. Resection of the ileo-cecalregion with the cystic mass was done with ileo-ascending end to end anastomosis using a single layer of interrupted Vicryl 4/0 sutures.

MOJ Clin Med Case Rep. 2020;10(1):1‒3.

1

©2020 Elrouby et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and build upon your work non-commercially.

Duplication cyst of the cecum; a rare cause of intestinal obstruction in infants

Volume 10 Issue 1 - 2020

Ahmed Elrouby, Mostafa Zain, Ahmed Hassan, Mansour Abdelkader, Ahmed Aboelela

Pediatric Surgery Department, Faculty of Medicine, Alexandria University, Egypt

Correspondence: Ahmed Elrouby, Pediatric Surgery Department, Faculty of Medicine, Alexandria University, Egypt, Tel 01223631687, Email

Received: November 27, 2019 | Published: January 10, 2020

Abstract

Although alimentary tract duplications are rare congenital anomalies which can occur anywhere along the gastrointestinal tract (GIT); cecal duplication is considered an extremely rare anomaly. We describe a 4-month-old female patient who were presented to our emergency department with a classical picture of acute intestinal obstruction in the form of abdominal distension and bilious vomiting warranting surgical exploration which revealed a duplication cyst at the cecalregion. Limited ileo-cecal resection along with the cyst was done with uneventful post-operative recovery with the diagnosis being confirmed by the pathological examination. Despite its rarity; cecal duplication should be put into consideration when exploring a neonate with intestinal obstruction.

Keywords alimentary tract duplication, cecal duplication, infant intestinal obstruction

MOJ Clinical & Medical Case Reports

Case Report

Open Access

Duplication cyst of the cecum; a rare cause of intestinal obstruction in infants 2

Copyright:

©2020 Elrouby et al.

Citation: Elrouby A, Zain M, Hassan A, et al. Duplication cyst of the cecum; a rare cause of intestinal obstruction in infants. MOJ Clin Med Case Rep.

2020;10(1):1‒3. DOI: 10.15406/mojcr.2020.10.00330

Figure 2 Intra-operative view of the cecal cyst.

The 8cm excised segment was sent for the histopathological

examination which report the presence of a cystic lesion at the

mesenteric border of the cecum measuring 3 cm×2.5cm. (Figure 3A,

B).

Figure 3(A-B) The resected ileo-cecal specimen showing the cyst on the

mesenteric border.

Microscopic examination of the noted cyst showed the presence

of all the layers of large intestine with diffuse chronic inflammatory

infiltrate of the mucosa and submucosa in association with prominent

lymphoid follicles in the submucosa. The muscularispropria was

thickened with congested and dilated blood vessels. There was no

evidence of ectopic or abnormal tissue.

The Patient passed an uneventful recovery, started oral feeding

on the 2nd post-operative day and was discharged home on 4thpostoperative

day. The child was followed up for 6 months and she was

apparently normal.

Discussion

In 1937 WE Ladd introduced the term of alimentary tract

duplications to unify the nomenclature of this wide spectrum of

anomalies that involve the mesenteric side of the associated

alimentary tract sharing its common blood supply. The most

common site of duplication is the Ileum.3

Colonic duplication cysts are very rare (13% of duplications of the

alimentary tract).Cecal duplication cysts are even rarer as only 9 cases

were reported in the English literature. 80% of these cases present in

the first 2 years of life, but it has also been reported in adults.4

More than 60 % of cases who have alimentary duplication

present in the first 2 years of life. Some of these cases are associated

with other congenital anomalies like vertebral anomalies.5 Split

notochord syndrome is considered the most satisfactory of the

numerous theories which explain the origin of alimentary tract

duplication. This theory relates the origin of this anomaly to maldevelopment

of the neuro-enteric canal. Other theories include partial

twinning theory, canalization defect theory and environmental factors

theory.1

Symptoms vary according to the nature of the cyst, size, shape, and

site. etc. It may present with abdominal pain, distension, vomiting,

upper or lower GI bleeding or intestinal obstruction. The mechanism

of obstruction in cecal duplication depends upon the amount of

mucous in its lumen. Fully loaded cecal duplication can obstruct

the lumen of the normal cecum and may result in acute intestinal

obstruction as in our case.1

The clinical diagnosis of this anomaly is very difficult and it is

usually discovered incidentally during operative exploration of

another cause. Laboratory and radiological investigations in this

situation are also non-specific.

Pathological evaluation of the enteric cysts is the mainstay of

diagnosis. Gross and microscopic appearance showing mucosa,

submucosa, muscularis, and serosa are the typical features. Good

sectioning of the cyst wall with the attached bowel helps in ruling out

the malignant changes.3

Various surgical procedures have been employed to deal with such

lesions. Most commonly used is the partial colectomy with end-to-end

anastomosis as in our case.5 Other techniques such as enucleation,

marsupialization, or evacuation of the cyst can also be used in selected

cases.1

Conclusion

Despite its rarity; cecal duplication should be put into consideration

when exploring a neonate with intestinal obstruction.

Acknowledgement & Funding

None.

Conflict of interest

The following authors have no Conflicts of interest.

References

1. Ijaz L, Husnain M, Malik SI, et al. Cecal duplication cyst presenting as

acute intestinal obstruction in an infant. APSP J Case Rep. 2011;2(1):11.

A B

Duplication cyst of the cecum; a rare cause of intestinal obstruction in infants 3

Copyright:

©2020 Elrouby et al.

Citation: Elrouby A, Zain M, Hassan A, et al. Duplication cyst of the cecum; a rare cause of intestinal obstruction in infants. MOJ Clin Med Case Rep.

2020;10(1):1‒3. DOI: 10.15406/mojcr.2020.10.00330

2. Mayer JP. Alimentary tract duplications in newborns and children:

Diagnostic aspects and the role of laparoscopic treatment. World J

Gastroenterol. 2014;20(39):14263.

3. Yisau A, Abdulraseed N, Kashim I, et al. Gastrointestinal duplications:

Experience in seven children and a review of the literature. Saudi J

Gastroenterol. 2010;16(2):105.

4. Singh VR, Shah P, Roplekar P, et al. Cecal duplication cyst: A rare case

report with review of literature. Int J Heal Allied Sci. 2016;5(2):115.

5. Pati A, Mohanty HK, Subudhi PC, et al. Duplication cyst of the cecum:

A case report. Indian J Surg. 2010;22(3):271–272.

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January 2020
3 Reads

Pediatric duodenal wall hematoma; an unexpected differential of an abdominal cyst

Elrouby A, Kotb M. Pediatric duodenal wall hematoma; an unexpected differential of an abdominal cyst. MOJ Clin Med Case Rep. 2019;9(1):21‒23.

MOJ Clinical & Medical Case Reports

https://medcraveonline.com/MOJCR/MOJCR-09-00294.pdf

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October 2019
5 Reads

One Stage Pull-Through Procedure for Hirschsprung’s Disease: Trans-Anal or Trans-Abdominal? A Comparative Study

Ahmed Elrouby., et al. “One Stage Pull-Through Procedure for Hirschsprung’s Disease: Trans-Anal or Trans-Abdominal? A Comparative Study”. Acta Scientific Paediatrics 2.6 (2019): 19-24.

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October 2019
3 Reads

Evaluation of the functional outcome of the neonatal one stage posterior sagittal anorectoplasty (PSARP) as a procedure to treat cases of high anorectal malformation in male neonates

Elrouby A, Waheeb S, Khairi A, Fawzi O. Evaluation of the functional outcome of the neonatal one stage posterior sagittal anorectoplasty (PSARP) as a procedure to treat cases of high anorectal malformation in male neonates. Arch Clin Exp Surg [Internet]. 2019;8(1):1. Available from: https://www.ejma

Archives of Clinical and Experimental Surgery

https://www.ejmanager.com/fulltextpdf.php?mno=3403

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October 2019
4 Reads

Neonatal gastrointestinal perforation is a major challenge; A retrospective study

Authors:
Ahmed Elrouby

Archives of clinical and experimental surgery

Objectives: The objective of our study was to study the outcome of the perforated gut in the neonatal age group in our

institute in relation to the personal data (age, sex), the operative details (abdominal incision, peritonitis &collection, the type

of the performed procedure, the type, site and cause of the perforation) and the length of the hospital stay.

Material and methods: The records of all neonates with perforated gut, who were admitted to the Pediatric Surgery

Department, Faculty of Medicine, Alexandria University, between January 2015 and November 2017 were retrospectively

reviewed. The personal data (age, sex), the operative details (abdominal incision, peritonitis &collection, the type of the

performed procedure, the type, site, and cause of the perforation) and the length of the hospital stay were collected and

analyzed. All of the previously enumerated factors were correlated to the final outcome of the patients. Patients with incomplete

data were excluded from our study.

Results: Our study included 44 neonates; all of them were under one month old. The patients were divided into three

groups (A, B, and C) according to their final outcome. Patients of group A were those who had been discharged after

surgical exploration, patients of group B were those who died after surgical exploration and patients of group C who died

before any surgical exploration. So the actual mortality rate in our study, including both patients of group B and group C

(18 patient) was 40%. Sealed perforation was found in 2 patients, solitary perforation in 28 patients and only nine patients

had multiple perforations. Nothing had been done for the two patients with sealed perforation; however, four patients had

direct closure of their perforated loop, three patients had resection anastomosis of the perforated loop, and 31 patients had

a stoma. Birth weight, prematurity, and the amount of peritoneal collection were the only factors which had a statistically

significant effect on the fate of our studied patients.

Conclusion: Neonatal perforated gut had a high mortality rate which could be affected by birth weight, prematurity and the

amount of peritoneal collection

Key words: Perforation, gastrointestinal, pediatric, mortality, stoma

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October 2019
3 Reads

Female hydrocele; forgotten differential in female inguino-labial swellings

Open J Clin Med Case Rep: Volume 5 (2019)

Open Journal of Clinical & Medical Case Reports

Introduction

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morbidities which are usually underestimated and often missed in the differential diagnosis of inguino-labial swellings due to their rarity. Canal of Nuck is a parietal peritoneum protrusion accompanying the round ligament in inguinal canal in females which is spontaneously obliterated. Non obliteration leads to develoPage

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Vol 5: Issue 18: 1610

pment of female hernia and or hydrocele just like patent processus vaginalis in males [1].

Although physicians consider hydrocele as a male anomaly, it’s present in females in rare occasions and because they usually don’t put this diagnosis in mind; it’s usually misdiagnosed as an irreducible hernia. So US is an excellent modality to differentiate between the two situations and guide further treatment [2].

Since few cases had been discussed in the literature about this topic; we present 3 years old female patient who was diagnosed clinically and confirmed by US to have right side hydrocele. We also reviewed the literature regarding this topic and discussed its clinical background.

Case Presentation

A three years old female patient was referred to us with a right sided moderately painful irreducible inguino-labial swelling. Her parents claimed that the swelling was first noticed since one year being about 1×1 cm which gradually increased in size. They complained of recurrent inguinal pain with neither abdominal pain, change in bowel habit nor urinary symptoms. On local examination, there was an irreducible swelling about 3×3 cm, mobile from side to side, positive cross-fluctuation and positive trans-illumination. There was neither impulse on cough, thrill on cough nor bruit with normal skin overlying. From this clinical picture; the differential diagnosis of hernia or hydrocele was made (Figure 1).

Investigation revealed normal routine laboratory tests and the ultrasonography revealed hypo-echoic 3×2 cm swelling with fine internal septations. Surgical exploration was planned.

Right inguinal transverse incision was made and after dissection of the Scapa’s and Camper’s fasciae, a cystic swelling was detected, dissected and delivered through the wound (Figure 2).

Opening of the external oblique aponeurosis was done to follow the extension of the cyst which was clearly diagnosed as encysted hydrocele of canal of Nuck without any evidence of associated herniation. (Figure 3). The cyst was carefully dissected up to the deep inguinal ring and hydrocelectomy with high transfixion ligation of canal of Nuck was done. Layered closure of the wound was done with peaceful post-operative recovery and no recurrence in the last 12 months.

Discussion

During embryological development of female fetus, the round ligament of uterus descends through the deep ring into the inguinal canal reaching the labia majora. An associated fold of the parietal peritoneum follows that and known as canal of Nuck. It was first described by Dutch anatomist, Anton Nuck in 1691 [3].

This canal usually obliterates at birth or early infancy. Incomplete obliteration leads to the development of hernia or hydrocele in females which is far less common than in males [4]. Huang et al. described in their study that the incidence of female hydrocele was about 1% [5].

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Female hydrocele is mostly idiopathic developing due to imbalance between endothelial secretion and reabsorption in the canal of Nuck. However, secondary causes like impaired lymphatic drainage, trauma or inflammation may be the cause [2,6].

The pathological types of female hydrocele include type I which is the encysted hydrocele developing anywhere along the round ligament; this is the most common type. Type II which has a communication like male communicating hydrocele and type III which is the bilocular hydrocele having a constriction at the deep ring with an intra-abdominal retroperitoneal part and so it’s reducible; this type simulates inguinal hernia [7].

Female hydrocele may be misdiagnosed as a congenital hernia because of its rarity, lack of clinicians’ knowledge regarding this entity and paucity of the relevant literature in the surgical textbooks. Furthermore at least one third of these cases are associated with inguinal hernia [8].

Clinically it presents as an irreducible painless or slightly painful swelling due to sub-acute inflammation or tense consistency. The swelling may show positive trans-illumination however the overlying fat and aponeurosis may obscure this sign. The differential diagnosis includes indirect inguinal hernia, femoral hernia, Bartholin’s cyst, post-traumatic hematoma, hydrocele of canal of Nuck, lipoma, vascular aneurysms, cystic lymphangioma, neuroblastoma metastasis in groin, ganglion, leiomyoma, sarcoma, endometriosis of round ligament and epidermal cyst [4].

High resolution ultrasonography can be helpful in the final diagnosis as the swelling appears as an anechoic or hypo-echoic sausage or coma shape superficial inguino-labial swelling medial to the pubic tubercle. MRI may be also helpful as it appears as hypo intense mass in T1 and hyper intense in T2 [8].

But finally the definitive diagnosis in almost all cases is confirmed by surgical exploration which is mandatory for all cases during which dissection of the hydrocele upto the deep ring is recommended with high transfixtion ligation. The binocular hydrocele or type III and hydrocele associated with inguinal hernia could be managed by laparoscopy [9].

Conclusion

Although it’s rare; hydrocele of canal of Nuck should be considered in the differential diagnosis of female inguino-labial swellings. It should be diagnosed based on clinical examination and confirmed by high-resolution ultrasound or MRI. The treatment of choice in this condition is complete surgical excision.

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Vol 5: Issue 18: 1610

Figures

Figure 1: The patient presented with right inguino-labial swelling

Figure 2: The cystic swelling delivered through the inguinal wound

Figure 3: The encysted hydrocele of canal of Nuck delivered out of wound

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References

1. Rees MA, Squires JE, Tadros S, Squires JH. Canal of Nuck hernia: a multimodality imaging review. Pediatr radiol. 2017; 47(8): 893-898.

2. Stickel WH, Manner M. Female Hydrocele (Cyst of the Canal of Nuck): Sonographic Appearance of a Rare and Little-Known Disorder. J Ultrasound Med. 2004;c23(3):c429-432.

3. Anton Nuck. Adenographia curiosa et uteri foeminei anatome nova. 1691.

4. Sarkar S. Hydrocele of the Canal of Nuck (Female Hydrocele): A Rare Differential for Inguino-Labial Swelling. J Clin Diagnostic Res. 2016; 10(2): PD21–PD22.

5. Huang CS, Luo CC, Chao HC, Chu SM, Yu YJ, Yen JB. The presentation of asymptomatic palpable movable mass in female inguinal hernia. Eur J Pediatr. 2003; 162(7-8): 493-495.

6. Shadbolt CL, Heinze SBJ, Dietrich RB. Imaging of Groin Masses: Inguinal Anatomy and Pathologic Conditions Revisited. RadioGraphics. 2001; 21(suppl_1): S261-S271.

7. Mc Cune WS. Hydrocele of The Canal of Nuck with Large Cystic Retroperitoneal Extension. Ann Surg. 1948; 127(4): 750-753.

8. Jagdale R, Agrawal S, Chhabra S, Jewan SY. Hydrocele of the Canal of Nuck: Value of Radiological Diagnosis. J Radiol Case Rep. 2012; 6(6).

9. Qureshi N, Lakshman K. Laparoscopic excision of cyst of canal of Nuck. J Minim Access Surg. 2014; 10(2): 87.

Manuscript Information: Received: November 12, 2019; Accepted: December 18, 2019; Published: December 27, 2019

Authors Information: Ahmed Elrouby*; Mostafa Kotb

Pediatric Surgery Department, Faculty of Medicine, Alexandria University, Egypt

Citation: Elrouby A, Kotb M. Female hydrocele; forgotten differential in female inguino-labial swellings. Open J Clin Med Case Rep. 2019; 1610.

Copy right statement: Content published in the journal follows Creative Commons Attribution License

(http://creativecommons.org/licenses/by/4.0). © Elrouby A 2019

About the Journal: Open Journal of Clinical and Medical Case Reports is an international, open access, peer reviewed Journal focusing exclusively on case reports covering all areas of clinical & medical sciences.

Visit the journal website at www.jclinmedcasereports.com

For reprints and other information, contact info@jclinmedcasereports.com

View Article
January 2019
2 Reads

Pediatric inguinal hernias, are they all the same? A proposed pediatric hernia classification and tailored treatment.

Hernia 2018 12 28;22(6):941-946. Epub 2018 Aug 28.

Alexandria University, Alexandria, Egypt.

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http://dx.doi.org/10.1007/s10029-018-1816-yDOI Listing
December 2018
17 Reads

Staged laparoscopic traction-orchiopexy for intraabdominal testis (Shehata technique): Stretching the limits for preservation of testicular vasculature.

J Pediatr Surg 2016 Feb 4;51(2):211-5. Epub 2015 Nov 4.

Pediatric Surgery Department, Alexandria University, Egypt.

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http://dx.doi.org/10.1016/j.jpedsurg.2015.10.063DOI Listing
February 2016
12 Reads
1.311 Impact Factor

Improving the outcome of pediatric emergency abdominal surgeries by application of enhanced recovery after surgery (ERAS) protocol

Research and Opinion in Anesthesia & Intensive Care

Improving the outcome of pediatric emergency abdominal surgeries by application of enhanced recovery after surgery (ERAS) protocol.IntroductionEnhanced recovery after surgery (ERAS) or the fast track protocols are evidence based protocols applied to standardize and optimize the perioperative care to reduce the surgical trauma, physiological stress and organ dysfunction which accompany surgeries in order to enhance the postoperative recovery, reduce hospital stay and improve the surgical outcome. ERAS protocols are not single size fitting all patients but modifications could be carried out according to the situation(1).ERAS was initiated by the Danish colorectal surgeon Henrick Kehlet and his co-workers from the Havidovre Hospital in Copenhagen, Denmark in 1990’s. They published that for the first time in 1995(2,3).ERAS protocol was studied several times in adult surgery but few studies could be reported about its application in pediatric abdominal surgery especially in emergency situations(4).Emergency surgery is considered key hospital service carrying high rate of morbidity and mortality. Many measures were applied to improve this outcome; one of them was ERAS protocols(5).Application of ERAS in emergency surgery remains uncertain mostly due to the challenge in applying its parameters in this situation like preoperative fasting which won’t be applicable. However, the important key point of optimal fluid management and CHO load could be applied. So, a tailored protocol based on the type of emergency is likely to be used(6).ERAS was first applied in emergency surgery by Loshiriwat in some cases of emergency colorectal surgery. The outcome of ERAS was measured by the morbidity and mortality, length of hospital stay, and time to return to normal activity(7).Emergency pediatric surgeries have also high rate of morbidity and mortality even more than elective cardiac surgeries due to multiple factors including patient factors, staff members and access to hospital. Application of fast track protocol in pediatric emergency abdominal surgeries aims at improving their outcome(8) .Aim of the workThe aim of the study was to assess the success of application of ERAS protocol in pediatric emergency laparotomy.Material & MethodsOur randomized controlled study included patients in pediatric age group with variable types of abdominal surgical emergencies during the period between January 2017 and January 2018The study patients were randomly distributed into two groups; the first group was the study or interventional group (Group A) and the second group was the control group (Group B). Patients of group A were subjected to ERAS protocol tailored to the emergency situation as shown in table 1(9) and group B were subjected to conventional protocol. PreoperativeØ    Preadmission counselling: After complete explanation of the management plan for the parents or care givers and the advantage and disadvantage of ERAS protocol with the possibility of readmission, a written consent was signed.Ø    Preoperative fasting, fluid & CHO load, bowel management: can’t be appliedØ    Antibiotic prophylaxis & premedication: Patients of group A were injected on induction by a single dose of 3rd generation cephalosporines (50 mg/kg)IntraoperativeØ    Anesthesia: All of the studied patients were subjected to controlled general anesthesia induced by sevoflurane inhalation in combination with fentanyl 1µg/kg & rocuronium 0.6mg/Kg injection. This was followed by endotracheal intubation and maintenance by Sevoflurane or isoflurane.Ø    Epidural anesthesia: Caudal epidural anesthesia was added to group A patients with 1ml/kg of 0.125 bupivacaine after local cleaning using needles of appropriate size under sterile conditions. Ø    Avoid salt and water overload: Fluid management was calculated as 4:2:1 rule as shown in table 2. An additional dose of 6–10 ml/kg/h was added to compensate for evaporation from the open wound, and more boluses were given depending on the extent of bowel trauma and accompanying sepsis. Ø    Maintain normothermia: This was accomplished by warming with a blanket under close monitoring of body temperature. Ø Abdominal drain: Avoidance of abdominal drain as far as we can was attempted in group A patientsØ Minimal surgical manipulation: Minimization of intraoperative intestinal manipulation was attempted as the situation permits in group A in the form of intra-abdominal reduction of intussusception without extra-abdominal delivery, local delivery of the bowel loop to be resected, rapid repositioning of intestine into the abdominal cavity if the bowel was formally explored.PostoperativeØ NGT: Avoidance of NGT as far as we can was attempted in group A patientsØ Prevent nausea and vomiting: on regular basis, antiemetics in the form of ondansetron 0.15 mg/kg IV and metoclopramide 0.1 mg/kg IV.Ø Early start of oral intake: All the patients in group A were encouraged to start oral fluids on first postoperative day with gradual increase in volume and consistency till approaching full oral feed on 2nd postoperative day.Ø Stimulation of gut motility: patients of group A had rectal suppositories as a routine rectal stimulation on 1st postoperative dayØ Early removal of catheters: Catheters in group A were removed as fast as we canØ Early ambulation: Children who are able to walk were encouraged to move around by the night of operation

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November -0001
2 Reads

Clinical and radiological predictors of the outcome of hydrostatic reduction of primary intussusception in childhood

Alexandria Journal of Pediatrics

Clinical and radiological predictors of the outcome of hydrostatic reduction of primary intussusception in childhoodIntroduction:Intussusception is the commonest cause of small intestinal obstruction in childhood which is the most common pediatric surgical emergency. Primary intussusception develops usually between four and ten months of age at the ileo-cecal region in about 90% of cases.1US guided hydrostatic reduction of intussusception has been described for the first time by Kim et al. in 1982 and since this date it was widely used in the treatment of the suitable cases of intussusception with acceptable results saving the patients from the morbidities which may accompany surgical exploration.2 Aim of the work:The aim of the present work was to study the clinical and radiological predictors of successful hydrostatic reduction of primary intussusception in childhood.Subjects and methods: This retrospective cross sectional study included all the patients who had primary intussusception with an age range of six months to three years as proved by US of the abdomen and who were indicated for hydrostatic reduction by saline enema between Jan 2017 and Dec 2018 at El Chatby University Children Hospital, Alexandria, Egypt.Patients presented by signs of peritonitis and/or perforated bowel on plain-X-ray (PXR) abdomen standing were excluded from the study.All the patients’ records were reviewed and the age, sex and body mass index (BMI) were recorded. Body temperature, level of consciousness and the presence of dehydration on admission were reviewed. Nature and duration of symptoms (red currant jelly stools, vomiting, abdominal pain) as well as the presence of abdominal distension, rigidity, tenderness, palpable abdominal mass and/or the presence of a prolapsing mass on digital rectal examination were reviewed and recorded. Finally, the presence of air fluid levels in PXR abdomen standing and the location of the mass in US abdomen were reported.Signing of the informed consent by the parents was followed by resuscitation and initiation of hydrostatic reduction using saline enema. Under the sonographic guidance of high resolution ultrasound Justvision400 (Toshiba Corporation, Japan) apparatus and with the patient lying in the left lateral position; a Foley’s catheter (16-18 Fr) was inserted rectally until the Y-piece reached. Then the balloon was inflated by 20-30 ml of saline and the catheter pulled out until the balloon hitched snugly in the rectum and the buttocks were tapped together for anal seal. The enema was then started by elevation of the container with about 1 liter of warm saline for 100-150 cm above the level of the patient allowing the fluid to descend by gravity intra-rectally. The attempt of hydrostatic reduction was repeated maximally for three times, each attempt lasted for 15-20 min with a latent period of two to three hours between the trials.Successful reduction was achieved when the US reveals disappearance of the mass and the free passage of fluid into the terminal ileum in association with the disappearance of signs and symptoms. Patients were followed up until the passage of stools as well as tolerating oral intake with a free abdominal US before discharge.The outcome of hydrostatic reduction was reported and the patients were divided into group A (successful reduction) and group B (failed reduction).  These groups were compared according to the previously mentioned parameters. Statistical description and analysis of data were done by the appropriate statistical tools with the software SPSS version 10.0.The study was designed in accordance with the ethical standards of our responsible committee on human studies in our institute and with the Helsinki Declaration of 1975, as revised in 2000.Results:The study included 140 patients and the procedure was successful in 91 patients (Group A; 65%) and failed in 49 patients (Group B; 35%). About 73 patients (52.1%) were males; the difference in sex distribution between the two groups did not show statistical significance as shown in table 1.·         Personal data:The age at presentation ranged between six and 36 months with a mean of 17.69±11.32 months. Patients of Group A had an older age (20.05±11.39 months) than patients of Group B (13.31±9.89 months); this difference showed a statistically significant effect on the success of hydrostatic reduction (Table 2; Student t test: t=3.49, p=0.001).The BMI ranged between 11.23 kg/m2 and 33.13 kg/m2 with a mean of 17.48±3.59 kg/m2; it was significantly higher in patients of group A (18.±3.94 kg/m2) than in patients of Group B (16.51±2.58 kg/m2). (Table 3; Student t test, t= 2.383, p=0.019)·         Clinical presentation:The period between the onset of the complaint and the presentation to our institute ranged between five and 70 hours with a mean of 16.44±11.45 hours; it was shorter in patients of Group A (11.42±7.96 hours) than in patients of Group B (25.78±11.15 hours); this difference was statistically significant (Table 4; Student test, t= 8.812, p=0.000). 1.    SymptomsThe presenting symptoms included abdominal colic, vomiting and the passage of red currant jelly stools. Abdominal colic was present in all of the studied patients; however, the frequency of the attacks varied among them being repeated every five minutes, ten minutes or fifteen minutes without showing statistical significance. Vomiting was the 2nd presenting symptom in frequency which developed in 54 patients (38.6%) without affecting the outcome significantly. The least common symptom was the passage of red currant jelly stool which developed in 45 patients (32.1%); the passage of red currant jelly stool was the only statistically significant factor in group B when matched with group A. (Table 5).2.    Clinical examination:All of the studied patients had been subjected to general examination, local abdominal examination and digital rectal examination.A. General examinationGeneral examination revealed that 33 patients (23.6%) were dehydrated, 16 patients (11%) were drowsy and 43 patients (31%) were feverish. These signs didn’t show statistically significant effect on the success of hydrostatic reduction as shown in table 6.B. Local abdominal examinationAbdominal examination revealed distension in 30 patients (21.4%), rigidity in 10 patients (7.1%), tenderness in 13 patients (9.3%), and a palpable abdominal mass in 53 patients (37.9%). The only abdominal sign which affected the outcome significantly is the presence of a palpable abdominal mass which reduced the success rate of hydrostatic reduction significantly as shown in table 7.C. Digital rectal examinationDigital rectal examination revealed the presence of the head of intussusception in 24 patients (17.1%) being prolapsed from the anus in four patients. This finding didn’t change the outcome significantly as shown in table 8. ·         Imaging evaluationAll of the studied patients had been evaluated by PXR abdomen standing and by US of the abdomen1.    PXR abdomen standing:PXR abdomen standing revealed the presence of air fluid levels in 56 patients (40 %); the presence of air fluid levels reduced the success rate of hydrostatic reduction significantly. (Table9; Chi Square test X2=59.911, P=0.000)2.    US of the abdomen:The presence of abdominal mass as confirmed by US abdomen affected the outcome significantly (Chi Square test, X 2=55.813, p=0.000). The site of the mass of intussusception as diagnosed by US abdomen varied among the studied patients with the highest frequency in the upper right abdominal quadrant which was detected in 78 patients (55.7%). The difference in the site of the mass affected the outcome significantly as shown in table 10 (Chi Square test X2=52.439, p=0.000).Discussion:Many conservative and surgical approaches had been used in the treatment of intussusception with an increased popularity of the conservative measures. Conservative measures include hydrostatic reduction under sonographic guidance and pneumatic or barium reduction under fluoroscopic guidance. On the other hand patients with failed reduction, peritonitis, bowel perforation or unstable general condition are treated with surgical exploration.3Barium enema had been considered as the principal method of reduction of intussusception for a long period of time; however, the risk of severe peritonitis and even death in case of bowel perforation reduced its usage and directed the physicians to replace it with pneumatic and hydrostatic reduction. Regarding pneumatic reduction under fluoroscopic guidance: it is used under pressure of 80-120 mmHg which carries the risk of tension pneumo-peritoneum in case of bowel perforation besides the risk of high radiation exposure. These disadvantages made Kim et al. to think about the hydrostatic reduction under sonographic guidance in 1982. He described this procedure as installing saline rectally through a Folley’s catheter reducing the invaginated segment of intussusception backwards under pressure of 90-150 mmHg.4The factors affecting the success of hydrostatic reduction of intussusception had been studied by many researchers. These factors included the age, the sex, the presence and the duration of vomiting, abdominal pain and rectal bleeding. Abdominal signs including distension, the site of the abdominal mass and the presence of peritonitis as well as the general signs including the presence of lethargy, fever and dehydration were also studied. The rectal prolapse of the intussusceptum as detected by digital rectal examination was also studied. The presence and the site of an abdominal mass as detected by US abdomen was also studied as well as the presence of small bowel obstruction and air-fluid level on PXR abdomen.3The success rate of hydrostatic reduction of intussusception varied among different studies. This study revealed 65% success rate, other studies like that of Van Den ED et al.5 revealed higher success rate (79%) and Khorana et al revealed a lower success rate (44%).6Difference in sex did not affect the outcome in this study significantly. On the other hand the effect of age at presentation was variable among different studies. Patients with older age group showed a significantly higher rate of successful hydrostatic reduction in this study. This is similar to the findings of Eklof et al. 7 who explained that by the higher competency of ileo-cecal valve in younger age groups; this highly competent valve does not allow saline to go back through it into the ileum resulting into a lower success rate of hydrostatic reduction in younger age groups. In contrast Talabi AO et al. found that the difference in age at presentation does not affect the success of hydrostatic reduction.

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November -0001

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Alexandria University

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Alexandria University Faculty of Medicine

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Al-Azhar University

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