19th Annual Meeting by sa6662B


									1) Pathophysiology of Chronic Constipation in Anorectal Malformations

    Holschneider A. M., Koebke J, Meier-Ruge W.

    Department of Paediatric Surgery, University of Cologne Cologne, Germany, Institute of
    Anatomy, Cologne, Germany, Department of Pathology, University of Basel, Berne,

Posterior sagittal anorectoplasty provides an optimal access to reconstruct the muscle complex in
anorectal malformations. It gives much better results than the abdominoperineal pull-through
procedures performed before 1984. However, severe chronic constipation occurs postoperatively
in about 10 % of the patients, which con only be treated by washouts.

Clinical investigations of 578 patients treated from 1962 to 1984 and from 1985 to 1997 are
presented here and both groups are compared to each other. In addition, a new continence score
with special regard to chronic constipation and overflow incontinence was used to follow up 133
patients of the second group. The score distinguishes between children above and below the age
of 3 years. To study the underlying reasons of severe chronic constipation in children with
anorectal malformations, macro- and microanatomical investigations on 4 normal newborns, 3
neonatal piglets with imperforate anus and 25 rectal biopsies from the caecum were performed.
The following reasons have been found to be probably responsible for postoperative constipation
and overflow incontinence: 1. Malformations of the smooth and striated muscle fibres or
connective tissue of the caecum; 2. Malformations of the intramural nerve plexus such as
aganglionosis, hypoganglionosis or IND; 3. Malformations and/or iatrogenic lesions of the
extramural nerve supply which runs anterior to the rectum and in front of the fascia of
Denonvilliers, which can hardly be identified in neonates with imperforate anus. Therefore
iatrogenic bladder injuries may occur after PSARP after extended mobilisation of the caecum. The
macro- and microanatomical situation in the piglet with imperforate anus is totally different from the
human newborn.

2) Laparoscopically Assisted Anorectal Pull-Through for High Imperforate Anus
      ElKholy A, Elbarbary M, Faris A
      Department of Pediatric Surgery, Cairo University, Egypt

Background / purpose: The aim of this study was to evaluate the Laparoscopic assisted
approach in the pull through procedure for high and intermediate types of imperforate anus in

Methods: Laparoscopic assisted pull through was done to 20 male patients with high imperforate
anus in Cairo University Specialized Children Hospital. Their ages ranged between 4-14 months at
time of surgery. All had defunctioning sigmoid colostomy in a previous stage. 3 patients had recto-
vesical fistula, 12 recto-prostatic, and 5 had recto-bulbar urethral fistula. Distal rectum dissection
and fistula securing were done through the laparoscope. The levator slings were identified in the
pelvis after fistula ligation. Transperineal retrograde access to the peritoneal cavity was carried out
through the pubococcygeus slings. Along this tunnel the colon was pulled through, and anoplasty
was completed. Regular postoperative anal dilatation was done and colostomy was closed in a
later stage. For proper assessment of continence, MRI and EMG to the external sphincter were
done before colostomy closure. The mean follow up period was 8 months.

Results: The mean operative time was 146 minutes. Postoperative complications occurred in 4
patients (20%); one had adhesive intestinal obstruction and 3 developed postoperative rectal
prolapse. Following colostomy closure, 2 patients (10%) were considered incontinent, 11 (55%)
had good results, and 7 (35%) had moderate results as regard continence.

Conclusion: Besides the known merits of laparoscopy, this technique carries the advantage of
not cutting through the continence muscles, with proper location of the pulled colon through the
levator sling under laparoscopic surveillance. However the absolute safety of the technique as well
as the long term results as regard continence, compared to the standard conventional surgeries is
not yet established.

3) Anterior sagittal anorectoplasty: A more conservative approach for management of
recto-vestibular fistula in Neonates and children.
      Saber M. Waheeb,
      Department of Pediatric Surgery, Alexandria University, Egypt

Objectives: many surgical techniques had been advocated for the treatment of vestibular anus in
girls; however, achievement of good continent results is the main goal. Anterior sagittal
anorectoplasty ASARP technique is assessed in this work as a treatment modality without dividing
the pelvic floor, thus offering better continent results, with less morbidity.

Material and Methods: Twelve girls with vestibular anus who were admitted to the pediatric
surgery unit, Alexandria University between Mai 2000, and Mai 2003 were included. Three cases
were neonates. In all cases ASARP was applied without protective colostomy, the technique was
universal in all cases. Follow-up was carried out up to 28 months (SD 3.2 months).

Results: the site of the new anus was satisfactory in all cases, with bilaterally equal muscle
contraction around it. Excellent external appearance of the posterior fourchette and perineal body
in those cases was noted. None showed stenosis or patulous anus. Normal bowel habit was
attained in all cases (no constipation or fecal impaction). Seven cases showed good continent
results (the remaining six cases were under 3 year old). One case showed mild mucosal prolapse.

Conclusions: ASARP is a reliable and easy technique to be applied in cases of vestibular anus. It
offers better visualization of the external muscle complex, thus sound closure of the posterior
fourchette, and perineal body can be achieved. Moreover, centralization of the rectum within the
muscle complex can be done without cutting of the levator ani muscle. Further studies are required
to widen the spectrum of its application

4) Appraisal of the Clinical Outcome and Anorectal Function after Posterior Sagittal
Anorectoplasty for High Anorectal Malformations: A Prospective Randomized Comparative
Clinical Study of One-stage vs. Multistage Procedure.
      Mohammed Abdel-Salam Shehata, Saber M. Waheeb,
      Alexandria University, Egypt

Background: PSARP procedure is claimed to have a better chance of enabling normal continence
in later years. Although PSARP has been enthusiastically adopted over previous techniques, there
are few careful long term follow-up studies, and questions have arisen regarding whether PSARP
is superior to other repair methods.

Objective: To resolve contradictions and to establish the actual degree of continence in patients
with a high anorectal malformation corrected by PSARP, this study was designed to analyze
quality & sensitivity the clinical, manometric and functional results of PSARP and to compare the
results of one stage PSARP with the multistage PSARP.

Patients: A prospective study of eighty patients with high anorectal malformation who were
selected randomly out of 193 cases admitted in the period from June 1997 to March 2000 to the
Main Alexandria University Hospital.

Methods: Twenty patients were selected at random for the one-stage PSARP (Group I).
Multistage PSARP were carried out for the remaining sixty patients (Group II). All patients were
assessed by electro stimulation, MRI, manometry, and FCS. Prospective follow up recorded the
efficacy of PSARP, the clinical and the functional outcome together with short and long term
complications. All patients were followed up for a period that ranged from three years to six years
with a mean of 4.52 ± 0.63 years.

Results: 86.25% were males. 78.75% presented with fistulas. Electro stimulation revealed that in
only 49 patients (61.25%), the new anal site was found to be central within the muscle complex.
43.75% were continent with good FCS. 28.75% were intermittently continent. 27.5% had
involuntary passage of stools at least once a day. one stage operation resulted in a much more
superior FCS than the multistage procedure with highly significant difference in the good FCS and
poor FCS cases, (P = 0.003742 & 0.000169 respectively). The mean FCS for the entire study
group was 3.0 ± 1.4. The mean RAP for the whole studied patients was 47.69 ± 10.64 cm H2 O.
RAP was < 40 cm H2 O in patients complaining of soiling. All continent patients showed MSP >
135 cm H2 O. One year after PSARP. There was no clear correlation between RV and soiling, but
it was notable that patients with severe soiling also had an RV > 150 mL. 76.25% showed a rectal
sensation      "urge      to      go";    36.25%        showed      a     normal      RAIR       RV
 results of MRI correlated well with FCS and electro stimulation. Eleven patients had postoperative
complications. Anal stricture occurred in three patients. Mucosal prolapse was found in four
patients. Rectourethral fistula was detected in two cases. Rectovaginal fistula was detected in two

Conclusion: PSARP allows preservation of the anatomy of pelvic floor muscles limits affection of
fecal continence. One stage PSARP is a safe effective procedure which gives the superior results
in treatment of patients with high Anorectal malformations. It minimizes postoperative
complications, colostomy drawbacks, costs, hospital stay and psychological problems

5) Temporary perineal drainage (TPD) to avoid colostomy in very sick male babies
with high imperforate anus (A Case Report)
      Safwat S. Andrawes
      Gertrude’s Garden Children's Hospital, Nairobi, Kenya.

Background: We loose many of these cases before, during or after doing Colostomy because
they present late and very sick and not fit for general anesthesia.

Idea/Aim: The idea of Temporary Perineal Drainage (TPD) is to decompress the abdomen
from the perineum for few days until the baby is stable and fit.

Method: This is a case presentation and description of the procedure. The (TPD) was
done under local anesthesia in the ICU bed.

Result: The baby had improved a lot and separated divided colostomy was done four
days later successfully and the baby went home safely.

Conclusion: I recommend that this procedure of (TPD) be done for the very sick male baby
with High imperforate anus who is not fit for General anesthesia to give them time to be fit for a
major surgery, also to be done in remote areas with late presentations until the baby is transported
to a safe hospital. The procedure is simple, safe, non invasive and life saving.

6) Progress in the Treatment of Diaphragmatic Hernia
      Michael E. Höllwarth
      Department of Paediatric Surgery, Medical University, Graz/Austria

The congenital diaphragmatic hernia is a relatively common malformation with an estimated
incidence of 1 : 2000 live birth. Additional malformations are associated in 35%-45%, and they
consist mainly of cardiac or neural tube anomalies. The defect in the diaphragm can be closed
without major difficulties in most cases. However, the underlying pulmonary vascular hypertension
and lung hypoplasia cause often significant respiratory insufficiency within the first 6 – 12 hours
and impose a major therapeutic challenge. The mainstays of the treatment strategy in the past
consisted of early surgical repair with chest tube drainage and vigorous therapy of the pulmonary
hypertension including hyperventilation (aCO2 under 30mmHg), muscle paralysis and vasodilator
medications, respectively. Despite progress in intensive care and ECMO-therapy, survival rates
remained disappointingly low till the 90’s (40% to 60%) in major centres and in our institution (48%
from 1975 – 1989).

During the last decade treatment strategies have been changed towards postponement of surgery
until stable conditions are achieved, conventional mechanical ventilation (CMV) including
permissive hypercapnia up to 60mm Hg, minimizing carefully barotrauma to the lungs and avoiding
any stress to the baby, and including efficient pain therapy. High frequency oscillatory ventilation,
NO and ECMO remain reserved for the most difficult cases. By that new treatment strategy,
survival rates up to 90% have been achieved recently in several centres. Consistent with these
reports, survival in our institution increased to 88% within the last 15 years (n=34) in all newborns
symptomatic within 6 hours after birth. Half of the 4 non-survivors died from respiratory
insufficiency despite ECMO, and half of the due to other diseases.
In conclusion, the new treatment strategies - gentle ventilation avoiding any barotraumas to the
hypoplastic lungs and any stress to the pulmonary circulation as well as postponement of surgery
until stable conditions are achieved - result in a significant increase of survival rates up to 90% of
symptomatic newborn with a congenital diaphragmatic hernia.

7) Therapeutic Options for Long-Gap Esophageal Atresia
      Arnold G. Coran, M.D.
      University of Michigan Medical School Ann Arbor, Michigan

Definition of Long-Gap Esophageal Atresia
- Gap measured in centimeters: 3-6        - Gap measured in Vertebral Bodies: 2-3
Ultra Long-Gap Esophageal Atresia
- > 6 centimeters         > 3 Vertebral Bodies
Surgical Options for Long-Gap Esophageal Atresia
   Proximal pouch stretching and subsequent primary anastomosis following initial gastrostomy
   Cervic al esophagostomy, gastrostomy and subsequent esophageal replacement: stomach,
    gastric tube, colon, jejunum
   Proximal esophageal myotomy and primary anastomosis. Occasionally distal esophageal myotomy
   Proximal esophageal pedicle flap and primary anastomosis
   Partial division of the stomach lesser curvature with mobilization of the distal esophageal and
    proximal stomach into the chest and primary anastomosis (Scharli)
   Partial gastric transposition into the right chest with primary anastomosis and partial
    fundoplication after a period of proximal pouch stretching
   Complete gastric transposition into chest with primary anastomosis in the neck of the stomach to
    the cervical esophagus after one month of gastrostomy feedings to enlarge the stomach
   Progressive stretching of proximal cervical esophagostomy onto the chest (Kimura)

Experience at C.S. Mott Children’s Hospital and University of Michigan Medical Center
with Pure Esophageal Atresia
- Total cases of Esophageal Atresia (EA) and/or Tracheoesophageal Fistula (TEF), 1941-1996: 564
- Total cases of EA and/or TEF, 1977-1996: 201

16 Cases of Pure Atresia

1      Partial        5 Esophageal        10 Primary repairs Transposition after proximal pouch
Gastric               Replacements        stretching, Only 1 Proximal Myotomy


1 Colon after                          4 Gastric Transpositions,
Esophagostomy                                   2 after Cervical Esophagostomy and Gastrostomy,

                                                2   Primary   without       preliminary   Cervical

- No Mortality      - Leak Rate: 10%           - Stricture Rate: 10-15%

8) Invited Guest lecture: Classification, Diagnosis and Current treatment of Vascular
      Richard G. Azizkhan
Cincinnati Children’s Hospital Medical Center, Cincinnati, USA

In 1982, Mulliken and Glowacki proposed a classification of vascular anomalies based on
biological and pathological features. This has become the basis of the currently accepted
classification scheme adopted by the International Society for the Study of Vascular Anomalies
(ISSVA). Despite this attempt to standardize terminology, confusion still persists in the scientific
literature. The current ISSVA classification is composed of two main groups: vascular tumors and
vascular malformations. The vascular tumors are comprised of infantile hemangiomas, as well as
a newly described spectrum of congenital hemangiomas, tufted angioma and kaposiform
hemangioendothelioma. Recently the identification of GLUT 1(a glucose transporter) marker was
found to be a marker for infantile hemangioma during all phases of development (proliferation to
involution). Other vascular tumors and malformations are negative for GLUT 1. Vascular
malformations are classified according to their vascular tissue of origin: e.g. capillary malformation
(CM), venous malformation (VM), arteriovenous (AVM) and lymphatic malformation (LM). Complex
mixed malformations may have most vascular components (CVLM).
Diagnosis and treatment of vascular anomalies has improved because of a more precise
classification and understanding of these lesions. Pharmacologic therapy such as steroids,
vincristine, and interferon are being selectively applied to vascular tumors that are life or function
limiting lesions. On the other hand other therapeutic strategies such as sclerotherapy,
embolization and surgical excision are being utilized for vascular malformations that are in general
unresponsive to these same drugs. In the future accurate phenotypic designation combined with
molecular and genotypic classification will lead us to improved therapies including anti-angiogenic
drugs and gene therapy.

9) Management of Congenital Diaphragmatic hernia: Waiting or tailoring the treatment?
    Ahmed Zaki, Mona Al Shehi.
    Pediatric Surgery Department, Mafraq Hospital, Abu Dhabi – United Arab Emirates

The “wait then operate” policy for congenital diaphragmatic hernia has resulted in better survival
rates. Many other modifications and therapies have been suggested over the years. We will
discuss our experience at Mafraq Hospital.

Between 1993 and 2004, we had 39 neonates born with congenital diaphragmatic hernia. In 2001
we adopted the new policy of lower ventilation treatment with a permissive hypercapnea, in order
to reduce the barotraumas and hoping to improve survival.

We had 28 neonates in the period 1993–2001 and 11 neonates in the period 2001–2004. Thirteen
(13) neonates died preoperatively, eight (8) and five (5) for respective periods. Postoperative
mortality was in four (4) patients (25%) in 1983-2001, and one (1) patient (12.5%) in 2001-2004. A
group of seven (7) neonates were operated upon on the first day of life & six (6) on the second day
of life. The therapy and the results will be further discussed.

In conclusion, therapy for neonates with congenital diaphragmatic hernia is changing as we
understand more the pathophysiology of the disease. Some neonates who have no signs of
respiratory affection can be operated on in first day; however the main-stay of therapy is
supportive therapy with trials to reduce the barotraumas for these neonates.

  10 ) Management of Esophageal Strictures in Epidermolysis Bullosa Patients
        Richard G. Azizkhan
        Cincinnati Children’s Hospital Medical Center, Cincinnati, USA

Epidermolysis bullosa (EB) is a spectrum of disorders characterized by the development of skin and
mucous membrane blisters following minor trauma. There are three major classes of inherited EB.
These include epidermolysis bullosa simplex (EBS), junctional epidermolysis bullosa (JEB) and
dystrophic epidermolysis bullosa (DEB).      This classification scheme is based on where in the
epidermis or the dermis the blisters originate. EBS blisters arise in the epidermis, while JEB and
DEB blisters arise in the lamina lucida and lamina densa of the dermoepithelial junction,
respectively. A non-inherited autoimmune form of EB, known as epidermolysis bullosa aquisita
(EBA) presents with subepithelial bullous formation and is caused by anitbodies to collagen VII, the
major structuring component of the anchoring fibril in the dermatoepithelial junction.

Although the cutaneous manifestations of EB are well known, the mucosal and gastrointestinal
pathology are also common and a significant source of morbidity in these patients. The esophagus is
more involved in more severely affected EB patients. Dysphagia, esophageal dysmotility and
esophageal webs/strictures have been reported in all major classes of EB with the highest incidence
in JEB and DEB patients. However, children with recessive DEB, especially those classified as
Hallopeau-Siemens variant, are particularly prone to growth retardation and the development of
esophageal strictures. Disease activity may be recognized initially by dysphagia and phagodynia.
Symptoms initially may be self-limited with the development and rupturing of blisters in the
esophagus. Recurrent blistering leads to scar formation and strictures. Approximately one half of
the strictures occur in the proximal one third of the esophagus near the cricopharyngeal region.
Although esophageal strictures occur at any age, the majority do not present in early childhood.
Those children that do present with esophageal strictures have severe DEB and have significant
growth retardation, poor nutrition and impaired wound healing. Esophageal shortening and
gastroesophageal reflux have been long term consequences of this disease process in some

Treatment consists of early and repeated dilatation of the esophagus in an effort to reduce the
symptoms and improve the quality of life. Today, the use of balloon dilatation under fluoroscopic
control under general anesthesia has become standard. This approach gives prompt relief of the
esophageal obstruction and many patients have extended periods of relief lasting months to years. I
have had no significant complications in more than 100 procedures during the past 20 years I have
tried to avoid rigid or flexible esophagoscopy as the friction associated with the endoscopy can
exacerbate the bullous formation and subsequent additional scarring. A brief course of oral steroids
may extend the interval between dilatation in some patients. All these patients require special and
gentle handling to minimize skin, oropharyngeal and tracheal trauma. Patients with microsomia may
require intubation using flexible bronchoscope. The natural history of epidermolysis bullosa with
esophageal involvement is not fully known, however, a number of patients appear to have
progressive esophageal strictures and eventually require permanent gastrostomy feedings. Children
with epidermolysis bullosa and esophageal strictures have life-long issues in maintaining adequate
oral nutrition. Using a variety of strategies, enteral nutrition and appropriate growth can be
maintained for all but the most severe cases.

11) Congenital Esophageal Stenosis: to Dilate or to Resect?
      Essam Elhalaby, Amel Hashish, Mohamed Elbarbary, Hisham Soliman, Sherif Kadah,
      Hatem Saafan, Alaa Hamza
      Tanta University , Ain Shams Universitiy & Cairo University Egypt

Background/Purpose: Congenital esophageal stenosis (CES) is a rare clinical condition of
childhood. The definitive preoperative diagnosis often is difficult to make, and the ideal therapeutic
strategy remains controversial. This study aims at determining the ideal therapeutic strategy for the
management of CES.

Material & Methods: Medical records of 17 patients with CES treated at 3 academic institutions
during a period of 10 years were reviewed retrospectively with regard to diagnostic method,
therapy, and outcome.

Results: The patients aged 3 months to 9 years at time of diagnosis. The stenosis was more
frequently located at lower third of esophagus (n= 10) than upper third (n= 3) and middle third (n=
4).    The diagnosis was made by esophagogram, esophagoscopy, and confirmed by
histopathologic examination. Fifteen patients were diagnosed primarily, while 2 patients were
diagnosed after surgical treatment for initial misdiagnosis of achalasia of the cardia. Only 6
patients had confirmed tracheobronchial remnants on histopathological studies, while the others
had either membranous (5 patients) or fibromuscular stenosis (6 patients).

All patients (except 2 with initial misdiagnosis of achalasia) were treated by repeated esophageal
dilations (2- 8 times) over a period ranging from 2 to 30 months. The dilation alone was successful
in 11 patients, but was complicated by esophageal perforation in one patient, who was managed
conservatively and has not required any further endoscopic dilatation.

Three patients underwent resection and anastomosis, 2 had myotomy, while one patient was
treated by esophageal replacement. Of those later six patients, 2 had fibromuscular stenosis and 4
had bronchial remnants. The indication for surgery was non-compliance of the patient or their
parents for repeated dilatations and / or failure of dilatation in 3 cases. One patient with bronchial
remnant was successfully treated by dilation but required surgery for Barrett’s disease. Two with
initial misdiagnosis of achalasia.
Conclusions: This study emphasizes the diagnostic difficulties in many children with CES.
Esophageal dilatation should be tried initially for all patients with CES even in those cases with
tracheobronchial remnants, which may be localized and not encircling the esophageal wall.
Resection should be reserved for cases not responding to repeated dilatation.

12) Traumatic Tracheobronchial Injuries in Pediatric population
      Amro R. Serag, Abdelmohsen M. Hammad
      Cardiothoracic Surgery Department – Tanta University – Egypt

Injuries to the tracheobronchial tree are well-recognized sequelae of massive blunt or penetrating
injuries of the neck or chest. Despite their occurrence is uncommon in the pediatric trauma
population; they represent life-threatening injuries.
Patients and Methods: Twelve patients with tracheobronchial injuries were reviewed over a 5-
year period. All patients except one (penetrating) were suffering from blunt trauma. There were
nine bronchial (seven right, two left) and three tracheal injuries. Those lesions showed a clinical
gaseous syndrome associated with pneumothorax, mediastinal and subcutaneous emphysema.
Diagnosis is based on clinical signs, imaging and bronchoscopy. Three cases had negative
bronchoscopic findings.
Results: Urgent (n=7) and delayed (n=2) thoracotomies were performed; reestablishing
anatomical continuity of the bronchial tree (n=7), lobectomy (n=1) and pneumonectomy (n=1) were
applied. Tracheal injuries were managed either conservatively (n=1) or by tracheostomy (n=2).
Postoperative bronchial stenosis occurred in one child and three children died (25%).
Conclusion: Tracheobronchial injuries should be recognized and treated early. However, initial
findings may not be specific, requiring the physician to display a high degree of suspicion. Without
prompt diagnosis and appropriate treatment, the risk for mortality and morbidity increases.

13) Invited Guest lecture: CME Credits: the European system
      Gian Battista Parigi
      Department of Pediatric Surgery, University of Pavia - Italy
      General Secretary and Treasurer, UEMS Section and Board of Paediatric Surgery

Since the very beginning of the modern medicine there has been a strong tradition of continuing
medical education (CME) in the medical profession, with the most powerful motivating factors
being positive ones such as doctors’ awareness of their responsibility for safe medical
performance, recognition of peers, collective emphasis on the quality of medical practice. In very
recent years nevertheless the “CME question” exploded, possibly due to two powerful instances:
the hectic evolution of medical knowledge and a mounting request from the public to have qualified
doctors. On the other hand stands the right of medical doctors to have formally recognized their
struggle for keeping pace with the medical evolution. All this happens in a world facing what has
been defined as the “3rd global revolution”, the “cultural digitalisation”: everything in this world has
to be computerised, computer technology works only with digits, and hence we must express in
numerical terms a concept, medical education, hardly prone to be expressed in this way.
The system devised to offer an answer to this issue is the so-called “credit system”. A credit is a
unit of CME and corresponds basically to one hour of educational activity. One credit does not
have to be always identical with a clock hour, but can be different depending on the type of
education. Credits will be awarded according to the CME activity involved: the initial basic
minimum target for CME is 50 credits per year. In one year not more than 100 credits should be
CME activities are classified in two categories: “External” and “Internal” CME; the former as a
general rule must be formally approved beforehand, while the latter does not need formal
approval. External formally planned CME includes: a) Scientific Congresses with European
registration; b) Scientific Congresses not registered (local); c) Courses, Workshops, Seminars; d)
Distance learning programs. Internal CME includes: a) Hospital based CME (Postgraduate
meetings, Research meetings, Department meetings, Hospital grand rounds, Journal club, Clinical
outcome meetings –audit-); b) Independent based CME (Reading medical literature, medical
writing, editorial or refereeing work, Internet learning, self assessment examination, medical
audiotapes and videos); c) Other activities (Visit to specialised units, preparation and delivery of
formal lecture or seminar, preparation and delivery of audit report, publication or presentation of
scientific papers or books, teaching, postgraduate examination work).
To harmonise and improve the quality of specialist medical care in Europe by improving quality of
CME and accessibility to CME for the medical specialists in Europe the UEMS has created since
1999 the European Accreditation Council on CME (EACCME), with the aim to facilitate transfer of
CME credits obtained by individual specialists in CME activities that meet common quality
requirements. That means fostering the transfer of CME credits between European countries,
between different specialties, in case of migration of a specialist within Europe, between the
European credit system and comparable systems outside Europe (in June 2000 has been signed
the agreement with the ACCME and the ABMS - American Board of Medical Specialties)
Implementation of CME encountered some problems, and there are still many open questions.
1) Mandatory or voluntary? In Europe CME is mandatory in Austria, Croatia, Czech Republic,
   Hungary, Italy, Netherlands, Norway, Romania, Slovenia, Switzerland, United Kingdom;
   voluntary in Belgium, Bulgaria, Cyprus, Denmark, Finland, Germany, Greece, Iceland, Ireland,
   Luxembourg, Portugal, Spain, Sweden; building up in France, Poland, Slovakia. In the world is
   mandatory in Australia, Canada, Iran, Mexico, New Zealand, Singapore, South Africa, USA;
   voluntary in Argentina, Chile, Costa Rica, Egypt, Israel, Japan, Kuwait, Malaysia; building up in
   Brazil, China, Jordan, Peru, Saudi Arabia. From the experience up to now matured, there is no
   evidence that “compulsory CME makes better doctors”.
2) CME (Continuous medical education) or CPD (Continuous professional development)? In the
   Basel Declaration of 20 October 2001, CPD is defined as “…the educative means of updating,
   developing and enhancing how doctors apply the knowledge, skills and attitudes required in
   their working lives. The goal of CPD is to improve all aspects of a medical practitioner’s
   performance in his/her work”.CPD incorporates and goes beyond the concept of CME, which
   generally is taken to refer only to expanding the knowledge and skill base required by doctors:

     should therefore be the preferred concept for the future. For the moment being, let’s get
     acquainted at least with CME and delay CPD to a further moment.
3) Which contents? According to some Colleagues, “…CME teaching is always theoretical, always
   the same lecturers with always the same boring presentations…” it “…could be improved if it
   was more practical, like the option to visit a hospital for a few days and work alongside a
   master". How to enhance compliance? Some countries (Belgium) introduced a financial
   support, or a paid leave (Iceland); some other Countries financial penalty for doctors not
   complying with CME requirements (Germany, Netherlands).
4) What about recertification? Legal recertification is not yet required by any Country, although
   some Scientific Societies require Professional recertification every 3 to 5 years (Japan, Costa
5) How to deal with external influences? CME business can imply influence of medical industry on
   the system funding (Italy, China), or influence of the government on the medical careers (UK).
6) How to deal with e-learning? E-learning offers fascinating perspectives in the field of medical
   education, but open huge problems about providers accreditation and credits verification.

From all these considerations is clear that CME is a multi-faceted problem, needing to be
considered from various points of view before expressing a sound judgement on its value.

14) Invited Guest lecture: The laparoscopic picture of inguinal hernias in children
      Felix Schier
      Department of Pediatric Surgery, University Medical Center Mainz, Germany

Purpose: To describe the laparoscopic picture of inguinal hernias in children.

Methods inguinal hernias were operated laparoscopically in 489 children (363 boys, 126 girls,
aged 4 days to 14 years, median 1.6 years). The internal inguinal ring was closed with a 4-0 non-
absorbable suture using 2-mm instruments.

Results: Follow up to date is 1 - 84 months (median 41). There were 4.1% hernia recurrences,
0.7% hydroceles and 0.2% testicular atrophies. 16 of the 18 recurrences occurred in boys and on
the right side. The contralateral inner ring was open on the left side in 16% of boys and 12% of
girls, on the right side in 18% of boys and 32% of girls. Direct hernias were found in 2.4%, femoral
hernias in 1%, hernias en pantaloon in 0.6% and a combined indirect/direct/femoral hernia in

Conclusions: Advantages of the laparoscopic approach include technical ease, the cord
structures remain untouched, the type of hernia is obvious, and trocar placement is identical for
any side or hernia type. Finally, recurrences are easier to deal with, be it from a previous open or
from a laparoscopic approach. Although recurrences were slightly more frequent in the early
stages, now they are closer to the rate with the open procedure. Laparoscopic inguinal hernia
repair can be a routine procedure with results comparable to those of open procedures. It is well
suited for recurrences, the vas remains untouched. The visualization of structures is clear and
leads to a defect-specific closure.

15) Laparoscopic Repair of Difficult Groin Hernias in Children
      Mohamed Elbarbary, Khaled H.K. Bahaaeldin
      Cairo University, Egypt

Background: Repair of Groin hernias are the most commonly performed surgical procedures
done by pediatric surgeons. Inguinal approach to these hernias has been both effective and
cosmetically accepted. However there still remain some cases, where inguinal approach is less
than ideal. Laparoscopic approach may a more effective analogue to the conventional approach in
these cases. These include bilateral hernias, very large oblique hernias, and hernia of canal of
Nuck, recurrent inguinal hernias and femoral hernias. Repair of recurrent case can prove difficult
and carries the risk of injury to important inguinal structures. Moreover identification of femoral
hernial defects can be difficult through the inguinal approach. Laparoscopic repair for groin hernias
in children was first reported in 1995.

Purpose: the purpose of this study is to report the Cairo University Pediatric Hospital (CUPH)
department of surgery’s experience in the use of laparoscopy in management of difficult groin
hernias in children.

Patients and Methods: 13 patients, presenting with potentially difficult groin hernias to our
department during the last year, were included in this study. There were 3 females and 10 male
patients. 19 laparoscopic repairs were attempted successfully. Age group ranged from 7 months to
9 years. 3 children presented with femoral hernias, 3 with hernia of canal of Nuck (2 were
bilateral), 7 presented with recurrent oblique inguinal hernias. Laparoscopic repair of these
hernias was done using 3 ports. The peritoneum was incised in the hernial ring narrowed using
interrupted non absorbable sutures

Results: All procedures were completed successfully repaired laparoscopically, and there were no
operative complications. The mean operative time for the inguinal hernia group including females
and recurrent cases was 23.6 minutes, shortest time was 13 minutes and longest was 32 minutes.
An added benefit was the closure of a contralateral patent processus vaginalis in three of our

Conclusion: Laparoscopy does provide an easier, safer alternative to conventional surgery, in the
management of selected cases of difficult groin hernias in children.

16) Ultrasonographic Diagnosis of Potential Contralateral Inguinal Hernia in Children
      Amel A. Hashish, Essam A. Elhalaby, Emad M Mashaly
      Departments of Pediatric Surgery& Radiology, Tanta University Hospital, Tanta, Egypt

Background/ Purpose: A controversy exists regarding the necessity of exploration of the other
side in children presenting with a unilateral congenital inguinal hernia. This study was undergone
to investigate the accuracy of the ultrasonographic preoperative recognition of an unapparent
contralateral inguinal hernia (or patent processus vaginalis).

Material & Methods: The contralateral inguinal canal in 94 children presenting with unilateral
inguinal hernia was examined by ultrasound using a 7.5 MHz transducer. The diagnosis of a
potential inguinal hernia was considered if one or more of the following features were noted: 1. The
detection of an intraabdominal viscus in the inguinal canal with increment and decrement of the
intraabdominal pressure; 2. the presence of a cyst like patent processus vaginalis (PPV) at the
internal ring of the inguinal canal; 3. The PPV and the inguinal canal are widened with abdominal
pressure increment (the length of the PPV is longer than 20 mm and the width of an internal
inguinal ring width greater than 4 mm in diameter). Only patients with positive ultrasonographic
findings undergone exploration of the contralateral inguinal canal at the same session following
repair of the clinically detected hernia. All other patients underwent surgery for the clinically evident
hernia side only. Follow up ranged from six to 11 months.

Results: A positive ultrasonographic findings were noted in 17 of the 94. One patient did not show
PPV at exploration (false positive). Another patient with a negative findings developed hernia 4
months later.
Conclusions: 1. the incidence of contralateral unapparent PPV in this series (18.1%) seems to be
less frequent than previously assumed. 2. Routine contralateral inguinal exploration is not
recommended and 3. Ultrasound is an accurate, non-invasive method to determine which patient
should have bilateral inguinal exploration

17) Intraoperative pneumoperitoneum for detecting contralateral inguinal hernia in high risk
children; Goldstein’ test revisited.
      Khairi A.
      Department of Pediatric Surgery, Alexandria University, Egypt.

Background: Contra-lateral exploration (CE) in children with a unilateral inguinal hernia (IH) is still
controversial, particularly in infants. Patients presenting with a left-sided hernia have a greater
chance of developing a contra lateral IH. Though the finding of a patent processes virginals (PPV)
in most series is usually present in over 35% of cases, yet the occurrence of a contralateral hernia
is usually seen in less than 15% of cases.

Patients &Methods: From August 2002 through July 2004, 138 cases of inguinal hernias were
repaired by the author. In 14 cases of the left-sided group, intraoperative pneumoperitoneum was
performed to detect any associated right-sided hernia. After routine dissection, the left-sided sac
was used to insufflate the abdominal cavity using CO2. This was followed by examining the right
side for any swelling or crepitus.

Results: One hundred and thirty eight cases of inguinal hernia were repaired by the author during
the study period; 20 females (14.5%) and 118 males (85.5%). The age ranged from 7 days to 13
years. Eighteen cases presented with bilateral hernias (13%), 78 cases with right-sided hernias
(57%) and 42 with left-sided ones (30%). Intraoperative pneumoperitoneum test was done in 14
cases, all with left-sided hernias. No sign for right-sided sac was detected in any case. No right
side exploration was done accordingly. The patients were followed up for periods ranging from 6 to
18 Months. No single case developed right sided hernia over the follow up period.
Conclusion: intraoperative pneumoperitoneum is a valuable technique to test for associated
contralateral hernia. The test can be done routinely particularly in children with a high chance of
having a contralateral hernia. This helps avoiding unnecessary contralateral exploration in this
group of patients.

18) A new method for non-operative treatment of omphalocele
      Mahomud M Mostafa, Ibrahim Ali, Mohamed A Osman, Khalid E Saleh
      Department of Pediatric Surgery, Assiut University, Faculty of Pharmacy, Alazhar University,
      Assiut. Egypt

Introduction: Giant omphalocele is a major clinical challenge for pediatric surgeons whereas
small to media sized defects can be repaired primary. Larger omphaloceles cannot be closed at
birth because the liver and small bowel has lost the domain of the abdomen. These infants often
require a staged abdominal wall closure using a Dacron, reinforced silastic silo as a temporary
extra-abdominal locate for the bowel.

Purpose: In some cases non-operative management using topical application of an escharotic
agent is another choice for treatment because of the presence of cardiovascular malformations
(10-15%), bad general condition, prematurity, and respiratory distress.

Methods: In our study, non-operative treatment of omphalocele was tried using pods of acacia
nilotica (grounded as powder) mixed with gentian violet to make a paste and applied topically twice
daily. (Acacia nilotica, family leguminosae, is a medium sized or large thorny tree, up to 20m high,
with dark stems and branches. The tree grows spontaneous in the Nile valley and hence its name
nilotica. Pods of acacia nilotica are flattened, constricted between the seeds and breaking into
indehiscent single-seeded fragments. Pods and leaves contain 8% digestible protein and are rich
in minerals. Deseeded pods from ssp indica have 18-27% tannin levels, where ass ssp.
Tomentosa and nilotica reach up to 50%. Bark, leaves and young pods are strongly astringent due
to tannin. The pods are used for tanning especially for goat hides. Ancient Egyptians already used
the pods for tanning lether and for dying).

Conclusion: Using a paste formed from powdered acacia nilotica seeds and gentian violet is a
simple, effective, cheap, available and natural method for non-operative treatment of large

19) Training to be a Paediatric Surgeon
      Dan Young.
      Royal Hospital for Sick Children, University of Glasgow, Glasgow, UK

In the nineteenth century training to be a surgeon was very different from, the problems a trainee
               th                                      st
faced in the 20 century, but what is it to be as the 21 century progresses?

A brief look at the early demonstrates that apart from apprenticeship the young surgeons traveled
extensively in Europe to gain experience from other European nations. Returning then to their
home pitch the opportunity for the advancement in the specialty soon developed. Examples of the
earlier surgeons in Glasgow will give an indication of these facts and that unless you had financial
support it was unlikely that you were going to rise high in the surgical world.
 The GMC was established in the middle of the 19 century and this organization gradually
developed a powerful influence on undergraduate education. The Colleges reached the height of
their influence in determining the standards that were necessary in the post-graduate field. This
                                                                              th    th
had major influence in the expanding hospital service that developed in the 19 to 20 centuries.

An outline of the changes, which evolved in the UK, and an outline of the necessary courses for
young surgeons will be given. In the mid century the introduction of the NHS caused major
changes. One of the benefits of that system was that it opened the doors of medicine in the UK to
many individuals from other countries. The NHS as it was established was such that it required
many overseas doctors to maintain the service but the secondary effect was that it was for many
doctors it was a very good training ground.
The 21 century poses many new problems and these affect surgeons in whatever country they
either qualify or practice. An outline of the present position in UK and the effect that is likely to
have in the future will be discussed. What is the relevance of this to surgery in Egypt?

20) Invited Guest lecture:
Intestinal Adaptation and Surgical Options Following Massive Intestinal Loss
      Brad W. Warner,
      Cincinnati Children’s Hospital Medical Center, Cincinnati, USA

Following massive small bowel resection, there is an important compensatory adaptation response
which occurs in the remnant intestine. This response consists of increases in villus height, crypt
depth, and intestinal length and caliber.

 Adaptation is important to allow patients to wean from parenteral nutrition. The mechanism for
adaptation is not presently well understood, however, our laboratory has established that a
functional intestinal epidermal growth factor receptor (EGFR) is critical. Experiments whereby the
EGFR is inhibited results in an attenuated adaptation response. On the other hand, stimulation of
the EGFR during adaptation results in an amplified response. In addition to the possibility for
growth factor modulation of the adaptation response, several surgical options exist for managing
patients to either induce adaptation, or improve intestinal function. These consist of the creation of
intestinal valves and reversed intestinal segments or interposition of a segment of colon, or
tapering the caliber of the bowel. Alternatively, there are several methods to increase intestinal
length including the Bianchi procedure and the serial transverse enteroplasty. Careful patient
selection with procedures tailored to individual needs will enable parenteral nutrition independence
in most patients.

21) Invited Guest lecture: Clinical Relevance of Neuronal Intestinal Dysplasia
      Holschneider, A. M., Homrighausen, L. H. , Dübbers, M., Kunst, M., Kellner, M.
      Department of Paediatric Surgery, Cologne, Germany

During the past 10 years 164 patients with neuronal intestinal malformations, except genuine
aganglionosis, were treated at the Department of Pediatric Surgery at Cologne Children’s Hospital.

The hypothesis of the study is that all neuronal intestinal malformations are expressions of
different disorders of maturation. All cases of dysganglionosis go through a process of
differentiation in which complete maturity as well as real hypoganglionosis resulting from apoptosis
of ganglia cells or neuronal intestinal dysplasia (NID) might be a possible finding.
Hypoganglionosis was found in 36 patients as final state, NID in 80 children. Intermediate states in
the process of development like immaturity combined with NID (n=14) or immaturity combined with
hypoganglionosis (n=3) were described. The common idea of NID, immaturity and
hypoganglionosis as autonomous diseases is relativated by this hypothesis.

Furthermore the study tries to show a correlation between described histopathological entities and
clinical expressions. Validation-parameters are constipation, determination of intestinal transit-time
and x-ray examination of colon and defecation with contrast enema and delayed radiograph.

Evaluation has not been finished, but at the present time it is obvious that there is no need of
therapy in the intermediate states (immaturity, immaturity + NID), while development of
hypoganglionosis (with or without NID) causes severe constipation often followed by surgical
treatment. Conclusive results are presented. A prospective study will be affiliated.

22) Peutz-Jegher's Syndrome in Children and Adolescent
        Ahmad Eltayeb Essa, Almoutaz .A.,E.Essa.
        Department of Pediatric Surgery, Assiut University, Egypt

Two cases of Peutz-Jeghers syndrome were reported. Both were presented with manifestations of
intestinal obstruction.
The syndrome is characterized by multiple intestinal polypi in the small and large intestine and
may be in stomach, in addition to melanin pigmentation of the lips and oral mucosa and possibly
other areas of the skin. These adenomatous polypi are liable for malignant transformation and may
be the cause of intestinal obstruction .This characteristic pigmentation is of a diagnostic
importance when associated with abdominal pain, bleeding per rectum or evidence of intestinal
obstruction. The resection should be conservative because the polypi are usually widespread.
Every patient with this pigmentation should be screened clinically and radiologically together with
his family because the syndrome may affect more than one member in the family and inherited as
autosomal dominant.

23) Transanal Endorectal Pull-through for Management of Hirschsprung’s disease
Experience with 27 Cases
      Mohamed El-Ghazaly Waly
      Department of Pediatric Surgery, Mansoura University, Egypt

Background and Purpose: Transanal endorectal pull-through is a step forward in the evolution of
the modified Soave’s pull-through. The aim is to evaluate the applicability of this technique without
the need for Lone Star Scott retractor.

Patients and Method: 27 Cases of biopsy-proven H.D. ranging in age from 40 days to 10.5 years.

Results: The technique was feasible in all cases except 2 were converted to laparotomy, frozen
section was used in 18 cases, the length of the resected segment ranged between 15 cm – 48 cm.,
operative time 80-210 min., hospital stay 3-5 days, bowel motion 3-10/day gradually decreased to
1-3/day. Cuff abscess occurred in 1 case, temporary soiling in 11 cases, persistent soiling in 1
case. Follow up period 6-38 months.

Conclusion: TEPT is not a sophistication of ordinary treatment of H.D. but is a simplification
without loss of safety. It is the new goal standard for management of the majority of patients with

24) Redo Surgery for Hirschsprung's disease: What Procedure for Which Patient?
     Essam Elhalaby, Amel Hashish, Hussam S. Hassan, Ahmrd Issa, Hesham Fayad, Ahmed
     Nofal, Sherif Shehata
     Tanta University, Egypt

Background/Purpose: Despite the remarkable progress in the management of Hirschsprung's
disease (HD), a significant percentage of patients may not do well after their initial definitive
operation and some may even require redo surgery. The choice of specific redo operation for a
particular patient is quite variable in various reported series. This study was undertaken to
review our last 1l-year experience with redo surgery for HD aiming to have a well-defined
protocol for the management of those patients.

Patient & Methods: From November 1993 to now, 33 patients (25 males and 8 females) with
unsuccessful surgery for HD have been treated at Tanta University Hospital, local health
insurance hospitals and private sector. Patients treated successfully by just dilatation for a
postoperative stricture or by conservative management for their recurrent episodes of
enterocolitis were not included in this study. Each patient was evaluated as regard to age at
primary and redo surgery; nature of initial definitive procedure; indication and details of redo
surgery, and the functional results at both short and long term follow up.

Results: The age of patients at time of redo surgery ranged from 1.5 month to 21 years. The
initial definitive operations were: myectomy (n =15), 5 of them have myectomy more than once;
conventional soave endorectal pull-through (ERPT) operation (n=12); Duhamel procedure
(n=5), and transanal ERPT (n=1). The indications for redo surgery were: severe intractable
stricture (n=7), residual aganglionic segments after myectomy (n=10) or pull through (n=5), and
intractable constipation with associated massive distal colonic dilatation with or without
recurrent enterocolitis (n=11). The redo surgical procedures included: Myectomy alone (n=9);
myectomy followed by pull through (=8), pull through (n=16). Of the 24 patients, who eventually
required pull-through, 16 undergone ERPT, 5 Duhamel, 3 Swenson. Follow-up ranges from 1
month to 11 years (mean, 4.5 years). There were no deaths in this series. Only 16 of the 28
(57.1 %) patients who are older than 3 yeas at last follow up have a normal or near normal
bowel habits, 5 (17.9%) are still suffering from constipation, and 7 (25%) have either frank
incontinence or repeated soiling.

Conclusions: 1. Redo surgery for HD seems to be less favorable compared to primary
procedures in terms of continence and stooling frequency. 2. Whenever feasible, ERPT should
be the first choice as a redo pull-through procedure. 3. Redo myectomy should be condemned
to avoid a "double hit injury' to sphincteric complex with resultant high frequency of anorectal

25) Rectal Ectasia - A Report of 11 Cases
      Mahdy Borghol, Abdullah Alrabeeah
      King Khaled National Guard Hospital, Jeddah, KSA

Rectal ectasia may be defined as a persistently dilated rectum, which despite having normal
ganglion cells, remains flaccid and non-contractile under fluoroscopy and which fails to evacuate
except with the aid of enemas or strong cathartics.

Eleven patients with rectal ectasia (6 infants, 3 aged 2-6, an 11 year old and a 16 year old) were
surgically treated. In all patients, other causes of constipation including Hirschsprung's disease
were excluded and for all, persistent medical measures were followed for several months before
surgical treatment was considered. Associated anomalies included severe anal stenosis, previous
imperforate anus surgery, musculoskeletal deformities of the hips and lower limbs, generalized
hypotonia and mental sub normality. Operative procedures performed were low anterior resection
for 6 and Swenson's pull through for 5 patients. Preliminary colostomy was used in all but one
patient. Histological examination of the specimens revealed no atrophy or hypertrophy of any
specific muscle layer. Follow-up ranged between 8 months and 4 years. Normal bowel function
and continence were achieved in 4 patients, 4 patients still require laxatives intermittently and 3
patients have varying degrees of incontinence.

Literature search for similar cases reveals no clear guidelines for the evaluation and management
of this condition. Some aetiological factors are identified; however, the pathogenesis remains
largely unclear. The management of these difficult cases requires careful clinical assessment and
thorough parental counselling prior to contemplating surgery. Expectation of normal bowel function
and control should be appropriately addressed especially in patients with abnormalities of the
sphincter mechanism where the risk of fecal incontinence is particularly significant.

26) Congenital Duodenal Obstruction
      Sherif N Kaddah, Ahmed T Hadidi, Hisham S Safoury
      Department of Pediatric Surgery, Cairo University, Egypt

Background: Congenital duodenal obstruction may be due to intrinsic or extrinsic causes.
Reported incidence rates range from 1:7,500, to 1:40,000 live births. Duodenal atresia and
malrotation are diseases of newborn infants. Cases of duodenal stenosis or perforated duodenal
web (diaphragm) rarely remain undiagnosed until early childhood.

Material and methods: 31 cases of congenital duodenal obstruction were operated upon in
Benha Children Hospital (BENCH), 15 cases of duodenal atresia, 6 cases of duodenal
diaphragm.7cases of malrotation, and 2cases of annular pancreas. Age incidence ranged from
2days to 7months.Bilious vomiting was the main presenting symptom. Plain radiography was done
in29 cases preoperatively, while upper GIT contrast study was done in 2cases with late
presentation at the age of 5and7 months. Diamond shaped Duodeno-duodenostomy was the
standard surgical procedure for duodenal obstruction cases, and division of bands of Ladd was the
operative procedure for malrotation

Result: Overall mortality was 29% mainly due to prolonged gastric stasis and neonatal sepsis.

Conclusion: The authors recommend early preoperative diagnosis with proper preoperative
correction of general condition of cases to improve mortality rates.

27) Ethanole Amine Oliate Injection for Pediatric Rectal Prolapse: Clinical Outcome and
Anorectal Function Tests
      Mohamed A Osman, Ibrahim Ali, Mostafa Alsharkawy, Mohmoud M Mostafa
      Department of Pediatric Surgery, Department of Radiology, Assiut University, Egypt

The purpose: of this study was to evaluate the clinical outcome of injection therapy of rectal
prolapse and its effects on anorectal function investigations

Methods: ten patients with complete rectal prolapse underwent injection rectopexy using ethanole
amine oliate. They were subjected to pre and post-injection evaluation including scoring of
incontinence, and anal endosonography.

Results: No recurrences of rectal prolapse were seen (median follow up 12 months). Continence
improved in 7 of 8 pre-injection incontinent patients. One of the patients had mild constipation after
injection. Pre-injection, endosonography showed asymmetrical and thickening of internal anal
sphincter and submucosa. After injection the maximum internal sphincter thickness decreased
from 1.5 to 1.2

Conclusion: injection rectopexy improved prolapse and incontinence in our patient and showed
recovery of internal sphincter. Injection rectopexy had no morbidity, no mortality of minimal
invasive technique with good out come of surgical rectopexy.

28) A Perforated Duodenal Ulcer in A 3 Month Old Baby: Case Report
       Ahmed A. Gomaa & Elbager O. Elhassen ,
       Pediatric Surgery Department, K.F.H, K.S.A.

Introduction: Duodenal ulceration is seldom diagnosed in young children, perforation being even
rarer. Some present with recurrent abdominal pain and anemia, whereas others have
haematemesis or melaena with or without perforation. In children the causes of peptic ulcers are
different from those of adults. The usual causes are non-steroidal anti-inflammatory drug treatment,
head injury, overwhelming sepsis, burns, major surgery, steroid therapy and Helicobacer pylori
infection, acting alone or in combination. The ulcers could be acute or chronic. We report an
unusual case of perforated acute duodenal ulcer in a 3 month old baby with brain tumor following
steroid treatment.
Case report
Three month old baby presented to emergency department with fever 38 C and vomiting for 2 days.
This baby was born from non consanguineous parents following an uneventful pregnancy and
diagnosed antenatally by ultrasound scan as having hydrocephalus. After birth there is gradual
increase in head size with no fits. Examination revealed a baby 6 kg weight, 58 cm height, and
45cm skull circumference. Rest of examination was considered normal. Laboratory investigations
considered normal. Skull x-ray showed widening of sutures.
Two days later, during his hospital stay, baby suddenly developed apnea and cyanosis,
endotracheal tube inserted. Baby admitted to pediatric ICU. Chest was full of crepitations with no
spontaneous respiratory effort, so mechanical ventilation started. After few hours, baby developed
bradycardia 70/min, anterior fontanel became very tense, increased skull circumference 46cm.
Fundus examination shows severe papilledema. CT scan brain showed bilateral gross dilatation of
lateral & 3 ventricles with marked reduction of brain parenchymal thickness. Heterogeneous mass
in posterior cranial fossa measures 4.5X 3.7cms compressing and obliterating the 4 ventricle (Fig
1). Ventricular tapping done by neurosurgeon to reduce intracranial tension, 50 c.c evacuated and
CSF sent for chemical and microbiological examination: considered normal. Baby started on
medical treatment with Dexamethasone, Diamox, Lasix and Antibiotics.
Neurosurgeon decided ventriculo-peritoneal shunt insertion. Baby shifted to pediatric ICU after
ventriculo-peritoneal shunt insertion on Rocephin, Vancomycine Dopamine IV drip, Dobutamine IV
drip, Dexamethasone and IV fluid. 1 postoperative day, baby developed abdominal distention.
Vitals were stable. Abdomen was soft but distended no tenderness, no rigidity, no organomegaly
and bowel sound was not audible. Abdominal X-ray showed a small rim of air under the diaphragm.
2 postoperative day, abdominal distention increased .Vitals showed Temp.37.7C, Pulse. 180/min,
blood pressure: 120/62, O2Sat:100%. Nasogasteric tube aspiration was 40 c.c dark green.
Abdomen became markedly distended, tender, and rigid and bowel sounds were absent. Liver
dullness was absent. Free fluid was not detected clinically. Digital examination of the rectum
considered normal. Laboratory Investigations. Abdominal ultrasound scan revealed a fluid
collection in the left subphrenic space.
Emergency laparotomy done, which revealed bile stained fluid seen in the peritoneal cavity, gut was
examined for perforation. Big perforation detected in anterior border of 1st part of duodenum (Fig 3),
with no distal obstruction and rest of viscera being normal. A biopsy was taken from the edge and
the ulcer was closed with Vicryl 3/0 interrupted sutures with omental patch reinforcement. Peritoneal
lavage was carried out using warm normal saline. Abdominal drain inserted. The wound was closed
in layers postoperatively, patient nursed in PICU on ventilatory support. Unfortunately, patient
continued to deteriorate and expired15 days later. The biopsy was reported as acute inflammatory
Peptic ulcer disease of stomach and duodenum in infants and children, not an uncommon disease,
should be given appropriate clinical consideration in pediatric practice. Recurrent abdominal pain of
childhood with nocturnal awakening caused by episodes of abdominal pain must investigated with
upper GI Endoscopy for peptic ulcer disease. We suggest that prevention of stress ulcers is a
major goal of therapy, and high-risk patients should be treated with antacids and H2-blockers such
as cimitidine or ranitidine as a prophylaxis.

29) Invited Guest lecture: Minimal invasive Pediatric surgery in daily practise - a critical
      J. Schleef
      Department of Paediatric Surgery, Children’s Hospital IRCCS Burlo Garofolo Trieste, Italy

Minimal invasive surgery is becoming in the last 10 years one of the most important topics. Many
“new” procedures and techniques were described. But there are still many questions left without a
precise answer. While there are many retrospective studies, case reports dealing with feasibility
and safety in new procedures, only a few reports are focusing on comparative studies and
prospective evaluation. A systematic research on the advantages and limits of paediatric minimally
invasive surgery is mandatory.

The impact of minimal – invasive surgery on our daily practise is constantly growing. In our own
department we are performing a prospective study on the feasibility and results of mini – invasive
procedures in abdominal and thoracic interventions. Preliminary results show, that at least 60% of
all surgery is performed by laparoscopic or thoracoscopic techniques. The complication rate is
comparable to open procedures. In some indications (hernia, varicocele) we believe that the
standard technique in association with a mini – invasive anaesthetic approach are fulfilling already
the criteria of mini – invasiveness.

The side effects of the application of CO2 are not well known in newborns. An own animal model
and studies of others describe many side effects on circulation and inflammatory response. Since
these problems are not evaluated completely, we should be careful to use laparoscopy in very
small infants and high risk babies.

Therefore, further systematic research on the advantages and limits of minimally invasive surgery
in children is mandatory.

30) Preservation of the gubernaculum during laparoscopic assisted orchiopexy. A new
innovation to improve testicular blood flow after spermatic vessels ligation.
      Sameh Abdel Hay
      Department of pediatric surgery unit-Ain Shams University Egypt.

Background: During laparoscopic assisted orchiopexy for impalpable testis ligation of spermatic
vessels may be needed for bringing the testis down into the scrotum. Such ligation usually impairs
the blood supply to the testis with possibility of subsequent testicular atrophy. The initial
description of Fowler and Stephens in 1963 for ligation of the spermatic vessels for lengthening of
the spermatic cord stressed the importance of preservation of the gubernacular vessels. In all
techniques used in laparoscopic assisted orchiopexy, cutting of the gubernaculum is an important
step for proper mobilization of the high intra abdominal testis.

Patients and methods: In our series we found that 85% of intra abdominal testes, the
gubernaculum does not hinder the testicular mobilization and subsequently can be preserved. The
technique for gubernacular preservation will be presented.

In conclusion, we recommend preservation of the gubernaculum initially during testicular
mobilization and only those cases with tough short gubernaculum will need its section to improve
the outcome of spermatic vessels ligation during laparoscopic assisted orchiopexy.

31) Laparoscopic Splenectomy In children
      Alaa Hamza
      Ain Shams university, Egypt

Several studies suggest that LS provides benefits over open splenectomy (OS).
 Splenectomy is frequently required in children with various hematologic disorders. Since 1991,
laparoscopic splenectomy (LS) has gained acceptance in the treatment of hematologic
disorders, including idiopathic thrombocytopenic purpura (ITP). The reported advantages of
laparoscopic splenectomy (LS) include less pain, shorter hospital stay, and improved cosmesis.
This report evaluates the outcome of children undergoing LS at a single children's facility. 20
children underwent LS by the lateral approach between Jan 1998 and February 2004.
Indications for LS were hereditary spherocytosis in 6, idiopathic thrombocytopenic purpura in
12 and sickle cell disease in 1, and partial spleenetcomy for splenic cyst in one case. LS were
completed in 18 children with two required conversion to open splenectomy. Accessory spleens
were identified in 2. Complications included ileus (one), acute chest syndrome (one), bleeding
(one). There was no mortality. Average operative time for LS was 106 minutes Operative time
for LS decreased with experience but the difference was not significant. Average length of stay
was 1.51 days (range 1-11) and was longer in sickle cell disease (2.47 days) versus hereditary
spherocytosis (1.29 days) and idiopathic thrombocytopenic purpura (1.16 days). We conclude
that LS is safe and effective in children with hematologic disorders and is associated with
minimal morbidity, zero mortality, and a short length of stay

32) Laparoscopic Assisted Pyeloplasty
      Amin Elgohary
      Almerfaq Hospital, Abu Dhabi, UAE

Between January 2002 and October 2004 we have used the laparoscopic assisted technique in a
variety of pediatric surgical conditions, aiming at benefiting from the advantages of both the open
and the laparoscopic technique.

One of the most rewarding is laparoscopic assisted pyeloplasty. These entail dissecting the
pelviureteric junction laparoscopically and bring the junction via a 2 cm port site to finish the
anastomosis outside the body cavity.

We have operated on 11 children between the age of 4 months and 4 years. 9 of these children
were under the age of one year. The procedure proved to be simple, less time consuming and of
great cosmetic result.

We would like to share our experience with the audience and show a video presentation.

33) Laparoscopic retroperitoneal nepherectomy & heminephroureterectomy in children
      Morsi HA, AbuElFetouh H, Daw M
      Cairo University, Egypt
      Departments of Pediatric urology, Cairo University, Egypt

Introduction: Over the last 2 decades, the use of laparoscopy has gained an increasing popularity
andextended application in all surgical specialties especially in Pediatric patients. Nephrectomy ,
nephroureterectomy & heminephroureterectomy is more common in Pediatric patients than in
adults because of congenital anomalies .

Material and methods: We present our developing experience in retroperitoneal nepherectomy,
nephroureterectomy & heminephroureterectomy in children. Between August 2003 and August
2004 we performed 8 cases: 3 heminephroureterectomies, and 5 nephroureterectomies for
different indications. We have tried the retro peritoneal access in all cases as the most anatomical
and to compare our results with the intraperitoneal access and open surgery. Urine analysis &
culture, serum creatinine, abdominal& pelvic ultrasound, PUT & IVU, cystourethrography, & renal
isotopic scan were performed to all patients. Follow up Urine analysis & culture, serum creatinine,
abdominal& pelvic ultrasound were performed to all patients. All patients were fresh cases except
one (percutaneous nephrostomy due to pyonephrosis).The procedure was done using 3 trocars (2
of 5 mm& the third 10 mm), insufflation of the retroperitoneal space was done without balloon but
under vision with progressive and gentle movement of the optic lens. The specimen was delivered
easily & gently from the incision of the 10 mm trocar and a drain was left.

Results: Operative time 145 minutes, with no need for blood transfusion. Very smooth
postoperative period with no need for analgesia, no bleeding intra or postoperative. Bowel
movement was detected 5 hours postoperative with oral intake allowed 6 hours postoperatively
with no problems. The drain was removed 12 hours postoperative and the child leaves the hospital
24 hours postoperative. 2 cases needed conversion to intraperitoneal access, one nephrectomy
due to previous retroperitoneal surgery & one heminephroureterectomy due early opening of the

Conclusion: Retroperitoneal nepherectomy & heminephroureterectomy in children is feasible &
safe and provides an excellent alternative to open surgery regarding postoperative pain,
convalescence & hospital stay. Retroperitoneal nepherectomy in our opinion is superior to
intraperitoneal approach regarding the more anatomical access, the incidence of intraperitoneal
complications and the postoperative convalescence

34) Laparoscopic repair of congenital diaphragmatic defects in children: an earlyexperience
with 7 cases

        Nabil M. Dessouky
        Cairo University, Egypt

Background:Surgical procedures are frequently performed on the diaphragm in children. The
development of video-assisted surgery brought about a significant change in the surgical repair of
these diaphragmatic conditions.

Material and Methods:Cases with congenital diaphragmatic defects presented over a period of a
year had undergone an attempt at minimally invasive surgical repair. Candidates for laparoscopic
correction were children having mild symptoms with good respiratory and haemodynamic

Results: The study included seven cases with congenital diaphragmatic defects: 2 Morgagni, 4
Bochdalek and one case of large sliding Para esophageal hernias. Their ages varied between 9 –
32 months with a mean of 16 months.
Four ports were used for laparoscopic access in most of the cases. All the herniated viscera were
repositioned into the abdomen. Laparoscopic repair was successful in 5 cases without the use of a
mesh. There was no recurrence with a follow-up period of 1-7 months.

Conclusion Under specific conditions, laparoscopy can be an effective and more advantageous
alternative to laparotomy for congenital diaphragmatic defect in children. A longer follow-up period
is needed for evaluation of the technique.

35) Invited Guest lecture: Fresh Thoughts on Bladder Exstrophy
      Mark C. Adams,
      Vanderbilt Children’s Hospital Division of Pediatric Urology Nashville, Tennessee

Introduction: Most discussion about bladder exstrophy has focused upon males. We have
recently applied the principles of total primary repair to females with bladder exstrophy or

Methods: Five newborn female patients with exstrophy variants and three older patients with
female epispadias were evaluated and repaired. In all repairs, the bladder and proximal urethra
were moved to the appropriate cephalad position after separation from not only the clitoris but also
the anterior vagina and pelvic floor. We had measured the distance from the interureteric ridge to
the anterior vagina in newborns with exstrophy at 10-13 mm, the same distance noted to the
prostate in males. After proximal mobilization of the bladder and distal mobilization of the vagina,
the urethra was lengthened by at least 2 cm using paraexstrophic flaps based at the bladder neck
in the opposite orientation as classically described. The repairs thus incorporated principles of
both proximal urogenital sinus repair with those of newborn exstrophy closure. Exposure allows
midline incision of the pelvic floor for posterior placement of the urethra.

Results: No patient developed a urethrovaginal fistula. The cosmetic results have been good with
no remaining element of a urogenital sinus. None of the newborns with exstrophy have achieved
complete toilet training, but all have a dry interval without continuous leakage. One is out of
diapers during the day. Three with classic bladder exstrophy have had good bladder growth (60,
75 and 85 mL) by one and a half year of age. Two patients with cloacal exstrophy variants have a
small bladder capacity and will likely require continent diversion eventually. All three girls are
continent and void well every two to three hours after epispadias repair. None have had any
urinary tract infection or clinical problems related to emptying.

Conclusion: After carefully examining several females with exstrophy variants, the vagina is in the
same position as the prostate in males, and we consider them to have an element of a urogenital
sinus. The sinus is open anteriorly with the bladder but also posteriorly up to the vagina. If
separation of the bladder and urethra from the phallus is advantageous in the male, similar
mobilization from the vagina and clitoris early may be beneficial in females as well. Long-term
follow-up with careful urodynamics and imaging of the pelvic floor muscles is critical to
understanding how continence may be better achieved in such patients.

36) Invited Guest lecture: Basics Principles in the Surgical Treatment of Neurogenic
Bladder in Children.
      JM Guys
      Hopital de la Timone Enfants – Marseille – France

The diagnosis of neurogenic bladder can be easy in myelomeningocele and much more difficult in
occult dysraphisms or medical etiologies. Careful clinical examinations and urodynamic
explorations are mandatory for the diagnosis and the follow up of these patients. Clinico-
anatomical correlations are poor.

If urinary leak is the first apparent symptom preservation of the upper urinary tract is the main goal
of the surgeon. If natural history of the neurogenic bladder is destruction of the detrusor and
paralysis of the trogon, obstructive uropathy is the main physiological concern. Urinary leak must
be integrated in the global context of the bladder function in order to determine urinary
incontinence type.

Ideal micturition is voluntary, must be complete, and needs a reservoir with a good capacity,
compliant, adequate sphincter outlet resistances and synergia between the two. Continence is
obtained by balancing these functions and association between medical treatment and surgery is

Bladder intermittent catheterism is the clue to obtain in must of the cases complete evacuation of
the bladder and protection of the upper urinary tract. Increasing bladder capacity is achieved more
often by augmentation cystoplasty (colon, ileus, stomach and ureter can be used).

Autoplasty at the beginning, artificial tissue engineering will be the future

Augmentation of the bladder outlet resistances need surgical reconstruction (Young Dees, Pipi-
salles procedures…) or uretral and bladder neck suspensions, artificial urinary sphincters,
endoscopic injections of bulking agents.

All these techniques can be proposed and combined according to the gender age of the patient
and social environment. The continent cystostomy allows us, in difficult cases and after
unsuccessful surgery of the bladder neck to obtain continence.

Others techniques are under evaluation and sacral neuro-modulation give at the moment some
promising results.

Taking care of the neurogenic bladder must be not limited to the urological point of view:
orthopedic troubles, digestive and sexual ones must not be forgotten in order to obtain at least an
“acceptable social life”.

All the above points will be precised either from the technical points and respective surgical
indications in the oral presentation.

37) Aerosol Transfer of Bladder Urothelial And Smooth Muscle Cells Onto Demucosalized
Colonic Segments For Porcine Bladder Augmentation In Vivo: A 6-Week Experimental
     Ashraf T. Hafez, Kourosh Afshar, Darius J. Bägli , Andre Bahoric, Karen Aitken, Charles R.
     Smith, Antoine E. Khoury,
     The Urology & Nephrology Center, Mansoura University, Mansoura-Egypt & Hospital for
     Sick Children, University of Toronto, Toronto, Ontario-Canada

Purpose: In a pilot study, we developed a cell transfer technology for populating demucosalized
colonic segments with bladder urothelium. This process was achieved through aerosol transfer of
a single cell suspension consisting of bladder urothelial cells, smooth muscle cells, and fibrin glue
onto demucosalized colonic segments. Herein, we further evaluated this new concept in a
controlled study.

Materials and methods: Twenty piglets (20Kg) were utilized. In all animals 50% of the bladder
with excised. A 10-cm segment of the sigmoid was isolated. Animals were then equally divided into
5 groups: (1) colocystoplasty only, (2) demucosalized colocystoplasty, (3) demucosalized
colocystoplasty plus covering of the demucosalized sigmoid with fibrin glue only, (4) aerosol
application of fibrin glue with single cell suspension of urothelial cells only to the demucosalized
colon, (5) aerosol application of fibrin glue with urothelial and smooth muscle cells to the
demucosalized colon. The 4 corners of the augmented segments were marked with 5/0 prolene
sutures. Animals were sacrificed 6 weeks later and the surface area of the augmented segment
was measured. Segments were submitted to histological and immuno-histochemical analysis.

Results: The surface area of the augmented segments showed increase in group 1 animals
(147% SD 17), stabilization in groups 4 & 5 (98% SD 5) and marked reduction in group 2 (21% SD
6) and group 3 (22% SD 2.7). On H&E & Masson trichrome staining all group 1 showed normal
colonic epithelium of the augment. All group 2 & 3 showed excessive scarring with urothelial
coverage only at the augment periphery, while the central augment area showed no epithelium.
Group 4 & 5 segments showed confluent epithelial covering with no fibrosis. There was no
evidence of colonic epithelial re-growth in any animal in groups 2-5. Cytokeratin 7 and Uroplakin III
staining demonstrated complete coverage of the augmented segment with urothelium only in
groups 4 & 5.

Conclusions: The addition of aerosolized cells of urological origin is a viable augmentation
approach that appears to achieve the much sought after inhibition of intrinsic fibrosis and
contraction of colonic segments when incorporated into the urinary tract without this cellular
component. Moreover, this technique appears to provide a histologically normal, confluent
urothelium, which sets the stage for prevention of the well-documented biochemical aberrations
inherent in augments containing gastrointestinal epithelium. While successful in this model
regardless of the incorporation of urologic smooth muscle cells, chronic studies are now warranted
to validate the short-term results, as well as to determine whether the urologic mesenchymal
population (smooth muscle) will be required to sustain the uroepithelial phenotype in the long term.

38) Treatment of Spastic Neurogenic Bladder by Surgical Augmentation: Ten years
      Adnan AL-Hussami
      Children Hospital – Damascus Uni.

Background & purpose: The aim of this study is to report our experience in the treatment of
spastic neurogenic bladder by surgical augmentation
 Material and method: This clinical study included 92 patients treated by bladder Augmentation,
ureter reimplantation, and appendicovasictomy during the period 1995 – 2004
Results and Conclusions:
1-Surgical Augmentation of spastic neuorogenic bladder is the treatment of choice
2-It provides a low pressure in the augmented bladder that protects the reimplantation of the
3-It provides a continent diversion
4-It provides an easy and clean entrance to make CIC
5-Encouraging the pediatrician to move to the radical and invasive treatment by the neuorogenic
bladder accompanying with Reflux and Incontinence to protect the kidney and to make the child
social acceptable.
6-This Orientation goes hand in hand with the international trend by the treatment of Spastic
neuorogenic bladder.

39) Primary Reconstruction of Exstrophied Bladder after Anterior Pubic Osteotomy
      kamal Abd Elelah
      Department of Pediatric Surgery, Mansoura University, Egypt

Background/purpose: Bladder exstrophy (BE) represents a challenging reconstructive problem.
This study was undertaken to assess the value of superior pubic ramus osteotomy (SPRO) for
repair of BE.

Material and Methods: 14 consecutive cases of (BE) were subjected to primary reconstruction
after anterior pubic osteotomy. Varieties of the studied cases, the associated anomalies and
postoperative complications were reviewed.

Results: Out of the 14 operated cases, 2 cases developed bladder dehiscence that was reclosed
4 months latter. In both cases pubic rediastasis had not occurred. 3 children developed
postoperative inguinal hernias, one of them was bilateral.

Conclusion: SPRO is safe and efficacious technique to obtain tension free approximation of the
pelvic ring in BE-repair with similar results to those obtained with more complicated osteotomies.

40) Surgical procedures and long-term follow-up of female patients with congenital adrenal
hyperplasia from 21-hydroxylase deficiency, with special emphasis on the results of
      Susan Krege,

Objective: To asses in a long-term follow-up, female patients with congenital adrenal

hyperplasia (CAH), with special emphasis on vaginal functional outcome and sexual activity after

Patients and methods: Twenty-seven patients with CAH (aged 14 – 33 years; six Prader grade
II, 14 grade III, six grade IV and one grade V) underwent surgery between 1972 and 1988. Three
of the patients underwent clitoridectomy, 24 clitoroplasty and 25 vaginoplasty (24 with a Fortunoff
flap and one a ‘pullthrough’ procedure). In 20 patients the vaginoplasty was a one-stage
procedure, undertaken at a mean (range) age of 3.6 (1 – 9) years, and in five patients a two-stage
operation. The analysis was based on the patients’ history and examination; the patients also
completed a questionnaire, including a psychological profile.

Results: Nine of the 25 patients (36 %) who underwent vaginoplasty developed intravaginal
stenosis; of these nine, six were Prader grade III and three grade IV. All had undergone a single-
stage procedure at a mean (range) age of 4.7 (2 – 9) years. Of the 16 patients who answered the
questionnaire, 14 had problems with their overall body image; patients in whom vaginal stenosis
was corrected were particularly anxious about sexual intercourse and had problems with orgasm.

Conclusion: The main problem during the long-term follow-up was intravaginal stenosis; all the
affected patients had undergone a single-stage procedure early in life to correct ambiguous
genitalia. This high rate of vaginal stenosis suggests that vaginoplasty should be undertaken at the
beginning of puberty, because higher oestrogen levels may prevent stenosis and, if necessary,
dilatation can be performed by the patient. These data also underscore the importance of
psychological support in the treatment of children with CAH

41) Total Urogenital Sinus Mobilization in Complex Female Urogenital Anomalies, Long-
Term Effects on Bladder Functions.
      Alaa F. HAMZA, Essam Elhalaby, Ihab Elshafey , Sameh A. Abdel Hay, Hatem sherif and
      Tarek Hasan
      Ain Shams University and Tanta University Hospitals, Egypt

Purpose: The principle of Total Urogenital Sinus Mobilization (TUM) is an established method for
the repair of congenital adrenal hyperplasia, Cloaca, female bladder exstrophy and other complex
anomalies. This study was undertaken to investigate the feasibility of using this technique in redo
cases and to audit its effect on urinary voiding pattern on long-term follow up, which is not well
documented in previous studies.

Methods: Total urogenital sinus mobilization was used as a part of repair in 32 patients: 18 with
congenital adrenal hyperplasia (10 high and 8 mid vaginal confluences) four of these patients were
redo cases, 8 with cloacal anomalies one was a redo case, 5 had bladder extrophy one was a redo
case and a redo case with pure urogenital sinus anomaly. Mobilization to the level of the
symphesis pubis allowed the vagina to reach the perineum in all cases. Their age ranged from 3
months to 11 years and follow-up ranged from 6 months to 4 years. Follow up included clinical
assessment, abdominal US, voiding cystourethrogram and urodynamic in some cases.

Results: Cosmetic results were excellent in 27 cases including 6 of the redo cases. Three patients
have mild female hypospadias and 2 of them will need a redo (TUM). Two other patients have
mild vaginal stenosis and will need a local flap. Clinically all patients with congenital adrenal
hyperplasia older than 2 years (14 patients) have normal Voiding pattern .Voiding cystourethrogram
and urodynamic evaluation in 10 patients with no sacral anomalies showed normal urethral length
and pressure in all cases. Disinhibited bladder contractions were found in 8 of those patients with no
clinical significance.

Conclusion: Total Urogenital Sinus Mobilization is a valuable technique in repair of complex and
redo female anomalies. Urological functions are well preserved despite the possibility of slight
denervation, which is not associated with a significant clinical manifestation on late follow up.
Unfavorable functional results are related to the primary disease rather than the technique itself.

42) Augmentation ureterocystoplasty in children with valve bladder syndrome.
      Saad A, El-Metwally H, Youssef m, Hanno A, Rayan A, Mokhless I.
      Section of Pediatric Urology, Alexandria University , Egypt.

Objective: Evaluation of the efficacy of augmentation ureterocystoplasty in the management of
hypo-compliant bladder in children with valve bladder syndrome.

Patients and methods: 8 boys with mean age of 5 years presented with high pressure bladder
and bilateral HUN with history of successful PUV fulguration. 6 refluxing renal units were
encountered. In 4 patients the entire ureter was folded and used for augmentation together with
ipsilateral nephrectomy for NF kidney, in other 2 patients lower ureteral patch was used to
augment the bladder together with transureteroureterostomy, in the remaining 2 patients the lower
ureter was used as a patch and ureteral reimplantation was performed. Preoperative and
postoperative cystogram and cystometry were used to comment on the bladder capacity and

 Results: marked improvement of the bladder capacity and compliance were encountered in all
cases with no side effects like ileocystoplasty and no post operative complications, however CIC
was needed also in all patients to evacuate the bladder completely. We needed to perform a
catheterizable stoma in only 1 patient for the presence of difficulty of catheterization

 Conclusion: augmentation ureterocystoplasty is an ideal option for hypo-compliant bladder in
children but in the presence of either NF kidney and megaureter or a sufficient experience to
perform transureteroureterostomy. This type of augmentation avoids the complications resulting
from the use of intestine to lower the intra-vesical pressure especially in patients with
compromised renal functions.

43) Management of neonatal pelvi-uretric junction obstruction, clinical experience.
     Atef El Ekiabi,
     Department of Pediatric Surgery, Zagazig University, Egypt

Objective: controversies in the management of neonatal BUG obstruction are mainly due to
insufficient data about the real course of the disease. We report our experience in management of
39 new born with BUG obstruction.

Patients and methods: 21 patients (renal units) were surgically corrected by pyeloplasty and the
remaining 18 patient were treated conservatively. Follow up of all cases was available fro 8 to 34

Results: in the surgically corrected group, out of 21 renal unit 19 (90%) were improved while 2
needed redo-pyeloplasty after 1 year of follow up. In the 18 patients (22 kidneys) treated
conservatively, 5 kidneys (22.7%) showed spontaneous relief of obstruction, 8 kidneys (36.4%)
deteriorated and needed surgical correction, while the remaining 9 kidneys (40.9%)         had
maintained function

Conclusion: Surgical corrections in neonatal BUG obstruction give excellent results. While for
infants with parietal obstruction and good renal function who are treated conservatively,
deterioration is expected in almost 40% of them. Based upon our experience, spontaneous
improvement usually occurs with in the first 6 months of life, thus we recommend close follow up
for infants with BUG obstruction and under conservative treatment and immediate surgical
intervention for those who show no improvement within the first 6 months.

44) Single-Layer Small Intestinal Submucosa (Sis) Versus Tunica Vaginalis Flap (Tvf) for
Correction of Penile Chordee
      Ashraf T. Hafez, Ahmed El-Assmy, Mohamed Abd El-Hamid, Mohamed E. Abo-Elghar
      Urology & Nephrology Center, Mansoura University, Mansoura, Egypt

Purpose: The aim of this study is to evaluate the use of single-layer small intestinal submucosa
(SIS) versus tunica vaginalis flap (TVF) for covering defects in the ventral surface of the tunica
albuginea to correct severe chordee.

Materials and Methods: A total of 24 New Zealand white rabbits underwent excision of a
rectangular area in the ventral surface of tunica albuginea. In 12 rabbits TVF was used to cover
the defect and in the remaining animals single-layer SIS was utilized. Animals were sacrificed in
groups of 4 at 2, 6 and 12-week intervals postoperatively. At 12 weeks prior to death artificial
erection and cavernosography were performed. Transverse sections of the penis at the graft site
were stained with H&E and Masson’s trichrome and examined microscopically.

Results: None of the animals developed hematoma or bleeding. The mean operative time for TVF
and for SIS grafts was 56 and 29 minutes respectively (P<0.001). At the time of autopsy,
contracture was not seen in any of the rabbits. Of the 24 rabbits, all had straight rigid erection and
cavernosography showed evidence of intact corporal veno-occlusive mechanism. Histologically at
6 and 12 weeks, the mesothelial layer of the TVF and the SIS graft were completely replaced by
well-collagenized tissue similar to that of normal tunica albuginea without inflammatory infiltrate.

Conclusions: Both TVF and single-layer SIS graft are viable comparable alternative options for
corporal body grafting. The off-the-shelf availability, significantly shorter operative time and
absence of donor site morbidity make single-layer SIS superior to TVF in correction of chordee.

45) W-Flaps in the Management of Post Extrophy Fistulae and Disfigurement
      Saad A, El-Metwally H, Youssef m, Hanno A, Rayan A, Mokhless I.
      Alexandria University, Egypt.
      Department of Pediatric Urology, Alexandria University, Egypt.

Objective: Evaluation of the use of bilateral W skin flap for the correction of lower abdominal
disfigurement with suprapubic fistula or disfigured epispadius following multistage exstrophy repair.

Patients and Methods: Six cases of disfigured lower abdomen following multistage exstrophy
repair, five cases with suprapubic fistulae, one case with repair that was managed by ureterocolic
anastomosis and the penis is left as complete Epispadius with disfigured lower abdomen. Age
ranged from 5 to 15 years with a mean age of 10 in 5 patients. The scars in the lower abdomen
were removed, fistulae closed and bilateral W-flaps was used to cover the defect in the lower
abdomen and correct the disfigurement and in the remaining 1 patient epispadius repair was
performed together with the bilateral W-flap to correct the disfigurement.

Results: Four of the five fistulae are closed successfully and only one fistula recurred but with
satisfactory cosmetic appearance in the lower abdomen. In the remaining one patient successful
Epispadius repair and satisfactory cosmetic appearance resulted.

Conclusion: Bilateral W flap technique is an ideal solution for the correction of suprapubic skin
disfigurement and suprapubic fistulae resulting from multistage exstrophy repair.

46) Necrotising Enterocolitis and Localised Intestinal Perforation - Different Diseases or
Ends of a Spectrum of Pathology?" .
      Victor Boston
      Ireland, UK

The different presenting features and the pathology will be discussed in the light of the current
literature. It is unlikely that Localised Intestinal Perforation (LP)is significantly different in it's
pathogenesis compared to Necrotising Enterocolitis (NEC) other than the fact that by definition LP
is localised and NEC is usually not. The reasons for this difference will be illustrated.

Congenital diaphragmatic hernia-State of art 2004, Fetal surgery
      Prof .J.Boix-Ochoa
      Autonomous University, Barcelona, Spain

The author has been involved with this pathology more than 35 years and with an experience over
450 cases.

Prognosis of survival, hidden mortality, embryological stages, arterial muscularization,
endocrinological fundamentals of the high pulmonary vascular resistances, and controlateral lung
anomalies have been subjects of his investigations. The C.D.H. is not a surgical emergency but a
medical one!

  The pillars of the persistent pulmonary hypertension of the newborn are discussed and their
results presented. Drugs, hyperventilation, NO, pulmonary instilled vasodilators, and ECMO., are
not the final solution where the lung blood gas exchange is impossible due to the severity of the
lung. In this group where dysplasia and a fixed non responsive vasoconstriction is instaured, the
survival is between 3-6%. The last challenge for this group is the foetal surgery. Logically the
outcome of this group can be predicted by sonography of the intrauterine lung-head ratio, and the
presence or absence of liver herniation into the thorax

To improve the intrauterine growth of the lung is the aim of foetal surgery; based on the knowledge
that foetal trachea occlusion promotes lung growth by preventing normal egress of lung fluid.

Harrison and his team were the pioneers, but open foetal surgery did not bring the expected
survival rates.  The fetoscopic tracheal occlusion with different methods is actually the best
approach, and the European way (Barcelona-Leuwen) with different philosophy proves to be the
one with the best results.-88% of survival rate in the group that before we only achieved 6%

The method, technique, fundamentals and follow-up are shown in an attempt to give another step
fighting this pathology, for the first time in the experience of the author we are a step in front of this

48) Invited Guest lecture: Conjoined Twins – Experience With 26 Sets In Saudi Arabia
      Abdullah Al Rabeeah
      Department of Surgery, Section of Pediatric Surgery, King Abdulaziz Medical City, Riyadh,
      Saudi Arabia

Conjoined twins are rare but interesting surgical anomalies that pose challenges to the medical
community. Between 1990 and 2004, twenty-six (26) sets of conjoined twins were seen at King
Abdulaziz Medical City and King Faisal Specialist Hospital & Research Center. Eight (8) sets were
found separable and were consequently successfully separated. In addition, two (2) sets of
parasitic twins were dealt with at the same time. The remaining sets had major anomalies
preventing successful separation.

Our experience provided us with few, yet important lessons. First, tissue expanders may not be
needed in most cases. Second, the use of Argon Laser and CUSA has significantly reduced blood
loss. Third, the optimal time for separation is when the combined weight of the twins exceeds
eight (8) kilograms. Lastly, the development of one multidisciplinary team will improve both the
experience and the care for such complex surgical problems.

In conclusion, conjoined twins are rare anomalies that require a team approach and careful
assessment and planning, prior to separation.

49) Conjoint twins
     Amin Elghory

50) Difficulties in the surgical management of Henoch-Schonlein purpera
      Ashraf H. M. Ibrahim
      Armed Forces Hospital, Southern Region, Saudi Arabia

Aim: to document the difficulties encountered in the surgical management of Henoch-schonlein
purpera (HSP).

Patients and Methods: Over a 9-y period, all charts of HSP cases reviewed by pediatric surgeons
were studied. Patient demographics, methods of diagnosis and managements were documented.

Results: Out of 67 patients with HSP, only 11 were thought to have active surgical problems. Prior
to the development of the rash, the difficulties encountered were an unnecessary scrotal
exploration in one, a negative laparotomy in one and resection of a gangrenous intussuscepted
loop of ileum erroneously diagnosed as acute appendicitis in one. A fourth patient with severe
epigastric pain and hematemesis, endoscopically diagnosed as gastroduodenitis improved
dramatically only after the development of the rash and steroid therapy. The difficulties
encountered after the rash were in 4 cases of intussusception and a case of profuse rectal
bleeding that affected the stability of the patient requiring surgery. Father refused and patient
improved on steroids. Two patients with testicular swellings were easily treated conservatively. In
two patients with ileo-ileal intussusception the diagnosis was straightforward both clinically and
sonographiclly. However, both cases required resection of the gangrenous bowel. Another patient
with ileo-ileo-colic intussusception failed to reduce with contrast enema. During surgery, there
were multiple intussusceptions. The ileal one needed resection while the jejunal reduced manually.
Finally, a patient had a recurrent gangrene of ileo-ileal intussusception. The diagnosis was difficult
due to masking of abdominal signs by steroids.

Conclusions: HSP with surgical complications represents a diagnostic and therapeutic challenge
both before and after the development of the rash. Unlike idiopathic intussusception, it is usually
ilio-ileal, may be multiple, and usually ends up by gangrene. The main tool of diagnosis is
abdominal sonography. Contrast enema for diagnosis and reduction plays a minor role. Steroids
may mask abdominal signs. A high index of suspicion for the possibility of recurrence should
always be raised and laparoscopy might be of great help.

51) Tertiary hyperparathyroidism in children the role of surgery.
      Hatem Saafan, Ashraf Kabesh, Ihab Elshafey, Alaa Hamza.
      Ain Shams University- Egypt.

52) Abdominal Lymphangiomas in Children: Is Complete Excision Mandatory?
      Amel Hashish, Hussam S. Hassan, Ahmed Issa, Essam Elhalaby
      Departments of Pediatric Surgery, Tanta University Hospital, Tanta, Egypt

Background/ Purpose: Complete excision with or without a limited bowel resection is the
standard treatment of abdominal lymphangiomas. However, marsupialization may be the only
feasible option in some patients with multiple retroperitoneal cysts. The purpose of this work was
to study the incidence of postoperative recurrence of these cysts on long-term follow up especially
in patients with multiple retroperitoneal cysts undergone marsuplization.

Patients & Methods: Thirteen children were diagnosed and treated for mesenteric cysts (N= 6)
and retroperitoneal cystic lymphangiomas (n= 7) at the department of pediatric surgery, Tanta
University Hospital during the period of 1993 to 2003. The medical records of each child was
reviewed as regard to age, sex, clinical presentation, imaging studies, operative findings,
histological features, operative details, and outcome on both short and long term follow up, which
ranged from 1- 9 years.

Results: There were 7 boys and 6 girls, their ages ranged from 1 week to 16 years (average age,
38.2 months). Five patients required emergency surgery and 8 underwent elective intervention.
The main presenting symptoms were abdominal pain and mass. Preoperative ultrasounds were
diagnostic for a cystic mass in all patients. The cysts were located in the small bowel mesentery in
4 cases, the base of the mesentery with retroperitoneal extension in 6 cases, and the transverse
mesocolon in 3 cases. Operative procedures performed included enucleation of the cyst (n= 6),
complete excision with intestinal resection (n= 5), and partial excision, and incomplete excision
with marsupialization of the remaining cysts in 2 infants with multiple cysts. No recurrence
occurred in this series.

Conclusions: Complete excision with or without a limited bowel resection should continue to be
the standard treatment of abdominal lymphangiomas. However, marsupialization of the remaining
cysts is an acceptable therapeutic option in some patients with multiple retroperitoneal cysts.

53) An Unusual and Rare Presentation of Mesenteric Cyst in: A 6-Years Old Boy
      Gamal Al-Saied, Abdulmoneem Shams, Mohammad Eshmawy, Mohammad A. Fahmy.
      Al-Azhar University Hospitals, Cairo, Egypt

Background/purpose: Mesenteric cysts are rare intra-abdominal pathology. Clinical presentation
depends on the size of the cyst. Small cyst may be asymptomatic or it may present with acute
abdomen. The aim is to present an unusual and rare presentation of mesenteric cyst.

Methods We have treated 6-years old, boy of a big mesenteric cyst presented as acute abdomen.
Patient was investigated for all the possible causes of acute abdomen by Abdominal U/S, C.T.
scanning and lab studies.

Results Ultimately abdominal exploration was done; on exploration there was a big mesenteric
cyst with twisted long pedicle arising from the mesentery of transverse colon, partially gangrenous
in some areas of the cyst wall. It was impacted in the pelvis between the urinary bladder anteriorly
and rectum posteriorly. It was excised successfully.
Conclusions: The mesenteric cyst in children is an uncommon disease with variable
presentations that always requires surgical treatment

54) Early Correction of Unilateral Cleft Lip/Nasal deformity
        Mamdouh AboulHassan
        Department of Pediatric Surgery, Cairo University, Egypt

Cleft lip/ nasal deformity is a common congenital anomaly that need a interdisciplinary team
approach to achieve optimal result. The classical approach has been not to treat the severe nasal
defects, in the fear that early surgery would interfere with nasal growth .However long term follow-
up in patients with early rhinoplasty has shown to hold its new shape and its growth to be normal.
In this study 20 cases of unilateral cleft lip/nasal deformity were studied using the modified C-flap
technique, complete mobilization of the alar cartilage and repositioning it in normal position using
stent sutures. Symmetrical nasal shape could be reached in 80%of the cases intra-operatively and
this could be maintained for follow up period (12month) in the majority of them. Although this could
not be reached in all cases intra-operatively (20%), the parents accepted it. It is concluded from
this study that simultaneous nasal correction during primary chieloplasty should be attempted in
all cases of unilateral cleft lip/nasal deformity as the result alleviate the need for rhinoplasty during
childhood period although fine touch up may be needed at puberty.

55) Surgical techniques in pediatric living related liver transplantation experience in 114
cases .
      Hisham Abd ElKader, Hatem Saafan, Raymond Reding & Alaa Hamza
      Liver transplantation unit, Wady El Neel Hospital, Cairo, Egypt. & Department of pediatric
      liver transplantation, Universite Catholique de Louvain, Brussels, Belgium

ObjectiveTo evaluate the impact of surgical techniques and its modification on Living-donor liver
transplantation in children

BackgroundBecause pediatric liver transplantation is approximately one-tenth as common as
adult liver transplantation, technical modifications have not developed as rapidly, and still much of
the surgical debate is centered around topics associated with adult liver transplantation.
Nevertheless, it was the pediatric population and their problem of size matched organ grafts that
motivated the search for the innovative surgical techniques that address this problem. During the
evolution of the procedure, several technical modifications took place so that LDLT is now the
accepted therapy for small children with end-stage liver disease

MethodsBetween 1993 and 2004, 114 pediatric recipients who underwent primary living-donor
liver transplantation at both institutions were reviewed. They were 55 males and 59 females,
median age at transplantation was 1.0 year ( range 0.4-16 years), median weight 14 kg (range 3-
49kg). The donors were 66 father, 43 mothers, 2 uncles, one aunt, one step-father, and one
grandmother. The pre-transplant diagnosis was as follows: extrahepatic biliary atresia (n=82),
metabolic liver disease (n=13), hepatic tumors (n=6), familial intrahepatic cholestasis (n=5),
fulminant hepatitis (n=3), autoimmune hepatitis (n=2), and one patient for each of primary
sclerosing cholangitis, congenital hepatic fibrosis, and Budd Chairi syndrome. The patients` charts
were reviewed retrospectively and the incidence and type of vascular complicat! ions and patient
and graft survival rates were analysed.

ResultsAlthough the demographics of patients have not changed significantly over the years, the
outcome has markedly improved owing to the learning curve effect and to the continuing
modifications on the surgical procedure. The patient survival rates at 1- and 5- years post-
transplant were 93% and 91% respectively, while the graft survival rates were 92% and 89%
respectively. The discontinuation of use of conduits for portal venous reconstruction together with
the use of microsurgical technique for the arterial anastomosis have led to significant improvement
in graft survival.

ConclusionThe Living-donor Liver Transplantation operation has undergone several significant
technical changes since its introduction in 1989. These changes have decreased the vascular
complications associated with this type of graft, but still the biliary complications pose a significant
impact on the outcome of the procedure .Living donation has proved to be safe, reliable and
sometimes the only solution for a substantial number of children dying every year from chronic
liver diseases.

56) Abdominal injury score versus abdominal ultrasound to predict injury in children after
blunt abdominal trauma.
     Amira Waly
     Zagazig University, Egypt

Objective: to evaluate abdominal injury score and abdominal ultrasound as a clinical tool to
predict intra-abdominal injury in children.

Patients and methods: 198 children who were exposed to blunt abdominal trauma were included
in this study. Abdominal injury score was calculated for all patients and accordingly, they were
divided into low, moderated and high-risk groups. Abdominal ultrasound was done for all patients
as a part of the primary survey. Results of investigations and outcome of all cases were recorded.

Conclusion: abdominal injury score is a good clinical predictor for intra-abdominal injury after
blunt abdominal trauma in children. It raises the accuracy of ultrasound and it is also a useful
triage tool of children considered for CT scan after blunt abdominal trauma.

57) Where we stand in management of craniosynostosis in Zagazig University
      Alaa Nabil El Sadek ,
      Department of Pediatric Surgery, Zagazig University, Egypt

Objectives: evaluation of different surgical techniques in management of craniosynostosis.

Patients and method: all patients of craniosynostosis (20 cases) where subjected to clinical
examination and CT scan with the three dimensional reconstruction. Different surgical techniques
were performed ranging from simple excision of the synostosed sutures to bilateral fronto-orbital
advancement and forehead reshaping in coronal and metopic craniosynostosis.

Results and conclusions: complete three-dimensional correction and head reshaping achieve
the best functional and esthetic results.

58) Invited Guest lecture: Pathopysiological Consequences of Minimally Invasive Surgery in
Infants and Children
      Benno M. Ure, Natalie K. Jesch, Gertrud Vieten, Joachim Kuebler
      Department of Pediatric Surgery, Hannover Medical University, Hannover, Germany

Minimally invasive procedures have evolved as standard techniques for various conditions in
pediatric surgery. Altogether, more than 50 types of minimally invasive operations have been
described. We previously reported that about 60% of abdominal and more than 40% of thoracic
procedures could be performed via laparoscopy or thoracoscopy, also in newborns and small

However, evidence-based data on the feasibility, advantages and disadvantages of minimally
invasive pediatric surgery are scarce. In this context, the impact on the immune system and the
function of specific organs, in particular in small children, is a major focus of our department.

The immunological consequences of CO2-pneumoperitoneum and thoracic insufflations of CO2
were investigated. In vitro and in vivo studies were focused on the function of macrophages
and PMN in different CO2 and pH atmospheres. We confirmed a beneficial impact of CO2
associated extra- and intracellular changes of the pH and determined some underlying
mechanisms. Other local, systemic and distant organ parameters were investigated using
laparoscopic surgery in the rat model. Specific preservations of immune functions after
minimally invasive surgery compared to full- and mini-laparotomy were determined.

Cardio circulatory effects of long-lasting pneumoperitoneum were investigated in rabbits, renal
effects in children. The results of this work lead to specific concepts in intra- and postoperative

Minimally invasive techniques are established in pediatric surgery. However, systematic
research on the benefits and burdens remains scarce. In particular, the impact of
immunological changes in septic children is unclear.

59) Invited Guest lecture: Robotic Surgery & Children
      Aayed Al-Qahtani,
      Department of Pediatric Surgery, King Saud University, Riyadh, KSA

Minimally invasive approaches for surgical intervention in pediatric patients continue to develop
both in technical complexity and equipment. Recently robot-assisted surgery has been introduced
and continues to find its place in minimal access surgery.

The advantages of robotic surgery include improved visualization with the three dimensional
system, easier intracorporeal suturing and knot tying , and more precise movement with tremor
filtering and scaling down of instrument tips movement. Having the surgeon at the console
controlling the visualization and the assisting instruments (in the presence of the fourth arm)
makes the best operative environment for any surgeon.

Telesurgery and telementoring are other additional advantages to the robotic surgical system. This
will enable the surgeons to disseminate the skills and expertise as has been shown when a
surgeon in New York performed a cholecystectomy for a patient in Strasbourg, France.

Do all these advantages apply to pediatric surgery? Are there some limitations or difficulties in
applying robotic surgery in children? Where are we now? And what will the future be? These are
questions to be answered in this presentation, in addition to other important aspects of robotic
surgical system in children that have been discussed during the first international pediatric robotic
surgery symposium held in Iowa, USA 2004.

The presentation will conclude with an overview of our experience in robotic pediatric surgery.

60) Laparoscopic Choledochal Cystectomy with Jejunal Roux-en-Y Reconstruction with 2-
mm instruments in three Children
      Felix Schier,
      Department of Pediatric Surgery, University Medical Center Mainz, Germany

Purpose: Advances in laparoendoscopic instrumentation and techniques continuously lead to the
application of minimally invasive surgery to more complex intraabdominal interventions, including
reconstructive procedures. This report illustrates the safety, efficacy and reproducibility of this
approach in the surgical management of choledochal cysts.

Methods: Laparoscopic excision of a type I choledochal cyst was performed on three girls, ages
10, 19 and 26 months. A 10-mm laparoscope was placed through an umbilical incision, and three
2 mm-instruments were inserted through the lateral abdominal wall. The gallbladder was left until
the very end and used for exposing the hilum of the liver. The cyst was excised and the
biliodigestive continuity restored with a retrocolic Roux-en-Y loop. Only the jejuno-jejunal
anastomosis was done extra-abdominally, through the umbilical port site. The hepatico-jejunal
anastomosis was performed laparoscopically with 6.0 absorbable monofilament sutures. In one of
the three children, both hepatic branches were anastomosed.

Results: Operative times were 4, 5 and 6.5 hours. There were no intraoperative complications. In
one child, the tip of a drain punctured the hepaticojejunal anastomosis. At postoperative day 5, the
drain was removed and the anastomotic leak over sewn laparoscopically with two stitches. In
another girl, there was minor bile leak, which closed spontaneously after 2 days.
Conclusion: Laparoscopic surgery for choledochal cysts proved safe and reproducible. Exposure
was excellent and the biliodigestive anastomosis appeared to be easier than with the conventional
open approach because of the magnifying effect of the laparoscope.

61) Neonatal surgical jaundice
     Sameh Abdel Hay, Amr Zaki.
     Ain Shams University, Cairo Egypt.

Background: The etiology of neonatal jaundice presents a long list of medical and surgical
causes. Early diagnosis is the cornerstone for having good results while dealing with surgical
jaundice. Differentiation between medical and surgical etiology by simple laboratory tests is not
possible and further diagnostic tools may add to the precision of the diagnosis.

Materials and methods: Two groups of patients with neonatal jaundice with their long-term follow
up will be presented. The first group comprises 28 pts treated in our unit between 1995 till 1998,
and the second 33 patients treated between 1999 till 2003. The use of laparoscopy as a diagnostic
tool in the second group led to early diagnosis and better outcome in the immediate results
although the number of cases having medical jaundice increased in this group

Results: Abdominal Ultrasonography remains one of the simplest and very useful diagnostic
modality that may depict choledochal cysts and the triangular cord sign diagnostic for biliary
atresia. The final diagnosis in certain situations may be reached only after surgical exploration and
operative cholangiogram. Conventional exploration is now replaced by laparoscopic exploration
and laparoscopic assisted cholangiography. Laparoscopy allows clear visualization of the biliary
tree, liver and the pattern of the biliary system using operative cholangiography. It allows taking a
liver biopsy in cases where medical etiology is suspected.

Conclusion: early diagnosis and measures to prevent the occurrence of post operative cholangitis
remains the cornerstone for good results after Kasai operation.

62) Laparoscopic Approach to Small Intestinal Obstruction in Children; A preliminary
      Abd Elmoniem S Shams, Rafik Shalaby
      Pediatric Surgery Unit, Al-Azhar University, Cairo, Egypt

Background / Purpose: The use of laparoscopy for the management of acute intestinal
obstruction is increasing. It has potential advantages over classical laparotomy. The objective of
the present study was to evaluate the feasibility and outcome of laparoscopic management of
small intestinal obstruction.

Material& Methods: A retrospective review of 30 children admitted for attempt of laparoscopic
treatment of acute intestinal obstruction was performed. Their mean age was 6.7±1.73 years.

Results: Of the 30 laparoscopic attempts, 20 (66.7 %) have been performed successfully, while
10 patients (33.3%) needed a conversion to laparotomy because of inadequate laparoscopic
visualization in 6 cases, gangrenous bowel in 2 cases, and inability t! o relieve the obstruction
laparoscopically in 2 cases. There was no intra or postoperative complications in the laparoscopic
group. The mean operative time for the laparoscopic release of intestinal obstruction was
68±12.32 minutes and 102±9.67 minutes for the converted cases. The mean time of return of
bowel function and mean hospital stay in the laparoscopic release of intestinal obstruction were
significantly shorter.

Conclusions: This study showed that laparoscopic release of intestinal obstruction in children is
worthy to attempt first. It is feasible, effective, and safe alternative to laparotomy for most patients
with acute intestinal obstruction.

63) Laparoscopic reduction of intussusceptions in children
     Hamdi Almaramhi, Aayed Alqahtani
     King Khalid university hospital and college of medicine Riyadh, Saudi Arabia

Background: Intussusceptions is a fairly common problem in children. Approximately 85% of
intussusceptions in children are reduced by pneumatic or hydrostatic enemas. The remaining will
require surgical intervention. However, 10% of those infants undergoing surgical exploration were
found to have reduced spontaneously. In order to reduce the number of unnecessary surgical
exploration, different laparoscopic assisted techniques have been described. In most of them the
reduction was assisted by an intra-operative enema. Our experience with none-assisted
laparoscopic reduction of intussusceptions is presented with a detailed description of the

Methods: The clinical records of all children with intussusceptions undergoing laparoscopic
reduction at our institution during a period of 18 months were reviewed retrospectively.
Demographic data, clinical presentation, duration of symptoms, diagnostic and therapeutic
modalities were evaluated. Follow up was also obtained.

Results: between November 2002 and June 2004, six patients underwent laparoscopic reduction
of intussusceptions. The age ranged from 4 to 26 months (average of 12.4). All were male except
one. Two patients had the symptoms for more than 24h prior to their presentation. Two were
diagnosed clinically and four were diagnosed using abdominal ultrasound. Five patients underwent
unsuccessful hydrostatic contrast enema reduction and one had an attempt of an ultrasound
controlled water enema reduction that failed followed by another unsuccessful contrast enema
reduction. All patients had successful laparoscopic reductions. There were no complications. Fluid
diet was started after full recovery from anesthesia and was tolerated by all patients. They were all
discharged within 24h post-operatively. The follow-up reported no complaints or recurrences.

Conclusion: in spite of the small number of patients included in this study, we believe that the
laparoscopic reduction of intussusceptions is a safe and a successful procedure. It does not need
to be assisted by intra-operative air or other types of enemas.

64) Laparoscopic assisted pyloromyotomy. A simple technique for laparoscopic application
in neonates.
      Sameh Abdel Hay, Ashraf Kabesh, Hesham soliman, Ihab El Shafei
      Ain Shams university Egypt.

Background: While deciding to perform laparoscopic procedure in the pediatric age group, we
should follow important criteria to realize a real benefit for these patients, avoiding complication
and performing the same well known technique performed during conventional surgery.
Pyloromyotomy is one of the surgical procedures that had been settled since its innovation by
Ramstedt. Performing the same technique by laparoscopic approach is appealing and if an expert
well trained surgeon, with the use the proper instruments this can performed safely.

Materials and methods results: Over the last 3 months, 5 patients with infantile hypertrophic
pyloric stenosis were treated by laparoscopic assisted pyloromyotomy. Their age range form 2 to 5
weeks and the procedure were done successfully in 4 out of 5 patients with a mean operative time
of 20 minutes. The conversion was in the first case due to technical and lack of experience. No
mortality or morbidity was encountered in this small series.

Conclusion: We recommend the use of this simple technique for pyloromyotomy.

65) Experimental Evaluation of Different Modalities For Bridging of Ureteric Gap.
      Sِameh A. Hay, M Debeky.
      Paediatric Urology Unit, Paediatric Surgery Department, Ain Shams University, Egypt

Objective: Replacement of the upper or middle ureter when affected with various pathology
causing its damage, poses a real problem that was not yet completely solved by the current
available techniques. Two new surgical techniques for bridging of ureteric gap are evaluated in
experimental animals and represented in this study.

Materials and methods; Ten male stray dogs weighing 20-25 kilograms were the base of the
study. They were divided into two groups, 5 dogs each. After creation of 2cm middle ureteric
defect, a tubularized demucosalized seromuscular gastric flap was used to bridge the defect for
the first group, and tubularized posteriorly fixed peritoneal flap for the second. Evaluation of the
substitutes included clinical follow up, monitoring of urine output, intravenous pyelography, and
histopathological examination for urothelial creeping after at least 6 weeks postoperative.

Results; one dog died of intraoperative complication in group II. All animals of group I survived the
whole experiment and showed good uptake of the gastric tube with satisfactory renal and ureteral
functions. Complete urothelial creeping with no gastric mucosal regrowth was evident by
histopathological examination. Four animals of group II showed progressive uraemia with complete
fibrosis of the peritoneal tube and ureteral obstruction.

Conclusion; By the end of the study we recommended the use of tubularized demucosalized
seromuscular gastric flap as a promising technique for ureteral substitution as it avoids the
complications of using an ectopic mucosa and also avoids the disadvantages of other
reconstructive techniques.

66) Seromuscular Gastric Patch: A New Technique for Management of Lower Esophageal
      Hussam S. Hassan
      Tanta University, Egypt

Introduction: Esophageal stricture is a surgical challenge. If resists dilatation, esophageal
replacement may be necessitated, which is attended with significant morbidity and mortality. None
of the esophageal substitutes can replace the esophagus properly. A number of operations have
been elaborated to correct lower esophageal strictures without resorting to replacement, non of
them, unfortunately is totally satisfactory.
Material and method: The study was conducted on 10 dogs. Through a right thoracoabdominal
incision, a seromuscular patch was raised from the greater curvature of the stomach at the antrum,
based on the left gastroepiploic vessels. A longitudinal incision through the lower and part of the
middle third of the esophagus was made. A longitudinal full-thickness strip of the lower esophagus
was removed. Then the patch, which had been passed into the chest, was sutured into the defect
in esophageal wall. Three weeks later, the dog was sacrificed, and a specimen containing the part
of the esophagus harboring the patch was taken for gross and microscopic examination.
Results: Out of 10 dogs in the study, all but one survived for the 3 weeks period. No leak occurred
in any of the animals. Gross and microscopic examination revealed healing of the patch with
epithelium spreading to cover the whole patch within 3 weeks.
Conclusion: Seromuscular gastric patch is a promising alternative to replacement in cases with
stricture involving the lower third and part of the middle third of the esophagus

67) Role of Germ Cell Apoptosis and Serum Inhibin B as Prognostic Markers of Fertility in
Children with Undescended Testis
      Saber Mohammed Waheeb, Abla Abou-Zeid, Teshreen M. Zeitoun
      Department of Pediatric Surgery, clinical Pathology, histology Alexandria University, Egypt

Objectives: Undescended testis is a common congenital abnormality in children that contributes
to impaired fertility in adulthood. The pathogenesis of the reduced fertility seen in cryptorchidism
has not been fully clarified. This work aimed at evaluating the role of germ cell apoptosis as well as
serum inhibin B as prognostic markers of fertility potential.

Patients and Methods: The study was carried on 32 children with unilateral undescended testis,
divided into three age groups; group 1 (<6 months), group 2 (6-12 months), group 3 (12-24
months). Control group included 22 age-matched children admitted for herniotomy.
Histological assessment of apoptosis using semi thin sections and immunohistochemical staining
for Fas were done for testicular biopsy of cryptorchid patients. Hormonal assay of serum inhibin B,
FSH, LH, and testosterone of patients and controls were done.

Results: Blunted gonadotrophins surge was observed in cryptorchid infants (group 1), which was
accompanied by defective transformation of genocytes to adult spermatogonia. In groups 2 and 3,
inhibin B was significantly lower in cryptorchid than their age-matched controls (P=0.014, P=0.01
respectively), while in these two groups testosterone level was very low in both patients and
controls with no significant difference detected. Reduced inhibin B was parallel with high Fas
expression and accelerated rate of germ cell apoptosis mostly in group two. In group 3, evidence
of testicular atrophy was depicted.

Conclusions: From the previous results, it could be concluded that the longer duration of
maldescent carries more risk of impaired fertility potential, mainly through delayed germ cell
maturation and enhanced apoptosis.

68) Effect of ligation of spermatic vessels on testicular histology during treatment of intra-
abdominal testis.
     Sameh abdel Hay, Amr Zaki and Manal Hassan
     Pediatric surgery unit and histology dept- Ain-Shams University. Cairo, Egypt

Background: At surgery about 5% of undescended testes are found in an intra-abdominal
position. If the testis is far from the internal ring or associated with short spermatic vessels, it is
sometimes impossible to place the testis in the scrotum by means that maintain continuity of the
spermatic vessels. In 1957 Fowler and Stephens popularized the concept of spermatic vessel
ligation for orchiopexy. Increased use of laparoscopy in the diagnosis and treatment of impalpable
testis has encouraged use of the two-stage Fowler-Stephen orchiopexy. To date, however, the
effect of clipping of spermatic vessels is not well studied.

Materials and methods: In a period of 2 years, laparoscopy was done to evaluate 48 impalpable
testes in 39 patients. We evaluated histology of 10 intra-abdominal testes in 9 patients at stages 1
and 2 of the Fowler-Stephens procedure. The patients were grouped in 3 groups: group 1 those
who received hormone HCG before ligation of spermatic vessels (4 patients); group 2 those who
received hormone HCG after ligation of spermatic vessels and before second stage (2 patients);
group 3 those who did not receive hormonal treatment.
Testicular biopsies are fixed in 3% glutaraldehyde, embedded in Epon, sectioned at 1 micrometer
and analyzed with light microscopy. The mean diameter of seminiferous tubules, number of germ
cells are assessed and compared.

Results: There was a significant reduction in the mean tubular diameter after ligation of spermatic
vessels. The effect of ligation of spermatic vessels appears to be aggravated in group 1, while
better results are obtained in group 2.

Conclusion: Ligation of the spermatic vessels during stage 1 orchiopexy for intra-abdominal
testes is associated with a significant reduction of mean diameter of seminiferous tubules. Giving
HCG before ligation of spermatic vessels may aggravate its effect.

69) Short Term Evaluation of Botulinum Toxin Injection in External Urethral Sphincter in
Children with Non-Relaxing External Urethral Sphincter
     Assem A, Shafeek M, Gafer S & Mokhless I.
     Section of Pediatric Urology, Alexandria University, Egypt.

 Objective: Evaluation of the efficacy of Botulinum toxin injection in the external urethral sphincter
in children with non-relaxing external urethral sphincter including neurogenic and non-neurogenic
voiding dysfunction

 Patients and methods: 20 patients (12 males and 8 females), mean age 11 years presented with
non-relaxing external urethral sphincter. Radiological investigations in the form of KUB, U/S,
VCUG and MRI spine were done. Urodynamic studies in the form of uroflowmetry, cystometry and
pressure flow study were done. Post voiding residual urine was estimated in every child. All
patients were subjected to injection of Botulinum toxin (BTX-A) in the external urethral sphincter
(ranging dose from 50 I.U. to 100 I.U.). Evaluation of the efficacy of the drug was done by the
measurement of the uroflow, post voiding residual urine and pressure flow study after 1 week, 1
month, 3 months and 6 months follow up.

Results: 14 patients showed improvement in the voiding symptoms, decrease in the post voiding
residual urine, improvement of the uroflowmetry and decrease in the voiding pressure lasting for 6
months. 4 patients needed several injections 2 months apart to reach the same response and 2
patients showed no response.

Conclusion: BTX-A injection in the external urethral sphincter in non-relaxing external urethral
sphincter in children is an effective modality in their treatment, however the technique is costly in
the light of the need of repeated injections at short intervals.

70) A Comparison of Percutaneous Drainage, Surgical Intervention, and Medical
Management as the Initial Treatment for Appendiceal Abscess in Children
     Dena Amr, Anna Kaminski, Kevin Patel, Harry Applebaum
     Kaiser Permanente Medical Center, Los Angeles, CA

Purpose: The increased use of CT scans has led to more accurate diagnosis and anatomical
definition of appendiceal abscesses in children, while advances in interventional radiology
techniques have added percutaneous drainage to the traditional initial treatment options of surgical
drainage or intravenous antibiotics alone. There is, however, little outcome data comparing these
currently available methods.

Methods: A retrospective review of all children undergoing management of appendiceal abscess
at our institution from 2/97–10/03 was performed. Patients were grouped by initial treatment
methods. Outcome measures included the need for additional interventions, length of hospital
stay, readmission, and recurrence of appendicitis.

Results: Thirty-five pediatric patients (M=16, F=19) with appendiceal abscess were identified.
Initial management (surgeon’s choice) was surgery (n=17), percutaneous drainage (n=13), or
intravenous antibiotics alone (n=5). Of the patients who initially underwent surgical drainage, four
subsequently underwent percutaneous drainage and one patient underwent a second operation
(transrectal abscess drainage). No interval appendectomies were performed. The average LOS
for surgical, percutaneous drainage, and medical groups was 11, 9, and 7 days respectively. The
LOS for surgical patients who subsequently underwent drainage was 17 days. The number of
readmissions for surgical, percutaneous drainage, and medical groups was 2, 5, and 0,
respectively. The cumulative LOS (including readmissions) for surgical, percutaneous drainage,
and medical groups was 12, 12, and 7 days, respectively.

Conclusions:         For pediatric patients with appendiceal abscess requiring intervention,
percutaneous drainage is a safe, effective, and arguably less invasive alternative to operation, and
is likely to be the only intervention required.

71) Thoracoscopic Ligation of a Tracheo-Esophageal H-Fistula in a Newborn
      Gaber Abdel Aziz , Felix Schier
      University Medical Center, Mainz, Germany

The H-type fistula represents the isolated form of tracheo-oesophageal fistula and it is relatively
uncommon. The conventional thoracotomy is associated with significant late sequelae; scapula
alata, scoliosis and excessive scarring (1).Thoracoscopic approaches avoid these consequences.
Thoracoscopic repair of oesophageal atresia, together with fistula ligation has been performed
earlier (2).However, thoracoscopic repair of H-type fistula was not attempted before. This is
probably because most H-fistulas are high enough to be accessible through a neck incision. Low
fistulas are better approached via the thorax. To our knowledge, this is the first report of a
thoracoscopic approach to H-type tracheo-esophageal fistula in a newborn.

72) Management of Antenatally Detected Obstructive Uropathy
        Wael Abdellatif Ghorab Sameh Abdel Hay Abdel HamidAshraf Ahmed KabeshMohamed
        Abdel Baky Fahmy
        Department of pediatric surgery Al Galae Teaching Hospital, Ain Shams university, Al
        Azhir University, Egypt

Introduction: The detection of renal abnormalities with antenatal US was first reported in the
1970s. Since then the increasing use of US has allowed an appreciation of the true incidence of
urological abnormalities, the most common is hydronephrosis, and has identified many cases that
require antenatal intervention or postnatal evaluation. Since 1982 fetal intervention for obstructive
uropathy has enabled the pediatric surgeon to become more involved with the decisions of
antenatal intervention (Herndon et al., 2000).

Background: Fetal hydronephrosis may be due to obstructive or non-obstructive lesions. The
commonest causes of obstructive lesions are uretero-pelvic junction obstruction, ureterovesical
junction obstruction and posterior urethral valve, while the most common causes of non-
obstructive lesions are physiological dilatation and vesicoureteral reflux. The major limitation of the
antenatal identification of urinary tract dilatation is that hydronephrosis does not necessarily imply
obstruction, nor give any indication of the function of an affected kidney. Fetal intervention needs a
high cost and sophisticated equipment and not yet introduced in Egypt. In this paper we applied
the policy of limited intervention during the antenatal period and timely programmed surgical
intervention in neonatal period.

Material and Methods: Twenty eight cases of obstructive Uropathy diagnosed antenatelly during
the last 2 year, mainly by ultrasound. Their data and protocol of management of each type of
obstruction will be discussed.

 Results: Sixteen cases of pelviureteric junction obstruction, 3 of them had bilateral obstructions, 6
cases of Posterior urethral valve and 6 cases of other rare anomalies were diagnosed. Vesico-
amminiotic shunt was done for 3 cases with unfavorable outcome and other cases managed
surgically in neonatal period.

Conclusions: There is little data on the impact of prenatal intervention on postnatal renal function.
Prenatal intervention can be considered in the presence of oligohydramnios and significant
bilateral hydronephrosis, bladder electrolytes suggestive of good renal function and no other life
threatening congenital abnormalities with the main goal is in restoration of amniotic fluid volume
and prevention of pulmonary hypoplasia. This potential benefit must be weighed against the
maternal and fetal complications of in-utero therapy and the unknown effect on renal function.
Postnatal evaluation and management is the main strategy in dealing with most cases of
antenatally detected obstructive uropathy.

73) Recent Advances in Management of Liver Tumors in Children
     Amir Azmy
     Royal Hospital for Sick Children, Glasgow, UK

74) Invited Guest lecture: The Wilm’s Tumor
      Michael E. Höllwarth
      Dept. of Paediatric Surgery, Medical University, Graz/Austria

The Wilm’s tumor is the most common malignant neoplasm of the kidney in childhood accounting
for 6% - 8% of all childhood tumors. The tumor derives from primitive metanephric blastema and is
in 95% unilateral. In 10% additional malformations or syndromes can be found. The clinical staging
and the histologic grading are essential for the appropriate therapeutic regimen. While the strategy
of the National Wilm’s tumor study group (NWTS) consists of primary tumornephrectomy followed
by chemotherapy - and radiotherapy if appropriate, the SIOP (Societe international of oncology
pediatrique) recommends primary chemotherapy for 4 – 6 weeks followed by tumornephrectomy
and further chemo-/radiotherapy. Although the different regimens have different disadvantages,
the overall results after 5 years are around 90% in both study groups.

Nephron sparing surgery became recently a new option for selected patients with a unilateral
Wilm’s tumor, when the primary chemotherapy (SIOP protocol) resulted in a significant reduction
of tumor volume. Inclusion criteria are: local stage I, tumor involving one kidney pole, no invasion
of the renal vein or collecting system, at least 50% of normal kidney tissue remain intact, and
resection must be possible with tumor free margins, respectively. We have performed in our
institution during the last 20 years a nephron-sparing procedure in 12 patients with Wilm’ tumor ( 8
with unilateral and 4 with bilateral tumor). During the long term follow-up only one child with a
bilateral tumor dies 2 month after surgery due to sepsis during chemotherapy.

In conclusion, a review of the problem of Wilm’ tumor is presented with special reference to the
option of nephron sparing surgery in unilateral and bilateral tumors.

75) Persistent Hyperinsulinemic Hypoglycemia of Infancy - Experience With 63 Cases
      Abdullah Al Rabeeah, , Ibrahim Al Alwan, Saleh Al-Nassar, Bassam Bin-Abbas, Abdullah Al
      Department of Surgery, Section of Pediatric Surgery, Department of Pediatrics, Division of
      Pediatric Endocrinology, King Abdulaziz Medical City, Riyadh, Saudi Arabia & King Faisal
      Specialist Hospital and Research Center, Riyadh Saudi Arabia

Between 1983 and 2004, sixty-three (63) infants with Persistent Hyperinsulinemic Hypoglycemia of
Infancy (PHHI) were seen. The age of presentation ranged from a few hours to six months. There
were twenty-six (26) males and thirty-seven (37) females. Consanguinity was reported in forty-four
(44) (70%) cases. One family had two affected siblings and one affected cousin. Three other
families reported loss of siblings due to hypoglycemia and seizures.

Clinical presentation was mainly with jitterness and seizures in association with hypoglycemia.
The diagnosis was suspected when glucose requirement was more than 12mg/kg/min and also
with good response to glucagon after exclusion of metabolic and storage diseases. High insulin to
glucose ratio was seen in all patients. Forty-eight (48) patients had 90% pancreatectomy with
excellent results in thirty-five (35), while the remaining required supplemental medical therapy.
Fourteen (14) patients were treated medically and one patient’s family refused treatment. Twenty-
one (21) patients sustained moderate to severe brain insult prior to diagnosis. There were no
deaths and only three patients showed evidence of malabsorption following pancreatectomy. Five
(5) patients developed diabetes mellitus a few years later.
In conclusion, PHHI seems to correlate well with consanguinity and family history. It also requires
clinical awareness to allow early diagnosis and prompt medical and supportive therapy. Early
surgery is recommended in most cases to avoid permanent brain damage. It appears that 90%
pancreatectomy offers the best surgical outcome without morbidity or mortality.

76) Lessons from Pancreatectomy for Nesidioblastosis
      Sameh Shehata
      Department of Pediatric Surgery, Alexandria University, Egypt

Objective: Review of our experience in pancreatectomy for nesidioblastosis in the pediatric
surgical center, Alexandria University, Egypt.

Methods: 10 cases of nesidioblastosis were seen during the period between "1998-2004", near
total pancreatectomy was performed for cases who failed aggressive medical treatment. Close
monitoring of blood glucose was performed pre and post operatively.

Results: age ranged between 3 weeks and 3 months.6 males and 4 females.3 patients were
controlled by medical treatment alone. Near total pancreatectomy was performed for 7 cases that
had intractable hypoglycemia despite aggressive medical treatment.3 cases had irreversible brain
damage. All cases who had pancreatectomy had residual hypoglycemia after surgery which
required increases glucose intake orally.

Conclusion: To prevent the devastating effects of hypoglycemia on the CNS of the infant,
Persistent infantile hypoglycemia should be recognized early and treated promptly. To avoid
mental retardation, surgical intervention should not be considered as a last resort.. Near-total
pancreatectomy, retaining the spleen and duodenum, is a safe procedure, well tolerated by infants
and children, and should be considered early for the correction of hypoglycemia of infancy that is
not readily controlled by medical intervention.

77) Antenatal Diagnosis in Pediatric Oncology and the Impact on Prognosis
       Yasser Saad
       Department of Pediatric Surgery, Alexandria University, Egypt

Background: Early diagnosis is the key for any successful management and promising prognosis.
Antenatal diagnosis is the earliest way of diagnosis in our pediatric surgical practice.
Objective: Reporting the value of antenatal diagnosis in pediatric oncology

Patients, methods & results: antenatal diagnosis of 11 cases of pediatric surgical lesions was
achieved within 3500 pregnant women over a period of 20 months. One of these cases was a
malignant kidney tumor. This antenatal diagnosis was confirmed postnatally. The baby was treated
by radical nephrectomy at the age of one week. The baby did not receive any chemotherapy and
survived or more than 7 years till now.
Conclusion: antenatal diagnosis was very beneficial for planning early management in pediatric
oncology with subsequent improving survival.

78) Sacrococcygeal Teratoma
      Sherif N Kaddah, Nassief H Al Afifi
      Department of Pediatric Surgery, Cairo University, Egypt

Background: Sacrococcygeal teratoma is the most common congenital neoplasm of the fetus.
This tumor contains derivatives of more than one of the three embryonic germ cell layers and
usually arises as a mass in the sacrococcygeal region. Fetuses with this malformation may have
associated morbidity and mortality related to prematurity, dystocia, traumatic delivery and
intratumoral hemorrhage.

Material and methods: This case study demonstrates a 2 days old male baby with a large
sacrococcygeal teratoma with a limb and a small phallus protruding from the mass.

Result: The mass was completely excised and the baby is doing fine so far.

79) Nasal Glioma
      Mahmoud Fawzy El Bestar
      Cairo university

Nasal glioma is a rare anomaly that represents ectopic glial tissue in the nose. Sporadic reports in
literature reflect the uncommon occurrence of this disorder. This ectopic tissue can manifest as
external, internal or combined masses around the nose. Five cases of nasal glioma seen at the
Children’s Hospital, Cairo University are presented. Four of these cases were external while only
one case had an internal nasal mass. All patients were evaluated by CT scan to exclude
intracranial extension. Surgical excision was done through conservative facial approaches.
Recurrence was noted in two patients, and was treated by wide resection. These lesions are often
underestimated. Adequate preoperative assessment combined with adequate resection can avoid

80) Orofacial Tumours and Tumours like Conditions in Children and Adolescent.
      Almoutaz .A.E.Essa, Ahmad Eltayeb Essa,
      Department of Pediatric Surgery, Assiut University, Egypt

One hundred and thirty cases of orofacial tumours and tumour like conditions were encountered in
the pediatric age group at Assiut University Hopspitals.The commonest benign tumour was
haemangioma (22 %) followed by Epulides (13%). Haemangiomas was treated by cryosurgery,
injection or excision .Epulides was treated by excision. Concerning Jaw tumours , are either
odontogenic tumours of which ameloblastoma is in need for resection of the bone with safety
margin while complex and compound odontomes are common in this age group were small in size
and treated by simple curettage ,and did not recur.
The commonest jaw tumours are mostly benign, non-odontogenic and mesenchymal tumours.
Their clinical behavior was variable and often did not correspond to the histological pattern. The
clinical aggressive variants displayed rapid growth and usually associated with pain. Resection
rather than curettage is the appropriate therapy when there has been earlier treatment failure by
local tumour removal or rapid tumour expansion or when the tumour extensively invades the jaw.
When resection is carried out, facial growth is not adversely affected if early reconstruction with
autogenous bone is performed.

81) Renal Salvage For Synchronous Bilateral Wilms’ Tumor
      Nabil M Dessouky, Aymen Hussein
      Cairo University, Egypt

Synchronous bilateral lesions accounts for 4 – 6 % of all Wilms’ tumors. Achieving curative
resection of such tumors by partial nephrectomy or tumor enucleation while maintaining renal
function represents a surgical challenge.
A nine month-old female child was reported to have a huge Wilms’ tumor -diagnosed by primary
needle biopsy- of the upper pole of the right kidney and two other nodules affecting the two poles
of the left kidney. No distant metastases were detected.
The patient received pre-operative neo-adjuvant chemotherapy for 4 weeks followed by bilateral
partial tumor resection.
Partial nephrectomy was performed for the right kidney lesion with enucleation of the other two
lesions of the left kidney. Post-operative renal assessment showed good function of the preserved
Chemotherapy regimen was continued post-operatively with no tumor recurrence after a follow up
of 6 months.

82) Normal & Abnormal Penile Features To Be Cosidered For Satisfactory Circumcision
      Yasir Saleh Jamal
      King Abdul-Aziz University Jeddah, KSA.

Circumcision is the commonest surgical procedure in our community but being considered a minor
procedure by both the parents and surgeons, it was not given proper care and usually left to be
done by junior doctors, nurses or traditional circumcisioner (mtaher) this resulted in unacceptable
high percentage of unsatisfactory circumcisions.          To avoid these unsatisfactory results, an
experienced surgeon who knows the normal & abnormal penile feature should do circumcision. In
this presentation, I will discuss the normal & abnormal penile feature that must be considered for
performing satisfactory circumcision additionally I will present some of the important unsatisfactory
result and its surgical correction

83) superposed diphalia a case report and review of the literature
      Nour el kholey, Essam el akkary
      Alexandria University, Egypt

A male boy with superposed duplication of the penis. The dorsal penis has a urethra. The ventral
penis is smaller and devoid of urethra. Excision of the ventral phallus and coverage by Byers flaps.
Review of the literature and discussion of the rare cases presented.

84) Common Gynecological Problems in Pediatric
      Mohamed A. Baky Fahmy
      Al Azher University, Egypt

Pediatric gynecology is an emerging subspecialty involving the collaborative efforts of health
professionals from gynecology, pediatrics, and urology. The gynecologic problems encountered in
the pediatric population are unique to this age group and involve physician skills differing from
those utilized with an adult population. In this review article the common specific surgical problems
to which the young female may be exposed will be discussed
Introduction: in our hospital as a maternity and children hospital we had a chance to deal with this
group of patients, so during the last 4 years 116 girls were referred with a surgical problems,
classified according their ages to Fetal, Neonatal, child and adolescent.

Materials and Methods: 23 cases of Ovarian Cysts, 12 cases of Labial adhesions, 18 cases of
Intersex and Adrenogenital hyperplesia, 9 cases of vaginal foreign body, 9 Hymnal tag and
imperforate hymen, Urethral prolapse 6 cases, Genital prolapse 4 cases Vulovaginitis, Breast
abscess, bleeding per nipple, cystic adenosis

Conclusion: Pediatric gynecology is a new specialty incorporating the expertise of gynecologists,
pediatricians, and often urologists. The pathologic processes in infants and young children differ
significantly from that of the adolescent or adult female. Because of the unique problems in this
population, practicing obstetrician-gynecologists are often uncomfortable evaluating and managing
these children.

85) Congenital H-shaped Rectourethral Fistula with ectopic anal opening: a report of two
      Mohamed M. Elbarbary, Gamal H. El Tagi, Mamdouh A. Abouelhassan
      Cairo University, Egypt

Background: Congenital "H-type" urethrorectal communication is extremely rare in the pediatric
population. Associated anomalies of the anus and the anterior urethra have been reported in some
Purpose: We report 2 cases of congenital H-shaped urethrorectal fistula associated with anterior
ectopic anal orifice and anomalies in the anterior urethra
Patients and Methods: Two male children presented with passage of urine from the anus. On
examination both children had an anteriorly placed anus, and a urethral fistula in the anterior wall
of the anus just above the dentate line. A 2 year old male was treated for this condition prior to
presentation at our institute. Although he had a normal looking penis and anterior urethra most of
the urine flow came per anum. On examination there was a stricture urethra at the root of the
penis. The second 6 month old boy had a micropenis and no urethra distal to the fistula was
identified. Both children were operated upon through a perineal approach when the anus was
repositioned in its normal position and the urethral fistula brought separately forward in the
perineum. Later in a second operation a buccal mucosal graft was inlayed in the older child to
bridge the stenotic urethra in the older child in a later stage. Bladder mucosal graft was used to
reconstruct the urethra in the younger child after hormonal treatment to enlarge his penis.
Results: The older child is awaiting completion of urethral reconstruction. Full correction of the
anomaly was possible in the younger child after 2 procedures. He developed neourethral meatal
stricture that required meatotomy. Both children have good bowel function and no faecal soiling.
Conclusion: Multiple procedures is needed to correct such complex anomaly. Proper identification
of all associated anatomical abnormalities is essential for optimum outcome.

86) The Use of Snodgrass Principals in the Treatment of Recurrent Hypospadias Fistulas
      Abdulwahed. O, Elzab. S, sabouni.T, Jabbour T.
      Division of pediatric surgery and urology Aleppo university hospital

The use of Snodgrass technique (TIPU) in the primary repair of hypospadias is now one of the
most popular techniques in the world. We report our experience in the use of Snodgrass principals
in the treatment of four patients with recurrent multi-operated wide fistulas. The average age was
10 years (4-17 years) with average prior fistula's cures of 3 times (1-5). All were anterior fistulas on
the distal third of the penis. the use of incised posterior wall of the fistula with the multi-layers
coverage in these 4 patients with a mean follow up of 6 months (3-24 months)gave us a primary
successful results. In conclusion: Snodgrass principals (TIPU) may be an interesting alternative
technique in the treatment of recurrent wide fistulas after the primary hypospadias repair but a
longer follow up is necessary as the same as for the Snodgrass technique itself although the
primary results were encouraging.

87) Rare and unexpected complication of circumcision; case report (5)
      Mohammed Youssef
      Section of Pediatric Surgery, Alexandria University, Egypt.

Background; circumcision is a very simple and basic minor operation which in spite of its
simplicity has many known complications e.g.; bleeding, infection, faulty circumcision etc.

Material and methods; in this case report we present a case of circumcision ended up with a very
dramatic complication which will affect the baby all over his life. The complication here was a
simple post circumcision bleeding which was managed in a wrong way by sutures, which could not
control the bleeding so the surgeon used a chemical substance, which was most probably lysol
leading to gradual and total loss of the penis.

Conclusion; basic surgical procedures have their own real and dramatic complications which
should be managed correctly from the start.

88) Routine Postoperative Urethral Dilatation: Is It Necessary After TIP Hypospadias
      Ismaiel Tanatawy, Dr. Amira Waly
      Department of Pediatric Surgery, Zagazig University, Egypt

Objective: to determine if patients who undergo TIP repair need regular postoperative dilatation to
prevent urethral stricture or meatal stenosis.

Patients and methods: the study included 40 boys with different degrees of hypospadias and
including recurrent cases. All treated by TIP repair. 20 patients had regular routine postoperative
dilatation for 6 months, while the other 20 patients had no routine dilatation. Both groups where
followed up for 6 months by clinical examination, uroflowmetry and arthroscopy.

Results: there was no evidence of scarring in the first group. We have one case of meatal
stenosis and another one of urethral stricture in the second group. The difference in out come was
not statistically significant.

Conclusion: routine postoperative urethral dilatation is not necessary after TIP urethroplasty

89) Hypospadias Chordee Revisited
      Sameh Shehata
      Alexandria University, Egypt

Objective: to study the types of hypospadias chordee and the techniques used for their correction.

Methods: analysis of 506 cases of hypospadias. The operative findings were recorded the type of
hypospadias, check on chordee by artificial erection the technique used to correct chordee.

Results: A total of 506 cases of hypospadias were performed in pediatric patients, mean age
was2.3yrs. Distribution of cases was as follows: Coronal 147 cases of whom 46 had chordee 31%;
Distal hypospadias in 191 cases, 139 had chordee 73%; Proximal hypospadias 153 cases, 136
had chordee 89%; Fifteen cases had chordee without hypospadias.

Total no. of cases of chordee was 336, 285 were mild to moderate, and 51 were severe. 292
cases were corrected by skin degloving alone: 87%; 41 cases required dorsal tunica
placation12%, while only 3 cases needed ventral tunica patching.

Conclusion The majority of cases of hypospadias have some degree of chordee; some of them
are hidden and appear only on artificial erection. Most cases of chordee can be corrected by
adequate skin degloving, however some cases are not corrected by degloving alone and need
additional measures.


To top