Tanta University, Faculty of Medicine

ORIGINAL ARTICLES
	Complete revascularization of patients with severe left ventricular dysfunction using mini extracorporeal circulation	p. 163
	Ibrahim M Yassin, Farouk M Oueida DOI:10.4103/tmj.tmj_7_18   Background and aim Mini extracorporeal circulation (MECC) when used as on-pump beating cardiac support during coronary artery bypass grafting can be a better alternative than the conventional cardiopulmonary bypass with aortic cross-clamping and cardioplegic arrest [(conventional cardiopulmonary bypass (cCPB)] in complete revascularization of patients with ejection fraction (EF) <30%. Patients and methods A retrospective study was conducted on consecutive 50 patients with chronic stable severely impaired EF (< 30%) who underwent isolated coronary artery bypass grafting surgery using MECC from January 2011 to June 2016 (group I), and they were compared with another 50 matched patients randomized to similar group connected to cCPB from January 2009 to June 2014 (group II). Emergency, unstable, combined surgery and end-stage renal disease patients on dialysis are excluded. Results There was no difference in CPB time, perioperative myocardial infarction (MI) or mortality between the two groups. Defibrillation was required in 10% in group I and in 82% in group II, with significantly lower cumulative energy of defibrillation (joules) (P<0.001). In group I, the requirement of inotropic support, incidence of atrial fibrillation (AF), the need for mechanical support, postoperative bleeding, the mean haematocrit value and the need for allogenic blood and products transfusion were significantly lower than in the group II (P<0.001), but the incidence of re-exploration was overall low (4% in group I) vs. 12% in group II), with a trend towards being significant (P=0.058). Postoperative creatine kinase MB isoenzyme and cardiac troponin I were significantly lower in group I (P<0.05) for 48 h. Lower postoperative creatinine (<0.01) was seen in group I. Duration of ventilation and length of ICU stay showed a trend towards being significant (P=0.053 and 0.057), but the total hospitalization time was significantly shorter in group I (P<0.05). Conclusion On-pump beating heart revascularization of low EF patients using MECC is a safe procedure with better outcome than cCPB in low EF patients. It is followed by a diminished release of ischaemia markers, better early and smooth postoperative course and lower total hospitalization time than after cCPB, and both result in a satisfactory clinical outcome.
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	The possible therapeutic role of mesenchymal stem cells in amiodarone-induced lung injury in adult male albino rats	p. 172
	Maram M.M Ghabrial, Maysa F.M Salem, Aml M.A.A El Ela, Safwat A.A El Deeb DOI:10.4103/tmj.tmj_4_18   Background and aim Lung injury and even pulmonary fibrosis represent a known adverse effect of amiodarone. No effective treatment was reported for pulmonary fibrosis except lung transplantation. Stem cell therapy holds a great promise for the repair of injured tissues. Mesenchymal stem cells (MSCs) have the potential to present a new trend of treatment. This work aimed to study the effect of bone marrow-MSCs on amiodarone-induced lung injury in albino rats by histological methods. Materials and methodsForty-two adult male albino rats were used. Seven rats were used as a source of bone marrow-MSCs. Thirty-five rats were divided into the following groups: negative control group included seven rats that received no treatment; vehicle control group included seven rats that received polysorbate 80; amiodarone group included 14 rats that received daily oral amiodarone for 6 weeks and were subdivided into two equal subgroups as subgroup 3a (amiodarone administrated) and subgroup 3b (kept for 4 weeks after amiodarone stoppage); and stem cell-treated group included seven rats that received stem cells after amiodarone stoppage. Lung specimens were examined histologically. Results Amiodarone group showed disrupted lung architecture, collapsed alveoli, and significant increase in the thickness of interalveolar septa. Bronchioles showed thickened smooth muscle layer and obliterated lumens. Highly significant increase in area percent of collagen fibers was observed. In stem cell group, there was improvement of these histological changes. Conclusion MSCs can improve the deleterious effects associated with amiodarone-induced lung injury.
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	Prognostic factors of patients requiring ventilatory support in the neuro-intensive care unit	p. 183
	Ahmed S Alkotami, Khaled H Rashed, Mohamed A Ragab, Hassan G Nassar DOI:10.4103/tmj.tmj_10_18   Background and aim Among ICU admitted patients, primary indication for mechanical ventilation is neurologic in 20%. This is much higher in a dedicated neuro-ICU. The purpose of this study was to assess the clinical predictors for outcome of patients requiring ventilatory support in the neuro-ICU.Patients and methods This was a prospective cohort study done at Neuropsychiatry Department and Center of Psychiatry, Neurology and Neurosurgery, Tanta University, from May 2016 to May 2017. All patients requiring ventilatory support after admission in our ICU, who were more than or equal to 18 years, and did not die before mechanical ventilation introduction were considered for the study. ResultsOf 63 patients, 30 (47.6%) died after mechanical ventilation introduction. Analysis of variables showed that all the following were significant predictors for mortality: old age, Acute Physiology and Chronic Health Evaluation-II score on admission, maximum Sequential Organ Failure Assessment score, National Institutes of Health Stroke Scale, Intracerebral Hemorrhage score on admission, ventilation strategy, main cause for ventilation, stroke type, and association of hypertension and cardiac diseases. Main cause of ventilation also significantly influenced modified Rankin scale among survivors. Conclusion Old age is associated with higher mortality, although mechanical ventilation can influence mortality among younger age groups. Early introduction of noninvasive positive pressure ventilation can improve in-hospital mortality. Outcome of ventilated patients is closely related to the main cause of ventilation, indicating mechanical ventilation is not essentially a therapeutic measure, however, a crucial supportive one. Application of Acute Physiology and Chronic Health Evaluation-II and Sequential Organ Failure Assessment scores and other prognostic and disability scores as National Institutes of Health Stroke Scale, Intracerebral Hemorrhage score and modified Rankin scale can monitor progression and significantly influence outcome of ventilated patients, especially when related to the main cause of ventilation.
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	A comparative study on the analgesic effect of tramadol or magnesium sulfate added to bupivacaine infiltration for postoperative pain management after lumbar disk surgeries	p. 203
	Soliman Ramadan Ahmed, Abd El-Raheem Mostafa Dowidar, Ashraf Al Sayed Al Zeftawy, Sameh Mohamed Fathy Ramadan SN, AD Mostafa, AA Al Sayed, SF Mohamed DOI:10.4103/tmj.tmj_57_17   Background Postoperative pain management aims to reduce patient discomfort and to allow early mobilization and recovery. Local anesthesia infiltration is a safe and effective anesthetic technique for many surgical procedures. Aim The aim of this study was to compare the effectiveness of local wound infiltration of bupivacaine plus tramadol and bupivacaine plus magnesium sulfate for postoperative analgesia after lumbar disk surgeries. Design A randomized double-blind study was conducted. SettingThe study was conducted at Tanta University Hospitals, Neurosurgical Department. Patients Sixty patients of either sex from 18 to 65 years old and undergoing elective lumbar disk surgery were included in the study. Patients and methods Patients were randomized preoperatively into three equal groups of 20 patients each. The patients of group I (bupivacaine group) received 20-ml solution containing bupivacaine 0.5% (10 ml), constituted with normal saline; the patients of group II (bupivacaine–magnesium group) received 20-ml solution, containing bupivacaine 0.5% (10 ml) with 500 mg of magnesium sulfate (5 ml) constituted with normal saline; and the patients of group III (bupivacaine–tramadol group) received 20-ml solution containing bupivacaine 0.5% (10 ml) with 2 mg/kg of tramadol constituted with normal saline. Postoperative pain as assessed using visual analog scale, and the time to first analgesic requirement and the total dose of rescue analgesia in the first 24 h postoperatively were also recorded. Results Wound infiltration with both tramadol and magnesium added to bupivacaine has provided a better pain control compared with bupivacaine alone. Visual analog scale values were significantly higher in group I than groups II and III at 4 h. First dose of supplemental analgesic was later in group III in comparison with groups II and I. Pethidine consumption was lowest in group III compared with the other two groups. Conclusion Local wound infiltration with a mixture of bupivacaine and tramadol after lumbar disk surgery produced an effective analgesia with reduced postoperative opioid requirements and minimal adverse effects compared with the other two groups.
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	Study of serum osteopontin levels in children with bronchial asthma in Egypt	p. 210
	Osama H Toema, Nabil M El-Esawy, Mohammed A Saad DOI:10.4103/tmj.tmj_47_17   Background Asthma is as an airway inflammation that results from interactions between various cells, cellular elements, and cytokines, which causes symptoms that include wheezing, breathlessness, and cough. Osteopontin (OPN) is a glycoprotein highly expressed in the bone and in a range of immune cells. It has chemotactic properties which promote cell recruitment to inflammatory sites and cytokine production. OPN affects IgE-mediated degranulation and migration of mast cells and other inflammatory cells taken together; these findings suggest a potential role for OPN in the regulatory pathway of asthma.Aim To measure the serum OPN level in asthmatic children to clarify its relation to bronchial asthma.Patients and methods The study was carried out on 60 asthmatic children aged 6–14 years. They were diagnosed and followed up in the Chest and Allergic Diseases Unit, Pediatric Department, Tanta University Hospital. Thirty asthmatic children were studied during acute exacerbation and 30 asthmatic children in clinically stable condition. Thirty healthy children were served as a control group. Pulmonary function tests and serum OPN level were done for patients and controls. Results The OPN levels were significantly higher in the asthma patients than controls. However, there was no statistically significant difference in OPN levels in asthma patients in stable conditions and those during exacerbations.Conclusion The present study has shown that asthma patients exhibit higher serum OPN levels than controls, suggesting a role for this protein in the pathogenesis of asthma that may help in the diagnosis of the disease.
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	Pattern of acute pediatric poisoning in Middle Delta Poison Control Centers	p. 215
	Fatma Gaber Ahmed Sobeeh, Nihal Salah El-Deen Abd El-Hay, Eman Ebrahim Draz, Khaled Mahmoud Saad DOI:10.4103/tmj.tmj_26_17   Background Pediatric poisoning is considered an important issue in many countries and accounts for a significant workload for emergency department consultations and hospital admissions. Thus, special epidemiological surveillance for each country is necessary to determine the problem according to which preventive measures can be taken. Aim The aim of this study was to determine the extent of acute pediatric poisoning in poison control centers located in Middle Delta as regards collected data. Patients and methods This retrospective study involved acutely poisoned pediatric patients aged less than or equal to 18 years old, who presented to poison control centers located in the Middle Delta in the 3 years period which extended from 1 January 2012 to 31 December 2014. The data had been collected from poison control centers located in the Middle Delta. The collected data included demographics, substance of exposure, manner of poisoning, data of clinical examination, data obtained from routine laboratory investigation, and patient's outcome. Results The findings of the study demonstrated that poisoning of children less than 6 years constituted the highest percentage. The majority of patients of acute poisoning were accidental. Accidental poisoning gradually decreases with increase in age. The most frequent poisoning caused by accidental manner was corrosives, while the most frequent poisoning in patients who attempt suicide was cholinesterase-inhibitor pesticides. Cholinesterase-inhibitor pesticides and corrosives constituted the highest percentage of poisoning. The most frequent manifestation was gastrointestinal manifestation and chest manifestation. Conclusion Poisoning of children constituted an important issue in Egypt. Poisoning of children less than 6 years constituted the highest percentage.
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	Programmed cell death 1 gene polymorphism association with activity and severity of systemic lupus erythematosus and rheumatoid arthritis in Egyptian patients	p. 225
	Wesam S Ibrahim, Salwa E Abdelghani DOI:10.4103/tmj.tmj_26_18   Background Programmed cell death 1 (PD-1) is an inhibitory regulator molecule of T cells and B cells. The PD-1 gene polymorphism was reported to be associated with autoimmune diseases like systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA), with conflicting results in different studies. AimThe aim was to investigate the potential association of PD-1.3 (rs11568821) polymorphism with SLE and RA in Egyptian patients and its relationship to the disease activity and severity. Patients and methods A total of 88 Egyptian patients with RA and 95 Egyptian patients with SLE as well as 85 healthy Egyptian controls were included in this study. PD1.3G/A (rs11568821) polymorphism was performed by restriction fragment length polymorphism polymerase chain reaction (RFLP-PCR) technique. Results There was a significant difference in the distribution of A allele of PD-1.3 between RA, SLE, and control groups (38, 40, and 16%, respectively). Patients carrying A allele had high risk for RA and SLE in comparison with healthy control. Patients with RA with AA genotype had a significantly higher levels of C-reactive protein, erythrocyte sedimentation rate, anticyclic citrullinated peptide positivity, disease activity index 28, and modified Sharp score compared with those with GG and GA genotypes. Moreover, in SLE, AA genotype was significantly correlated with low C3 and C4, high proteinuria, positive anti-dsDNA antibody production, and damage index. Conclusion PD1.3G/A (rs11568821) polymorphism was associated with an increased risk of RA and SLE in Egyptian patients, so it could be a reasonable genetic risk factor for both diseases. Moreover, patients with RA and SLE who are homozygous for A allele are susceptible to have increased disease activity and severity.
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	Comparitive study between levobupivacaine versus bubivacaine in spinal anesthesia for cesarean sections	p. 232
	Esraa H Abd-El Wahab, Sohair M Soliman, Sabry M Amen, Sameh R El-Shehdwy DOI:10.4103/tmj.tmj_34_17   Background Levobupivacaine showed a lower risk of cardiovascular and central nervous system toxicity than bupivacaine, which is the most popular local anesthetic agent in obstetric practice. The aim of this study was to investigate the clinical efficacy of levobupivacaine 0.5% compared with bupivacaine 0.5% for spinal anesthesia for cesarean sections. Aim The aim of this study was to compare the efficacy of levobupivacaine 0.5% versus bupivacaine 0.5% in spinal anesthesia for cesarean section. Patients and methods A total of 60 pregnant women in American Society of Anesthesiologists I–II group scheduled to have an elective cesarean operation were allocated into the study. Patients were randomly divided into two groups (30 patients in each group). Group I (bupivacaine group): in this group, patients received 2.5 ml bupivacaine 0.5%. Group II (levobupivacaine group): in this group, patients received 2.5 ml levobupivacaine 0.5%. Heart rate and mean arterial blood pressure were recorded intraoperatively. The onset time of sensory block and postoperative pain were assessed by visual analogue scale; time of postoperative first rescue of analgesia and duration of motor blockade were assessed by the Bromage score postoperatively. Results There was no significant difference between both groups as regards hemodynamics (heart rate and mean arterial pressure), two-segment regression of sensory block, time of first feeling of pain, total dose of consumption of analgesia, and visual analogue score. There was a significant decrease in the time to reach maximum sensory and motor block in group II compared with group I. Time of two-segment regression of motor block was significantly lower in group II than in group I.Conclusion Adequate surgical anesthesia can be achieved with both levobupivacaine and hyperbaric bupivacaine, as tested by the loss of pinprick sensation in both groups. Levobupivacaine given intrathecally can provide a safe and effective analgesic choice for parturients undergoing elective cesarean section, as the incidence of side effects with its use was significantly lower in comparison with hyperbaric bupivacaine.
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Paediatric Surgery

ORIGINAL ARTICLES
	Role of laboratory markers in predicting severity of acute appendicitis	p. 1
	Samarth Virmani, Padubidri Santosh Prabhu, PT Sundeep, Vijay Kumar DOI:10.4103/ajps.AJPS_47_16   Background: Accurately differentiating simple and complicated acute appendicitis (CAA) in children preoperatively can be challenging. The aim of this study is to evaluate the ability of the neutrophil-to-lymphocyte ratio (NLR), total leukocyte count (TLC), percentage lymphocyte, and percentage neutrophil counts to predict the type of appendicitis a patient has preoperatively and to determine the better indicator among these. Materials and Methods: Record of 233 patients under 18 years of age who underwent appendectomy from 2005 to 2014 was evaluated. Based on perioperative findings of the surgeon, the patients were grouped under categories simple acute appendicitis (SAA) and CAA. Information such as age, gender, and laboratory investigations of the patients were recorded and analyzed. Results: SAA included 185 patients and CAA included 48 patients. An NLR >4.8, TLC >13,500 cells/mm3, percentage lymphocyte count <14.8%, and percentage neutrophil count >75% were found to be associated with complicated appendicitis. The highest sensitivity and specificity among these findings were found with the percentage lymphocyte count, which were 70.8% and 63.8%, respectively. Conclusion: The preoperative percentage lymphocyte count serves as a better indicator than TLC, NLR, and percentage lymphocyte count and is a useful parameter in differentiating simple and complicated appendicitis and can be used as a valuable adjunct to the surgeon's clinical evaluation.
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	Indocyanine green clearance test to evaluate liver function in rat model of extrahepatic biliary atresia	p. 5
	Hemonta Kr Dutta, DN Rao, DK Gupta DOI:10.4103/ajps.AJPS_78_16   Background: Indocyanine green clearance test (ICG-K) has been shown as a sensitive marker of liver function in patients with cirrhosis. However, its role in the assessment of liver function in children with biliary atresia is not well established. The present study was undertaken to evaluate the ICG-K in an experimental model of cholangitis and partial biliary obstruction. Materials and Methods: Thirty albino rats were divided into 3 groups of 10 each. After exploration under anesthesia, a vial of OK-432 diluted in 0.2 ml of normal saline was injected into the common bile duct (CBD) in rats of Groups B and C. In the control Group A, only saline was injected. Re-exploration was done at 3 weeks in Groups A and B and at 6 weeks in Group C, and freshly prepared ICG was injected into the inferior vena cava. Blood samples were collected at periodic intervals, optical density of the serum was measured, and half-life of ICG and fractional clearance (K) were calculated. Blood and tissue samples were obtained for biochemical tests and histological examination. Results: The histological changes in CBD and liver were maximum in Group B; this correlated well with the K-value in this group, which was significantly delayed. In Group C, clearance was delayed than the control group with histological changes ranged from mild to moderate inflammation. The control group had normal histology of liver and CBD, and only four rats showed mild portal inflammation. Conclusion: ICG clearance rate is a reliable marker of liver function and can be utilized for evaluation of liver function in postoperative extrahepatic biliary atresia patients.
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	Congenital pouch colon associated with anorectal malformation: A rare anomaly of Asian Region – experience of Kurdish centre	p. 10
	Rossella Angotti, Qadir Qadir Mohamed Salih, Francesco Molinaro, Francesco Ferrara, Marina Sica, Edoardo Bindi, Mario Messina DOI:10.4103/ajps.AJPS_84_16   Background: Congenital pouch colon (CPC) is an unusual malformation associated with anorectal malformations (ARMs) that are seen especially in Asia. The aim of this study was to analyse our series of CPC associated with ARM in our centre and report our experience based on the rarity of pathology. Materials and Methods: This is a retrospective study conducted at the Department of Paediatric Surgery in North Iraq. We identified patients from a prospectively kept database, including all patients managed between 1997 and 2014. Results: In total, 17 patients (3 females and 14 males) were included; all had CPC and high ARM; male:female ratio was 5.6:1. Two females had colo-vestibular fistula, 1 had a colo-cloacal fistula, all males had imperforate anus with colovesical fistula. Pre-operative diagnosis of CPC was made in eight patients (47%). Four patients (23.5%) had an incomplete pouch colon (Type III and IV), and 13 (76%) had complete pouch colon (Type I and II). All patients were managed with staged surgery. Mortality rate was 17.6% (3/17). Conclusions: CPC associated with ARM can be defined as 'Asian' complex malformation. Few cases are reported in Literature from Europe and USA. However, it is known that it is ever more frequent the collaboration between Asian and European surgeons (as in our study), so the suspicion should be considered in all patient high ARM who come from Asian region. We reviewed literature and report our experience of 15 years, after a retrospectively analysis, to share it and add our data to their reported.
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	Congenital pouch colon: Our experience with coloplasty	p. 16
	Sudhir Singh, JD Rawat, Piyush Kumar DOI:10.4103/ajps.AJPS_88_16   Background: Congenital pouch colon (CPC) or congenital short colon is an entity found mainly in Indian subcontinent. In CPC, colon is replaced with partially or completely abnormal pouch connected to the genitourinary tract by a fistula (colovesical). Management protocol is different in different institute. In this article, we are sharing our three stage standard management approach; principle and technique of coloplasty in cases in which colon length is not adequate for pull through and their follow-up. This study aims to show the result of coloplasty in complete CPC. Materials and Methods: This is retrospective observational study, of 5 years duration. The medical record of these patients was reviewed for demographic information, clinical features, investigations performed, operative notes, post-operative events and the outcome of surgery. Results: Total of 626 ARM cases were managed in 5 years duration in which 64 were of pouch colon. The age of presentation was 1–15 days. In fifty patients who completed their, all stage in that 34 patients were in which coloplasty were done in rest of 16 cases excision of CPC and colonic pull through done in view of adequate colonic length (type III and IV) for pull through. In 34 patient in which coloplasty were done showed satisfactory cosmetic and functional out came after stoma closer in follow-up. Conclusions: Properly created coloplasty and three stage procedure for complete pouch colon give better result and less complications. Excision of pouch is not requiring in all cases of CPC.
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	Nephrectomy in children with wilms' tumor: 15 years of experience with "Tumor Delivery Technique"	p. 22
	Yoram Mor, Dorit Esther Zilberman, Roy Morag, Jacob Ramon, Chaim Churi, Itamar Avigad DOI:10.4103/ajps.AJPS_113_16   Background: The contemporary surgical approach to Wilms' tumors follows that used in adults with renal cell carcinomas, namely, early occlusion of the renal vessels and then removal of the kidney as an intact mass. For years, the surgical approach at our institution has been different, starting with blunt separation of the kidney from the surrounding tissues, followed by its delivery outside the abdominal cavity while it is only attached to the major blood vessels which are subsequently ligated. We aimed to present this "tumor delivery technique" and evaluate its outcomes. Materials and Methods: We retrospectively reviewed medical records of children who underwent nephrectomy for Wilms' tumor using "tumor delivery technique." All procedures were performed by the same team, according to the same surgical principles. Results: Between 2000 and 2015, 36 children were operated. Median age was 31 months (interquartile range [IQR]: 6–45 mo), and median maximal tumor diameter was 10 cm (IQR: 8–13.9 cm). Tumors were located to the right side in 47%, left side in 42%, and bilateral in 11%. Twelve children have received preoperative neoadjuvant chemotherapy. Capsular disruption and tumor spillage were documented in 4 cases (11%). Conclusions: "Tumor delivery technique" is an easy and safe approach which might reduce the overall complication rates and the incidence of intraoperative tumor spillage.
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	Infantile hypertrophic pyloric stenosis – Our experience and challenges in a developing country	p. 26
	Uchechukwu Obiora Ezomike, Sebastian Okwuchukwu Ekenze, Christopher Chim Amah, Elochukwu Perpetua Nwankwo, Nene Elsie Obianyo DOI:10.4103/ajps.AJPS_51_16   Background: This study aims to evaluate the experience and challenges in managing patients with infantile hypertrophic pyloric stenosis (IHPS). Patients and Methods: From January 2007 to December 2015, data from patients with IHPS were retrospectively acquired and analyzed using SPSS version 15. Pearson correlation used to assess linear relationships and Student t-test to compare means. P < 0.05 was taken as statistically significant. Results were expressed as percentages, means ± standard deviation and illustrated in tables and graphs. Results: Twenty-six cases were managed with the mean age at diagnosis of 49.16 ± 21.4 days. Mean birth weight was 3.7 kg and mean weight at presentation was 3.3 kg. Firstborn was affected in 29%; 91% were term deliveries; 9% were post-term; none was preterm; and 36% were exclusively breastfed. Mean duration of symptoms was 25.6 ± 18.9 days. Hyponatraemia was seen in 36%, hypokalaemia 37.5%, alkalosis 35% and hypochloraemia 62%. Mean pyloric tumour length was 22.85 ± 6.56 mm and pyloric wall thickness 5.51 ± 1.36 mm. There was a significant correlation between duration of symptoms and serum potassium level (R = −0.6326, P = 0.002). Mean symptom duration in patients with hypokalaemia was 39.88 ± 23.41 days and without hypokalaemia 17.15 ± 9.78 days (P = 0.006). Mean hospital stay was 9.45 ± 3.27 days. Four patients developed four complications and three patients died (11.5%). Mean age at presentation for pre-operative mortalities was 84 ± 39 days and 46 ± 17.98 days for others (P = 0.015). Conclusions: IHPS presents late in our environment and occurs mainly in term males. There is a significant positive relationship between duration of symptoms and serum potassium level and the mean duration of symptoms was significantly longer in those with hypokalaemia. Pre-operative mortality was significantly associated with longer duration of symptoms.
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	Role of ano rectal myomectomy in children with chronic refractory constipation	p. 31
	Rajeev Gurunath Redkar, Vinod Raj, Anant Bangar, Varun Hathiramani, Swathi Chigicherla, Shruti Tewari DOI:10.4103/ajps.AJPS_99_17   Background: Chronic refractory constipation (CRC) is an uncommon type of constipation. These children have persistent symptoms even after treatment with high dose laxatives, which may cause abdominal distension, vomiting, cramping and bloating. We conducted this study to assess the diagnostic and therapeutic role of anorectal myomectomy in children with CRC. Materials and Methods: This study includes 107 patients who fit the criteria of CRC. Complete bowel preparation with polyethylene glycol solution, enemas and antibiotics was carried out before surgery in all patients. The anorectal myomectomy was carried out under general anaesthesia with the patient in the high lithotomy position. The patients were followed up from 6 months to 13 years postoperatively. The success of myomectomy was based on the daily and complete passage of stools without the need for medication or enemas. Results: A total of 99 patients were included in the study, of which, 86 (86.86%) patients showed a good response to anorectal myomectomy. Of these, 32 patients had normal histology, 14 had histology suggestive of Hirschsprung's disease, 8 had hypoganglionosis, 10 had ultra-short segment Hirschsprung's disease and 22 had hypertrophic nerves with immature ganglia. Poor response was seen in 13 (13.13%) patients of whom 5 had normal histology, 5 had Hirschsprung's disease, 2 had hypoganglionosis and 1 had ultra-short segment Hirschsprung's disease. Conclusion: Anorectal myomectomy is an effective and technically simple procedure in selected patients with CRC for both diagnostic and therapeutic purposes.
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	Functional assessment of the patients with perineal and vestibular fistula treated by anterior sagittal anorectoplasty	p. 36
	Naoki Hashizume, Kimio Asagiri, Suguru Fukahori, Shinji Ishii, Nobuyuki Saikusa, Naruki Higashidate, Motomu Yoshida, Daisuke Masui, Saki Sakamoto, Shiori Tsuruhisa, Yoshiaki Tanaka, Minoru Yagi DOI:10.4103/ajps.AJPS_91_17   Background: Anterior sagittal anorectoplasty (ASARP) has been a standardised operative treatment for anorectal malformation (ARM). This retrospective study was undertaken to evaluate patients with perineal fistula (PF) and vestibular fistula (VF) treated by ASARP in our institution. Patients and Methods: Twenty patients (PF, n = 14; male, n = 8 and female, n = 6 and VF, n = 6) were evaluated. Eighteen patients underwent primary ASARP without protective colostomy. Two patients underwent colostomy because of intestinal atresia and suspected of other type ARM. The age range of operation was from 4 months to 5.0 years. Sixteen patients (PF, n = 13; male, n = 7 and female n = 6 and VF, n = 3) over 3 years of age were evaluated according to the Krickenbeck classification. Results: Operative complications occurred in one patient. Minor wound dehiscence occurred in six patients. Mucosal prolapse occurred in two patients. According to the Krickenbeck classification, amongst male patients with PF, all patients had voluntary bowel movements (VBMs) and two patients had Grade 1 soiling, while four patients had Grade 2 constipation. Amongst female patients with PF, all patients had VBM and no soiling, one patient had Grade 1 and two patients had Grade 2 constipation. In patients with VF, one patient was continent with Grade 1 soiling. One patient had Grade 2 and two patients had Grade 3 constipation. Conclusions: ASARP without colostomy carried a risk of wound dehiscence. The ASARP technique provided normal or moderate outcomes for VBM and soiling. However, in about half of patients, defecation management with laxative therapy was required to achieve a normal condition.
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	A 1-year randomized controlled trial to compare the outcome of primary repair of hypospadias with vascular cover using tunica vaginalis flap with those using preputial dartos fascia	p. 42
	Santosh B Kurbet, Ramesh S Koujalagi, V Geethika, Vikram Nagathan DOI:10.4103/ajps.AJPS_104_17   Background: Tubularized incised plate (TIP) urethroplasty is the most common technique noted to correct hypospadias. However, urethrocutaneous fistula (UCF) is still one of the most common complications of this technique. Several techniques of providing vascularized flaps to the neourethra have been recommended to decrease this complication rate. The aim of the study was to assess the outcome of primary repair of hypospadias using tunica vaginalis (TV) flap with those using preputial dartos (PD) fascia. Patients and Methods: Children diagnosed with hypospadias between the age group of 9 months to 18 years, who fulfilled the criteria were randomly divided into two groups by computerized randomization technique. Initially, TIP urethroplasty was done. Children with PD vascular cover were included in Group A and those with TV vascular cover were included in Group B. All the patients were followed up for a minimum of 6 months after surgery. Results: Two (10%) patients in Group A developed UCF and one (5%) patient developed stricture urethra in the follow-up period. None of the patients developed UCF in the Group B. One (5%) patient had stricture urethra in Group B. Two (10%) patient developed meatal stenosis in Group A. Two (10%) patient in Group B developed meatal stenosis. Conclusions:TV flap could be an alternative to PD flap as a vascular cover of neourethra in patients undergoing primary hypospadias repair by TIP urethroplasty.
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CASE REPORTS
	A staged operation for anopenile urethral fistula	p. 48
	Issei Kawakita, Shohei Honda, Hisayuki Miyagi, Masashi Minato, Kazuyoshi Okumura, Akinobu Taketomi DOI:10.4103/ajps.AJPS_52_17   Anopenile urethral fistula (APUF) is not rare, but there are only a few detailed reports regarding its surgical treatment. We describe a patient with APUF who had no anal opening, and meconium was discharged from the external urethral orifice. The patient was treated with a staged operation.
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	Metanephric stromal tumor: An unusual presentation of a rare paediatric renal neoplasm	p. 50
	Nouha Ben Abdeljelil, Rim Hadhri, Manel Njima, Yosra Sghaier, Lassaad Sahnoun, Abdelfatah Zakhama DOI:10.4103/ajps.AJPS_56_17   A 2-year-old boy with prenatal diagnosis of a malformation uropathy was referred to paediatric surgery department. On systemic examination, there were no palpable masses. An ultrasonography of abdomen with color Doppler, a renal artery angiographic and scintigraphy revealed a preostial aneurysm at the left renal artery. The patient had a left nephrectomy. Grossly, the specimen measured 75 mm × mm 50 × 20 mm with renal artery aneurysm measuring 30 mm × 35 mm. On cut section, the renal parenchyma contained a whitish tumor that measured 35 mm × 10 mm. Histopathologically, this tumor was diagnosed as metanephric stromal tumor.
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	Spontaneous common hepatic duct perforation in a child: A rare case report	p. 53
	Kanoujia Sunil, Archika Gupta, Ajay Kumar Verma, Abhishek Kumar Singh, Shiv Narain Kureel, Anand Pandey DOI:10.4103/ajps.AJPS_74_17   Spontaneous perforation of common bile duct is a rare phenomenon; few cases are reported in literature. Hence, there is a dilemma for the management of these cases, but with modern radiological equipment and high degree of suspicion, it is possible to diagnose early. The overall prognosis of this condition is good, provided an early surgical intervention is instituted; we are reporting a case of a 6-year-old male with spontaneous perforation of common hepatic duct. Managed by repair of rent over T-tube, postoperative period was uneventful, T-tube was removed after 3 weeks, and the patient is doing well in follow-up.
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LETTERS TO THE EDITOR
	Meckel's diverticulum: Is this the time for a large multicentric study?	p. 56
	Mirko Bertozzi, Antonino Appignani DOI:10.4103/ajps.AJPS_12_17
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	The evolving surgical approaches in challenged resource settings	p. 58
	Mirko Bertozzi, Antonino Appignani DOI:10.4103/ajps.AJPS_13_17
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	Plastibell circumcision	p. 60
	Sora Yasri, Viroj Wiwanitkit DOI:10.4103/ajps.AJPS_16_18
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	Extrahepatic biliary atresia, liver function tests, and hemoglobin variants	p. 61
	Ioannis Kyriakidis, Athanasios Tragiannidis, Nikolaos Gompakis DOI:10.4103/ajps.AJPS_124_16
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