Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. MethodsWe did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung's disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. FindingsWe included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung's disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58•0%) were male. Median gestational age at birth was 38 weeks (IQR 36-39) and median bodyweight at presentation was 2•8 kg (2•3-3•3). Mortality among all patients was 37 (39•8%) of 93 in low-income countries, 583 (20•4%) of 2860 in middle-income countries, and 50 (5•6%) of 896 in high-income countries (p<0•0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90•0%] of ten in lowincome countries, 97 [31•9%] of 304 in middle-income countries, and two [1•4%] of 139 in high-income countries; p≤0•0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2•78 [95% CI 1•88-4•11], p<0•0001; middle-income vs high-income countries, 2•11 [1•59-2•79], p<0•0001), sepsis at presentation (1•20 [1•04-1•40], p=0•016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4-5 vs ASA 1-2, 1•82 [1•40-2•35], p<0•0001; ASA 3 vs ASA 1-2, 1•58, [1•30-1•92], p<0•0001]), surgical safety checklist not used (1•39 [1•02-1•90], p=0•035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1•96, [1•4...

Background: The most frequent cause of paediatric acute abdomen is acute appendicitis. If acute appendicitis is not treated promptly, one third of cases progress to complicated appendicitis. Complicated appendicitis is associated with significant morbidity and its management protocol differs significantly from that of uncomplicated appendicitis. In this study, we assessed the relationship between serum sodium levels and complicated appendicitis. Methods: We conducted a prospective observational study from July to December 2020 at the Department of Neonatal and Paediatric Surgery, The Children Hospital, Pakistan Institute of Medical Sciences, Islamabad, on a sample size of 140 patients who met inclusion and exclusion criteria. For this study, we divided the patients into two groups. Group 1 had uncomplicated appendicitis and Group 2 had complicated appendicitis. These findings were then compared to preoperative serum sodium (Na) levels. Results: The median serum sodium level in group 1 (uncomplicated appendicitis) was 137.81 mg/dl, while in group 2 it was 131.35 mg/dl (Complicated Appendicitis). The sensitivity and specificity of serum sodium levels at a cut-off point of less than 135 mg/dl were 84.80% and 89.40%, respectively. Conclusion: Hyponatremia is currently thought to be a new marker for differentiating between complicated and uncomplicated appendicitis. It is a low-cost, high-efficiency predictive marker for diagnosing and differentiating complicated appendicitis in children.

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Background: The survival and outcome of neonates with anorectal malformations (ARM) have much improved in the developed countries due to optimal perioperative and postoperative care but in developing countries, sepsis, low birth weight, delayed presentation, and lack of intensive care for neonates are still important in affecting the outcome. This study was carried out to evaluate factors of poor outcome (mortality) in neonates with ARM. Method: This is a prospective analytical study. A total of 44 consecutive neonates with Anorectal malformations (ARM) presenting to the Department of Pediatric Surgery, The Children’s Hospital, Pakistan Institute of Medical Sciences, Islamabad, were included. Variables studied included age at presentation, gender, birth weight, type of malformation, sepsis at presentation, type of surgery performed, postoperative complications, and their relationship to the outcome. The statistical analysis was performed using SPSS version 21. Results: A total of 44 neonates with ARM were included in the study. In the study population, 56.8 % (25) were males and 43.2% (19) were females. The mean age at presentation was 2.1 ± 0.5 days. The mean birth weight was 2.5 ± 0.6 kg. Overall mortality was 29.5% (13) with 13.63% (6) patients died pre-operatively. The most common cause of death in postoperative patients was sepsis (40%). There was a statistically significant relationship between low birth weight (P= <0.01) and sepsis at presentation (P=0.001) with mortality. No statistically significant association was found when the outcome was compared with age at presentation (P=0.21) and postoperative complications (P=0.16). Conclusion: In developing countries, the lack of resources, lack of trained midwives/LHVs, intensive care are contributing factors to sepsis and delayed presentation, and ultimately mortality. Good antenatal care, awareness of the midwives/Lady Health Visitors to refer such patients in time, and provision of adequate intensive care can improve the outcome of surgery in ARMs.

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