A fatal combination of duodenal atresia with preduodenal portal vein, malrotation, and hypoplastic left heart syndrome: A case report

Background: Duodenal atresia (DA) is often associated with anomalies that include annular pancreas, cardiac anomalies, intestinal malrotation, situs inversus, or splenic anomalies. Association of duodenal atresia with complex cardiac anomalies is scarcely reported in the literature. Case Presentation: A term neonate was diagnosed with duodenal atresia and found to have a preduodenal portal vein and malrotation. A gastro jejunostomy was added to the procedure, due to the pre duodenal portal vein. On post-operative day 4, the patient had sudden desaturation. The respiratory system was normal and there was no evidence of septicaemia. On the post-operative echocardiogram, the diagnosis of hypoplastic left heart was made and the patient eventually succumbed to his complex cardiac disease. Conclusion: This is a rare combination of multiple anomalies and we report the clinical and anatomical findings of this patient.

Intraoperative Dilemmas in Polyorchidism: To Pex or not to Pex!!

Supernumerary testis or polyorchidism is a rare congenital anomaly. It is often associated with processus vaginalis anomalies and with increased risk of malignancy and infertility. The approach to management has changed over time, with improvements in imaging techniques allowing surveillance to replace surgical excision or exploration and biopsy. In this study, two patients were managed with orchidopexy and have had a close follow-up of 2 years.

Autologous stem cell transplant for high-risk neuroblastoma: Achieving cure with low-cost adaptations

BACKGROUND

The majority of patients in low- and middle-income countries (LMIC) are unable to receive optimal therapy, including autologous stem cell transplant (ASCT) for high-risk neuroblastoma. Management is intensive and multidisciplinary; survival is often poor. We report a single-center outcome of high-risk neuroblastoma, with adaptations optimized for LMIC.

PROCEDURE

The study was retrospective. Patients were treated on the backbone of the high-risk neuroblastoma study-1 of SIOP-Europe (HR-NBL1/SIOPEN) protocol with ASCT. Adaptations incorporated to decrease cost, requirement for inpatient admission, infections, and faster engraftment included (a) optional outpatient administration for rapid-COJEC, (b) two sessions of stem-cell apheresis, (c) storing stem cells at 2-6°C without cryopreservation for up to 7 days, (d) no central lines, (e) no antibacterial/antifungal/antiviral prophylaxis, (f) omitting formal assessment of cardiac/renal/pulmonary functions before ASCT, and (g) administration of pegylated granulocyte colony-stimulating factor on Day +4.

RESULTS

Over 5 years 9 months, 35 patients with high-risk neuroblastoma were treated. Rapid-COJEC was administered over a median duration of 80 days (interquartile range: 77, 83). Conditioning regimen included melphalan (n = 7), oral busulfan-melphalan (Bu/Mel; n = 6), or intravenous Bu/Mel (n = 22). The median viability of stem cells stored for 6 days (n = 28) was 93% (range: 88-99). Two (5.7%) patients had ASCT-related mortality. The 3-year overall and event-free survival was 41% and 39%, respectively. A relapse occurred in 20 (57%) patients. Treatment abandonment was observed in one (3%) patient.

CONCLUSIONS

Administration of therapy in a disciplined time frame along with low-cost adaptations enables to manage high-risk neuroblastoma with low abandonment and an encouraging survival in LMIC. Stem cells can be stored safely without cryopreservation for up to 7 days.

Fine needle aspiration cytology of paediatric soft tissue tumours highlighting challenges in diagnosis of benign lesions and unusual malignant tumours

INTRODUCTION

The type of soft tissue lesions seen in children differs from that seen in adults. The role of fine needle aspiration (FNA) cytology in their diagnosis is not well documented.

AIM

To study the cytopathological spectrum of paediatric soft tissue tumours to highlight uncommon benign and malignant lesions and the challenges in their diagnosis.

METHODS

A 3-year retrospective audit of all paediatric soft tissue FNA cytology cases from 2015 to 2017 was performed. Smears were reviewed along with cell block immunocytochemistry and follow-up histopathology of resected specimens wherever available.

RESULTS

A total of 127 cases were reviewed, which included 72 benign and 55 malignant soft tissue tumours. Uncommon lesions described herein are myxoid fibrohistiocytic tumour, myxoma, lipoblastoma, Bednar tumour, malignant extra-renal rhabdoid tumour and desmoplastic small round cell tumour. Histopathology confirmation was available in 25 cases, out of which 16 cases were completely concordant. In eight cases, all benign diagnoses, histopathology provided more accurate subtyping than FNA. These included cases of lipoblastoma, myxoma and spindle cell haemangioma.

CONCLUSION

FNA cytology of paediatric soft tissue tumours is accurate in classifying lesions as benign or malignant which helps in treatment planning. Immunocytochemistry performed on cell blocks is useful for subtyping malignant lesions.

Pediatric Trauma: Management and Lessons Learned

Aim:

The aim is to prospectively study 125 trauma patients admitted in the pediatric surgery ward in our institute.

Materials and Methods:

Pediatric patients admitted in the ward after initial resuscitation in the triage room were included. Isolated neurosurgical and orthopedic injuries were excluded. X-ray cervical spine, hip, and chest and a focused assessment with sonography in trauma ultrasound were done for all patients. Computed tomography of the abdomen or chest was done where relevant. Injury profile and surgical intervention when needed were analyzed.

Results:

Road traffic accidents and fall from height caused 73.6% of the injuries. School-going children were most commonly affected (60.8%). Distinctive injuries were noted such as abdominal wall hernias and delayed bladder perforation. All solid organ injury irrespective of grade treated conservatively. Forty percent of the children required surgical intervention. Five patients after laparotomy were found to have surgical conditions unrelated to trauma, whereas another 14 required delayed surgery. Five patients had injuries secondary to sexual abuse. All except two patients were discharged in a satisfactory condition and are doing well in the follow-up.

Conclusion:

In spite of extensive injuries and the need for multiple surgeries, children with trauma have a good prognosis. Close observation during admission and also in follow-up are essential, as many patients may require delayed surgery ≥1 week from injury.

Parents' perception and factors affecting compliance with preoperative fasting instructions in children undergoing day care surgery: A prospective observational study

Background and Aims:

Fasting guidelines have been recommended in the paediatric population to minimise the risk of pulmonary aspiration. The present study was planned to assess the compliance with fasting instructions in children undergoing ambulatory surgery and identify the factors affecting it.

Methods:

A total of 1,050 ASA I and II children aged 1–12 years, scheduled for day care surgery were enrolled. Parents of these children were given a questionnaire with specific questions like fasting instructions, source of instructions, actual fasting times and reasons for not following instructions.

Results:

Only 90 (8.5%) parents followed fasting instructions as advised. Of the 960 non-compliant patients, 31 (2.9) inadequately fasted while 929 (88.4%) fasted more than advised. While only 5.2% mentioned aspiration, 25% cited vomiting as the reason for fasting. Younger parents (OR = 0.853, 95% CI-0.796 to 0.915), fasting instructions in writing (OR = 10.808, 95% CI-1.459 to 80.059) and separate instruction for solids and liquids (OR = 6.016, 95% CI- 3.663 to 9.883) were found to affect compliance with fasting instructions.

Conclusion:

To avoid risks of prolonged or inadequate fasting in day care surgical patients, good coordination between the anaesthetist and the surgeon and an updated knowledge about the preoperative fasting instructions among the health-care providers is essential. Separate written fasting instructions for liquids and solids should be given to the parents according to their order in the operating list to ensure better compliance with fasting instructions.

Clinical Presentation and Surgical Management of Neonatal Tumors: Retrospective Analysis

Aims:

Neonatal tumors (NTs) include a group of diverse neoplasms. In this study, we reviewed our data for clinical presentations, management options, and outcome.

Materials and Methods:

All patients from 0- to 1-month age presenting with solid tumors, from 2006 to 2018 were studied. The gender, presentation, location, type of tumor, and management were analyzed. The final diagnosis was made with histopathology in all cases. Hemangiomas and lymphangiomas were excluded from the study.

Results:

A total of 32 neonates were studied. The most common tumor was sacrococcygeal teratoma (SCT,16) followed by teratoma at other sites including two cases of fetus-in-fetu, soft-tissue sarcoma (STS, 4), mesenchymal hamartoma (2), hemangioendothelioma (2), and other rare tumors. Three tumors were diagnosed antenatally; of whom, two were neither visible externally nor palpable. Complete surgical excision was done for all except in a case of ovarian cyst where near-total cystectomy was done. No patient received chemotherapy or radiotherapy. Six patients had postoperative complications, including two who had local recurrence requiring excision. There was one mortality. All the other patients are doing well during follow-up.

Conclusion:

NTs have varied presentations. SCT and STS were the most common benign and malignant tumor, respectively. Early diagnosis and complete surgical excision are often curative for all, regardless of the pathology with the minimal role of chemotherapy or radiotherapy.

Type IV Congenital Pouch Colon in Male Children: Anatomical Variations and a Proposed New Subclassification

Background:

Congenital pouch colon (CPC) is a rare variant of anorectal malformation. In male patients, CPC communicates distally with the urogenital tract by a large fistula. The CPC cases which do not fulfill the criteria as mentioned in the classical description are reported along with the pertinent literature review.

Materials and Methods:

This was a retrospective study from January 2004 to December 2017 of male children with Type IV CPC. We evaluated clinical presentation, primary management, anatomical relationship, previous surgical intervention, definitive management, result, and outcome in terms of continence status on Templeton score.

Results:

Fifty-one children were included in the study among whom 36 children (Group 1) had a colovesical fistula and 15 children (Group 2) had no communication of the pouch with the genitourinary tract. In Group 2 children, the clinical presentations and management were varied: 4 underwent primary pull-through procedure, whereas 11 underwent staged procedure. Group 2 included three children in whom a narrow and thin-walled anal canal or anal canal with lower rectum was present, which was incorporated during the pull-through procedure. On continence assessment, only one child in Group 1 had “good” continence score compared to four children (three having anal canal) in Group 2.

Conclusion:

CPC Type IV can present without genitourinary tract communication (fistula), contrary to its emblematic description. Awareness about anatomical variations and adaptation of surgical technique accordingly is vital. The identification of the anal canal with or without the lower part of the rectum (even though apparently narrow and thin walled) and incorporation of this in bowel continuity lead to better outcomes in terms of continence.

Pediatric empyema thoracis: What has changed over a decade?

OBJECTIVES

The purposes of this paper are to study clinicobacteriological profile, treatment modalities and outcome of pediatric empyema thoracis and to identify changes over a decade.

DESIGN

This is a retrospective study.

SETTING

Department of Pediatrics of a tertiary care hospital in North India.

PATIENTS

We enrolled 205 patients (1 month-12 years) of empyema thoracis admitted over 5 years (2007-11) and compared the profile with that of a previous study from our institute (1989-98).

RESULTS

Pleural fluid cultures were positive in 40% (n = 82) cases from whom 87 isolates were obtained. Staphylococcus aureus was the most common isolate (66.7%). Methicillin-sensitive S. aureus accounted for 56%, Methicillin-resistant S. aureus (MRSA) 10% and gram-negative organisms 18.3% of isolates. Intercostal drainage tube (ICDT) was inserted in 97.5%, intrapleural streptokinase was administered in 33.6%, and decortication performed in 27.8% cases. Duration of hospital stay was 17.2 (±6.3) days, duration of antibiotic (intravenous and oral) administration was 23.8 (±7.2) days and mortality rate was 4%. In the index study (compared with a previous study), higher proportion of cases received parenteral antibiotics (51.7% vs. 23.4%) and ICDT insertion (20.5% vs. 7%) before referral and had disseminated disease (20.5% vs. 14%) and septic shock (11.2% vs. 1.6%), less culture positivity (40% vs. 48%), more MRSA (10.3% vs. 2.5%) and gram-negative organisms (18.4% vs. 11.6%), increased use of intrapleural streptokinase and surgical interventions (27.8% vs. 19.7%), shorter hospital stay (17 vs. 25 days) and higher mortality (3.9% vs. 1.6%).

CONCLUSIONS

Over a decade, an increase in the incidence of empyema caused by MRSA has been noticed, with increased use of intrapleural streptokinase and higher number of surgical interventions.

Neonatal Esophageal Perforation with Esophageal Atresia: A Case Report

Esophageal perforation (EP) in a neonate is very rare and is often iatrogenic. Preterm neonates with esophageal atresia (EA) are at more risk, as EP can occur during any test or intervention at pharyngeal region. We are presenting the management of EP in a preterm neonate with EA who presented with pneumomediastinum.

Endoscopic Management of Vesicoureteral Reflux and Long-term Follow-up

OBJECTIVE

To report our experience with endoscopic management of vesicoureteral reflux (VUR) by injection of a tissue bulking substance - Dextranomer/ hyaluronic acid co-polymer at vesicoureteric junction.

DESIGN

Retrospective analyses of case records.

SETTING

Pediatric Surgery department in a tertiary care government Institute.

PARTICIPANTS

500 children (767 renal units) consecutively referred to the out-patient department with vesicoureteral reflux noted on micturating cysto-urethrogram (MCU) over a period of 13 years (2004-2016).

INTERVENTION

Preoperative VUR grading and renal scars on radionuclide scans were documented. Dextranomer hyaluronic acid copolymer was injected through a cystoscope at the vesicoureteral junction as a day care procedure under short anesthesia. Patients were followed (average duration 27.3 mo) with clinical assessment, periodic urine cultures and renal scans.

MAIN OUTCOME MEASURE

Cessation of VUR and symptomatic relief / clinical success postoperatively at 3 months.

RESULTS

Complete symptomatic relief was obtained in 482 (96.4%) patients. In 681 units where MCU was available, 614 (90%) units showed resolution of VUR.

CONCLUSIONS

Endoscopic injection of tissue bulking substances at vesicoureteric junction to stop VUR seems to be an effective intervention.

Omphalocele and epigastric heteropagus: implications and treatment

In heteropagus twins, the parasitic twin is incompletely formed which is attached to the autosite. We report a case of epigastric heteropagus twins with omphalocele. The parasite had two lower limbs, a rudimentary upper limb, genitalia with developed phallus and scrotum but absent testis. An omphalocele was present just below the attachment of the parasitic twin. A single kidney with ureter and a bladder filled with urine seen during exploration. The parasite bowel was attached to a sleeve of liver tissue from the autosite within the omphalocele sac and this connection was also the main source of its blood supply. Less than 20 cases of omphalocele with EH have been reported previously. The thin sac with underlying adherent bowel led us to go ahead with surgery in the neonatal period for both, excision of epigastric heteropagus and omphalocele repair. The rectus sheath around the omphalocele sac helped in the final wound closure.

Congenital Bladder Diverticulum in a Neonate Simulating Posterior Urethral Valves

Primary bladder diverticulae are rare anomalies of the bladder. They usually present with recurrent urinary tract infections and dysuria. We present a case of retrovesical diverticulum, which presented with urinary retention behaved like a case of posterior urethral valves. A high index of suspicion and a well performed micutrating cystourethrogram helps in clinching the diagnosis. Excision of these diverticulae with or without ureteric reimplant is curative in most cases.

Bronchoscopic Airway Foreign Body Extraction without Using Optical Forceps

Aim:

Airway foreign body (FB) is a very common pediatric surgical emergency. On certain difficult occasions, the extraction of FB with optical forceps (OFs) is difficult. These conditions create a life-threatening scenario. We present some of the alternative methods of FB extraction for these situations.

Patients and Methods:

This is a retrospective case review of patients presenting to pediatric emergency with airway FB. All patients had a chest X-ray done before the procedure. Rigid bronchoscopy was performed in all patients for retrieval.

Results:

A total of 20 patients (6 females) were successfully scoped. The age ranged from 1.5 years to 12 years (mean 3.5 years). Bronchoscopic removal was aided by dormia basket (DB) in 13, Fogarty's catheter (FC) in 6, and magnet aided removal in 1. Complete removal was achieved in all patients.

Conclusions:

We recommend that DB, FC, and a magnet should form an indispensable part of bronchoscopy set. The use of these alternative methods is successful and allows ventilation during the removal in contrast to removal by OFs. These should be kept as an option if retrieval is difficult.

Crossover Upper Pouch in Type C Esophageal Atresia: An Uncommon Variant Causing Diagnostic Dilemma

Esophageal atresia with tracheoesophageal fistula (EA-TEF) is a well-known congenital anomaly and Type C variety of gross classification is the most common. Even for Type C variety, anatomy of upper pouch and lower pouch is not always the same. We are presenting three cases of Type C EA-TEF with unusual anatomy. In this type, upper pouch crosses over the lower pouch for a significant length. The cases are described here to highlight this variant of Type C EA-TEF which produces diagnostic dilemma. An early diagnosis of this variant, prevents morbidity and mortality.

Comparison of the ProSeal laryngeal mask airway with the I-Gel™ in the different head-and-neck positions in anaesthetised paralysed children: A randomised controlled trial

Background and Aims:

Head and neck movements alter the shape of the pharynx, resulting in changes in the oropharyngeal leaking pressures and ventilation with supragottic airway devices. We compared the effect of the different head-and-neck positions on the oropharyngeal leak pressures and ventilation with the I-Gel™ and ProSeal™ laryngeal mask airway (PLMA) in anaesthetised paralysed children.

Methods:

A total of 70 children were randomly assigned to receive PLMA (n = 35) or I-Gel™ (n = 35) for airway management. Oropharyngeal leak pressure in maximum flexion, maximum extension and the neutral position was taken as the primary outcome. Peak inspiratory pressures (PIPs), expired tidal volume, ventilation score and fibreoptic grading were also assessed.

Results:

No significant difference was noted in oropharyngeal leak pressures of PLMA and I-Gel™ during neutral (P = 0.34), flexion (P = 0.46) or extension (P = 0.18). PIPs mean (standard deviation [SD]) were significantly higher (17.7 [4.03] vs. 14.6 [2.4] cm H₂O, P = 0.002) and expired tidal volume mean [SD] was significantly lower (5.5 [1.6] vs. 6.9 [2] ml/kg, P = 0.0017) with I-Gel™ compared to PLMA. Fibreoptic grading and ventilation score were comparable in both the groups in all the three head-and-neck positions.

Conclusion:

PLMA and I-Gel™, both recorded similar oropharyngeal leaking pressures in all the three head-and-neck positions. However, higher peak pressures and lower expired tidal volume in maximum flexion of the neck while ventilating with I-Gel may warrant caution and future evaluation.

Effects of intraoperative liberal fluid therapy on postoperative nausea and vomiting in children-A randomized controlled trial

BACKGROUND

Postoperative nausea and vomiting (PONV) is one of the most distressing complications following surgery. Supplemental perioperative fluid therapy might be an effective strategy to reduce PONV in children.

OBJECTIVES

The study was conducted to evaluate the effects of intraoperative liberal fluid therapy with crystalloids on PONV in children.

METHODS

In this randomized trial, a total of 150 children of 3-7 years undergoing lower abdominal and penile surgery under general anesthesia were randomly assigned into two groups. "Restricted group" received 10 mL kg^-1 h^-1 and "Liberal group" received 30 mL kg^-1 h^-1 infusion of Ringer's lactate solution intraoperatively. All patients received a caudal block and intravenous paracetamol for analgesia. No opioids and muscle relaxants were used. All episodes of nausea-vomiting and the requirement of rescue antiemetic were assessed during 24 hours postoperatively.

RESULTS

The incidence of PONV was significantly less in the liberal group patients as compared to the restricted group; 33 (45.8%) patients in the restricted group had vomiting as compared to 20 (27.4%) patients in the liberal group (RR 0.59, 95% CI: 0.38-0.93, P=.021). The adjusted odds ratio of PONV for the liberal group vs restricted group was 2.24 (95% CI: 1.12-4.48, P=.022). The incidence of fluid intake during the first 6 postoperative hours was significantly higher in the restricted group patients; 60 (83%) children in the restricted group complained of thirst as compared to 12 (17%) children in the liberal group (RR 0.19, 95% CI: 0.18-0.33, P=.0001). The parents of the liberal group were more satisfied as compared to the restricted group (mean difference -0.9, 95% CI: -1.8, -0.1, P=.04). None of the children had any complication attributed to the liberal fluid therapy.

CONCLUSION

Liberal intraoperative fluid therapy was found to be effective in reducing PONV in children undergoing lower abdominal surgery.

Pleomorphic Lipoma of the Neck in an Infant: A Rare Clinical Entity

Lipomas are rare in the pediatric age group. A 10-month-old male child presented with an asymptomatic neck mass which was evaluated and excised completely. Histopathology was consistent with pleomorphic lipoma, not previously reported in children.

Anorectal Malformations in Males: Pros and Cons of Neonatal versus Staged Reconstruction for High and Intermediate Varieties

BACKGROUND

High and intermediate types of anorectal malformations (ARMs) in male neonates may be managed either by primary neonatal reconstruction without colostomy cover or by traditional policy of staged reconstruction after neonatal colostomy. Posterior sagittal anorectoplasty (PSARP) is the current widely practiced reconstructive technique with varied results.

AIM

To assess our functional results of PSARP without colostomy in male neonates with high and intermediate ARMs compared to 3-stage (neonatal colostomy - PSARP - colostomy closure) methodology in a high volume tertiary care institution of a developing country.

PATIENTS AND METHODS

The number of colostomies performed for male high/intermediate anomalies and the number of babies who completed 3-stage reconstruction during a 10-year period is analyzed. The outcome of primary neonatal PSARPs during the same period was analyzed. Eighty primary PSARPs were compared to 81 staged reconstructions for outcome analysis, using Kelly score.

RESULTS

A total of 453 colostomies were performed, but only 253 of them completed all stages of reconstruction (52%). Good continence was achieved in 45% of cases of primary PSARP versus 26% in 3-staged surgery.

CONCLUSIONS

Primary PSARP in neonatal period without colostomy is a good option for high and intermediate ARMs in males if the treating surgeon is reasonably skilled in neonatal surgery and PSARP procedures.

Outcome of poorly functioning kidneys secondary to PUJO preserved by pyeloplast

AIMS

To study the intermediate term to long-term functional status of kidneys with split renal function(SRF) <15% secondary to PUJO which are preserved by pyeloplasty and to find out whether these kidneys can recover or eventually need nephrectomy.

METHODS

24 patients with SRF<15% and undergoing pyeloplasty with or without prior percutaneous nephrostomy (PCN) were studied. Those with associated VUR, B/L disease and redo pyeloplasties were excluded. Follow up USG and EC scan were done at 3, 9 and 18months and yearly thereafter to document functional status after surgery.

RESULTS

The preoperative SRF ranged from 0.6% to 15% with a mean of 10.61±5.23%. This improved in the postoperative period to a mean of 18.08±7.3%, 18.17±8.63% and 18.42±8.42% at 3months, 9months and 18months follow up respectively, indicating that the maximum improvement occurs early after relief of obstruction and then tends to stabilize or plateau.

CONCLUSIONS

We identified no patients who required nephrectomy. Hence, doing pyeloplasty directly for poorly functioning kidneys is much more feasible and PCN should be reserved for acute emergencies like pyonephrosis, grossly palpable kidney or gross hydronephrosis in both kidneys or a solitary kidney.

Evaluation of I-Gel™ size 2 airway in different degrees of neck flexion in anesthetized children - a prospective, self-controlled trial

BACKGROUND

A previous study by our group demonstrated an increase in oropharyngeal leak pressures and a deterioration of ventilation in maximum neck flexion with the I-Gel^™ . To ascertain the optimal degree of neck flexion which increases OPLP without compromising ventilation we conducted a prospective self-controlled trial with the I-Gel^™ in different degrees of neck flexion in anesthetized paralyzed children.

METHODOLOGY

The I-gel^™ was inserted in 60 children undergoing inhalation induction with muscle paralysis for routine general anesthesia. Recordings of peak inspiratory pressures (PIP) at flexion of 15°, 30°, and 45° were taken as the primary outcome. Expired tidal volume, ventilation scoring, fiberoptic gradings, and OPLP in different degrees of flexion were recorded as secondary outcomes.

RESULTS

There was a significant increase in mean PIP in cm H₂ O at flexion 30° [13.3 (95% CI 12.8-13.8) cm H₂ O, P < 0.001] and 45° flexion (16.5 [15.9-17.1] cm H₂ O, P < 0.001) compared to neutral. A decrease in the expired tidal volume was seen at flexion of 30° (7.6 [7.3-7.8] cm H₂ O, P = 0.00) and 45° (7.6 [7.3-7.8] cm H₂ O, P = 0.00). There was deterioration of ventilation score, mean [range] at 30° flexion 2[0-3], and 45° flexion 1[0-3] compared to the neutral 3[2-3]. There was a significant increase in OPLP with an increase in degree of flexion.

CONCLUSION

We conclude that 15° neck flexion can safely be applied without compromising ventilation with the I-Gel^™ in anesthetized paralyzed children. However, Flexion of 30° or more warrants caution or the use of alternative devices like an endotracheal tube due to increase in PIP and worsening of ventilation score.

Laparoscopic retrieval of unusual intra-abdominal foreign bodies in children

Foreign body (FB) ingestion is a common problem among the pediatric population. On numerous occasions, the FB is left to pass out spontaneously without expecting any harm. There are instances when the FB is either to dangerous to be left alone, that is a button battery or a sharp object. There may be FB, which is either stuck in GIT or have migrated. The situation in these instances demand active intervention. The traditional option has been laparotomy and retrieval. We present here three cases where two needles and a belt buckle were removed by laparoscopy thus avoiding a laparotomy. These cases prove that laparoscopy should be the first choice for such kind of retrieval. These cases had a successful outcome with full recovery.

Thoracoscopic repair of esophageal atresia with tracheoesophageal fistula: Basics of technique and its nuances

Aim:

To review the technique of thoracoscopic repair of esophageal atresia with tracheoesophageal fistula (TREAT) and results reported in literature and with authors’ experience.

Patients and Methods:

The technique of TREAT was reviewed in detail with evaluation in patients treated at authors’ institution. The patients were selected based on selection criteria and were followed postoperatively. The results available in literature were also reviewed.

Results:

A total of 29 patients (8 females) were operated by TREAT. Mean age was 2.8 days (range 2-6 days). Mean weight was 2.6 kg (range 1.8-3.2 kg). There was a leak in four patients, and two patients had to be diverted. They are now awaiting definitive repair. Twenty-one patients have completed a mean follow-up of 1.5 years and are doing well except for two patients who had a stricture and underwent serial esophageal dilatations. The results from current literature are provided in tabulated form.

Conclusions:

TREAT is now a well-established procedure and currently is the preferred approach wherever feasible. The avoidance of thoracotomy is a major advantage to the newborn and is proven to benefit the recovery in the postoperative patient. The technique demonstrated, and the tweaks reported make the procedure easy and is helpful to beginners. The outcome is very much comparable to the open repair as proven by various series. Various parameters like leak rate, anastomotic stricture are the same. The outcome is comparable if you TREAT these babies well.

Acetylcholinesterase histochemistry (AChE)--A helpful technique in the diagnosis and in aiding the operative procedures of Hirschsprung disease

Background

Hirschsprung’s disease (HD) is an anomaly characterized by the absence of myenteric and submucosal ganglion cells (GC) in the distal alimentary tract. Diagnosis of HD is made by the absence of GC and missing out on even a single ganglion cell can be very devastating. Acetylcholinesterase (AChE) histochemistry, done on frozen sections is said to be a very useful ancillary technique in the diagnosis and in aiding the operative procedures of HD.

Methods

To assess this, 73 samples from 42 suspected/known cases of HD were subjected to frozen section analysis with rapid haematoxylin and eosin, toluidin blue stain along with AChE histochemistry. The remnant sample was paraffin embedded for routine haematoxylin and eosin staining.

Results

On frozen section analysis, 33 samples showed absence of ganglion cells, AChE histochemistry showed a positive staining pattern in 17 samples and paraffin embedded routine, H&E stained sections showed absence of ganglion cells in 19 samples. Sensitivity and specificity of both tests ie frozen section rapid H&E/AChE histochemistry in the diagnosis of HD, were calculated taking paraffin embedded H&E stained sections as the gold standard. Sensitivity of frozen section rapid H&E in the diagnosis of HD is 57.57 % and specificity is 79.10 %. The p-value is <0.0001, which is significant. The sensitivity of AChE histochemistry in the diagnosis of HD is 90.47 % and specificity is 96.36 %. The p-value is <0.0001, which is significant.

Conclusions

Acetylcholineesterase (AChE) histochemistry is a very useful ancillary technique in the diagnosis and in aiding the operative procedures of HD. It acts as a double check in the diagnosis of HD.

Recto sigmoid bladder reservoir for patients with exstrophy: three dimensional evaluation for outcome analysis

OBJECTIVE

To report the results of recto sigmoid bladder reservoir (RSBR), a variant of ureterosigmoidostomy (US) in patients with bladder exstrophy (BE) using a three dimensional evaluation system.

PATIENTS AND METHODS

This was a predominantly retrospective evaluation for all patients of BE undergoing RSBR who had completed minimum of 1 year follow-up. The patients were evaluated using a three dimensional system which included evaluation of urinary continence per rectally, status of upper tracts and health related quality of life (HRQOL).

RESULTS

A total of 19 patients (four females) were evaluated. Mean age was 8.4 years, and mean duration of follow-up was 3.4 years. Mean age at RSBR was 5.1 years. Ten patients had good rectal continence. There was occasional minimal urine leak while passing flatus or on straining in nine. All patients had preserved renal function except one. The mean HRQOL score was 129.7 out of maximum of 150..

CONCLUSIONS

RSBR gives marked improvement in quality of life in patients of BE. In the literature there is a non-uniformity in the results reporting outcome of US. The presented three dimensional assessment provides a comprehensive way to report the results in the short/long term. If used by other surgeons it would make comparison across centers feasible.

An extremely rare case of classic complete caudal duplication: Dipygus

Dipygus is a complete caudal duplication deformity in its severest form. The structures derived from the embryonic cloaca and notochords are duplicated to various extent. We report a male baby who presented to us with complete somatic and visceral duplication below the umbilical level associated with gastroschisis and imperforated anus. Staged surgical corrections were suggested and three out of the four stages were performed successfully.

Risk of surgical site infection in paediatric herniotomies without any prophylactic antibiotics: A preliminary experience

BACKGROUND

Different studies underline the use of pre-operative antibiotic prophylaxis in clean surgeries like herniotomy and inguinal orchiopexy. But, the meta-analyses do not recommend nor discard the use of prophylactic pre-operative antibiotics. The scarcity of controlled clinical trials in paediatric population further vitiates the matter. This study assessed the difference in the rate of early post-operative wound infection cases in children who received single dose of pre-operative antibiotics and children who did not receive antibiotics after inguinal herniotomy and orchiopexy.

MATERIALS AND METHODS

This randomised prospective study was conducted in Paediatric Surgery department of PGIMER Chandigarh. Out of 251 patients, 112 patients were randomised to the case group and 139 were ascribed to the control group. The patients in control group were given a standard regimen of single dose of intravenous antibiotic at the time of induction followed by 3-4 days of oral antibiotic. Case group patients underwent the surgical procedure in similar manner with no antibiotic either at the time of induction or post-operatively.

RESULTS

The incidence of surgical site infection in case group was 3.73 % and that in control group was 2.22%. The observed difference in the incidence of surgical site infection was statistically insignificant (P value = 0.7027). The overall infection rate in case and control group was 2.89%.

CONCLUSIONS

Our preliminary experience suggests that there is no statistically significant difference in the proportion of early post-operative wound infection between the patients who received single dose of pre-operative antibiotics and the patients who received no antibiotics after inguinal herniotomy and orchiopexy. The risk of surgical site infection in paediatric heriotomies does not increase even if the child's weight is less than his/her expected weight for age.

Effect of propranolol vs prednisolone vs propranolol with prednisolone in the management of infantile hemangioma: a randomized controlled study

AIMS AND OBJECTIVES

The purpose of this study was to compare the efficacy of orally administered propranolol versus prednisolone versus both in the treatment of potentially disfiguring or functionally threatening infantile hemangiomas.

MATERIAL AND METHODS

A prospective study of 30 patients aged 1 week-8 months was randomized into three equal groups. These were as follows: A, propranolol (2-3 mg/kg/d); B, prednisolone (1-4 mg/kg/d); and C, receiving both for a minimum duration of 3 months. Dimensions, color, consistency, ultrasonography, photographic documentation based on Visual Analogue Scale (VAS) were recorded before and periodically after starting treatment. A minimum 75% improvement was considered as success with no regrowth up to 1 month of stopping treatment.

RESULTS

Mean initial response time (days) in A (4.1±3.3 SD) and C (4.7±3.4SD) was significantly lower than B (9.78±7.8SD) (p<0.047). Significant change in consistency was noted very early in A (24 hours) compared to B and C (8 days). VAS results are as follows: (a) color fading--significant reduction in A within 48 hours compared to B and C (p=0.025), (b) flattening--more significant and earlier in A and C than B (p<0.05), and (c) mean reduction in size: significant in A and C at 3 months (p=0.005, p=0.005), 6 months (p=0.005, p=0.008), 12 months (p=0.005, p=0.008), and 18 months (p=0.02, p=0.04), whereas in B, it was seen only at 6 months (p=0.008).

CONCLUSIONS

Propranolol had a consistent, rapid therapeutic effect compared to prednisolone. A combination of the two had a comparable but not higher efficacy than propranolol alone. Prednisolone was associated with a higher number of complications, thereby decreasing patient compliance.

Neonatal small intestinal zygomyocosis misdiagnosed as intussusception in a two-day-old child with a review of the literature

Neonatal mucormycosis is caused by fungi belonging to the class Zygomycetes. Clinically, it mimics necrotizing enterocolitis. We describe a case of 2-day-old baby who presented with abdominal distension and vomiting. A clinical diagnosis of intussusception was suspected. An exploratory laprotomy revealed gangrenous bowel wall and no intussusception or any gas-filled vesicles. Histological examination of the gangrenous segment showed transmural ischemic necrosis with fungal hyphae of zygomycosis. The baby is doing well postoperatively at a follow-up of 3 months. Hence, a high degree of clinical suspicion is important in neonates not responding to usual therapy or antibiotics.

Long segment jejuno-ileal duplication cyst with ectopic gastric mucosa detected on 99mTc-pertechnetate scintigraphy

Enteric duplication cysts (EDC) are uncommon congenital anomalies that may occur anywhere along the digestive tract. Ectopic gastric mucosa (EGM), another rare condition, is usually present as short segments in the small intestine and may be associated with EDC. Abdominal scintigraphy with 99mTc pertechnetate may be useful in the diagnosis, since the radiotracer is concentrated by functioning gastric mucosa. In this case report, the authors describe a child with a 150 cm long jejuno-ileal duplication cyst containing EGM identified by intense 99mTc pertechnetate uptake on scintigraphy without any pharmacological intervention.

Heterosexual precocity: rare manifestation of virilizing adrenocortical oncocytoma

Adrenocortical oncocytomas are extremely rare, and most of the tumors are benign and nonfunctioning. To our knowledge, only 30 cases have been reported in English published studies, and most patients are 40 to 60 years of age. So far, in the pediatric age group, only three cases of functioning adrenocortical oncocytoma have been reported. We report a case of functioning adrenocortical oncocytoma in a 3 1/2-year-old female child who presented with premature pubarche, clitoromegaly, and increased serum dehydroepiandrosterone sulfate and testosterone. She was managed successfully with right adrenalectomy, and the tumor histology was consistent with adrenal oncocytoma.

Vesicoureteral reflux: Endoscopic therapy and impact on health related quality of life

Aim:

To evaluate the health related quality of life (HRQOL) after endoscopic injection treatment for vesico ureteral reflux (VUR) in children.

Materials and Methods:

Fifty four children received treatment and were prospectively evaluated for their quality of life scores, according to resolution of reflux on cystograms and status of renal scars.

Results:

Of the 81 refluxing units, 72 (89%) had resolution of reflux whereas 9 (11%) did not resolve. The total average QOL was higher for the patients in the resolved group as compared to the non resolved group. Comparison of pre and post procedure renal DMSA scans in 44 patients showed status quo in 26, regression of scars in six, progression in two and formation of new scars in 6. The total increase in HRQOL was highest in regression group (67.91), and lowest in progression group (36.45).

Conclusions:

Successful endoscopic treatment of VUR is associated with improved quality of life, as indicated by higher HRQOL scores in the resolved group.

Isolated cystic cervical oesophageal duplication: a rare congenital anomaly

Oesophageal duplication is a rare congenital anomaly. The cystic form is the usual presentation of the duplication, found predominantly in the lower third. Less than 20 cases of isolated cystic oesophageal duplication in the cervical region have been reported till date in the English literature. We are reporting this case because of its rarity.

Hydronephrosis due to pelviureteric junction narrowing: Utility of urinary enzymes to predict the need for surgical management and follow-up

AIM

To study the role of urinary enzymes N-acetyl-β-glucosaminidase (NAG), alkaline phosphatase (AKP) and gamma glutamyl transferase (GGT) in the diagnosis and follow-up of patients with suspected pelviureteric junction obstruction (PUJO).

MATERIALS AND METHODS

A total of 70 patients, 29 managed conservatively (group A) and 41 managed by pyeloplasty (group B), were studied prospectively. A serial measurement of urinary enzymes NAG, AKP and GGT level was performed in both the groups. The mean levels of these urinary enzymes were compared between the two groups and among the patients of the same group at presentation as well as during follow-up.

RESULTS

There was a significant fall in the mean AKP level in patients managed conservatively at 8 months of follow-up. Similarly, in the operated group, there was a significant fall in the AKP levels at both 3 months and 8 months of follow-up. The mean level of GGT also showed a significant fall after 3 months of surgery but did not show further significant change at 8 months after surgery. The mean levels of NAG and GGT in the conservatively managed group were significantly low compared with that of patients requiring pyeloplasty at presentation as well as in the follow-up. The mean level of AKP was significantly low in the conservatively managed group when compared with the patients requiring surgery, but did not differ significantly in both the follow-ups after surgery.

CONCLUSIONS

The level of urinary enzymes NAG, AKP and GGT are significantly high in the patients with hydronephrosis (HDN) requiring pyeloplasty when compared with the patients managed conservatively. The level of AKP significantly falls after pyeloplasty in the patients of HDN due to PUJO. There is a negative correlation with the preoperative level of enzyme NAG with split renal function in the patients of HDN requiring pyeloplasty.

Management of esophageal atresia with a tracheoesophageal fistula complicated by gastric perforation

PURPOSE

Gastric perforations generally develop in neonates with esophageal atresia (EA) and a tracheoesophageal fistula (TEF), requiring preoperative mechanical ventilation. To the best of our knowledge, spontaneous gastric perforation in patients who have not been treated with mechanical ventilation has not been described in the literature. There is also no current consensus or treatment protocol available for the management of these patients.

METHODS

Over a period of 6 years, six patients with EA and TEF presented with gastric perforation at our center. We studied the clinical presentation, initial resuscitation, surgical management, and outcome of these six patients.

RESULTS

Out of the six patients, five were treated with initial flank drain insertion for peritoneal decompression. In all of the patients, a thoracotomy was performed first, followed by a laparotomy for closure of the stomach perforation. Four of the six patients survived and were discharged uneventfully. Two patients died of sepsis. Early feeding was established in all of the patients.

CONCLUSIONS

Spontaneous gastric perforation can occur in patients with EA and TEF even without mechanical ventilation. Initial stabilization with peritoneal drain insertion and subsequent thoracotomy for esophageal anastomosis followed by laparotomy for stomach repair, both done in a single sitting, should be the ideal management of such patients.

Surgical management and outcome analysis of stage III pediatric empyema thoracis

Aim:

Report of 125 pediatric patients of empyema thoracis treated by open decortication, highlighting the presentation, delay in referral, operative findings, the response to surgical intervention and follow-up.

Materials and Methods:

All the children who underwent open decortication for stage III empyema thoracis during the study period were included. Preoperative workup included hemogram, serum protein, chest radiographs and contrast-enhanced computed tomographic (CECT) scan of the chest.

Results:

One hundred and twenty-five patients (81 males, 44 females) (age 3 months–12 years, mean 4.9 years) were operated during a 4.5-year period. Among them, two children underwent bilateral thoracotomies. Also, 81.6% patients were referred 3 weeks after the onset of disease (mean duration 9 weeks). Intercostal chest drainage (ICD) had been inserted in (119) 95% cases. Thickened pleura, multiloculated pus and lung involvement were invariably seen on CECT scan. Bronchopleural fistula was present in 10 patients and empyema necessitatis in 2. Decortication, removal of necrotic tissue and closure of air leaks was performed in all the patients. Necrotizing pneumonia was seen in (35) 27.5% cases. Mean duration of postoperative ICD was 7 days. Follow-up ranged from 3 months to 4 years (mean 12 months). There was no mortality. Six patients had proven tuberculosis.

Conclusions:

The duration of the disease had a direct relationship with the thickness of the pleura and injury to the underlying lung. Delayed referral causes irreversible changes in the lung prolonging recovery. Only 18% presented within the early period of the disease. Meticulous open surgical debridement gives gratifying results. The status of the lung at the end of surgery is a major prognostic factor.

Scrotal abscess with a rare cause

A 4-year-old boy presented with a short history of right-sided acute scrotal pain and swelling. At exploration, pus was found in the hemiscrotum but no local cause could be found. Further exploration showed the pus coming through a patent processus vaginalis from a collection in the right iliac fossa secondary to acute appendicitis.

Gastric lipoma

We report a 12-year-old-boy with gastric lipoma. Upper gastrointestinal (GI) endoscopy with biopsy and abdominal computed tomogram (CT) scan revealed the diagnosis. Open surgical excision of the mass with stomach preservation was done. The clinical presentation and management are discussed and the literature reviewed here. This is the sixth pediatric case reported in the English literature.

Peripheral primitive neuroectodermal tumor of the chest wall in childhood: clinico-pathological significance, management and literature review

Peripheral primitive neuroectodermal tumor of the chest wall is a rare malignant tumor usually occurring in children. The tumor shares a similar histology, immunohistology and cytogenetics to Ewing's sarcoma. The location of the tumor in the chest wall poses a major challenge with respect to the diagnostic workup and treatment which involves multidisciplinary management. Neoadjuvant chemotherapy is given initially and is followed by complete surgical resectioning of the mass followed by repeat chemotherapy with or without radiotherapy. We report a case of peripheral primitive neuroectodermal tumor of the chest wall in a 5-year-old boy and review the literature regarding its diagnosis and management.

An unusual case of Erb's palsy in a neonate: a case report

Erb's palsy occurs in neonates following traumatic delivery, where excessive traction on the neck stretches these nerve roots. Nonobstetric causes of Erb's palsy are rare in neonates. The authors report the presentation of a female neonate with Erb's palsy following a postero-lateral thoracotomy. The infant underwent surgery on day 3 of life for esophageal atresia and presented with right upper limb weakness on day 21 of life. She demonstrated features of Erb's palsy with normal higher mental functions. An electromyography and nerve conduction study confirmed Erb's palsy. The surgical procedure in the index case did not involve the brachial plexus. However, her right upper limb was positioned hyperabducted during the intraoperative period, which possibly had led to the palsy. The key message of this report is that prolonged stretching of the brachial plexus roots during surgery of the neck and thorax can be an important nonobstetric cause of Erb's palsy in neonates.

Lumbocostovertebral syndrome with associated VACTERL anomaly

Lumbocostovertebral syndrome is a rare clinical association syndrome rarely accompanied by associated VACTERL anomalies. Only one similar case has been reported previously. We describe the second case, where a male neonate born at 38 weeks of gestation had an unusually high number of congenital anomalies including thoracic hemivertebrae with kyphoscoliosis, a high anorectal malformation, dextrocardia with an atrial septal defect, renal pelvic pyelectasis, hypospadias, and congenital talipes equinovarus.

Posterior urethral valves: Morphological normalization of posterior urethra after fulguration is a significant factor in prognosis

AIM

To assess the changes in urethral morphology 3 months post fulguration of posterior urethral valves (PUVs) on micturating cystourethrogram (MCUG) and correlate these changes with the overall clinical status of the patient.

MATERIALS AND METHODS

A total of 217 children, managed for PUVs during a period of 6 years in a single surgical unit were prospectively studied. The ratio of the diameters of the prostatic and bulbar urethras (PU/BU) was calculated on the pre- and post-fulguration MCUG films. They were categorized into three groups based on the degree of normalization of posterior urethra (post-fulguration PU/BU ratio).

RESULTS

GROUP A

Of the 133 patients, 131 had normal urinary stream and 4 (3%) had nocturnal enuresis. Vesicoureteral reflux (VUR), initially seen in 83 units (31% units), regressed completely at a mean duration of 6 months in 41 units (49%). Of the 152 non-VUR, hydroureteronephrosis (HUN) units, 11 were poorly functioning kidneys. Persistent slow but unobstructed drainage was seen in 23 units (16%) over a period of 1.5-5 years (mean 2.5 years). Group B: All the 11 patients had a normal stream. Four (36.4%) had daytime frequency for a mean duration of 1 year and one (9%) had nocturnal enuresis for 1 year. Grade IV-V VUR was seen in five patients (three bilateral), which regressed completely by 3 months in five units (62.5%). In the non-VUR, HUN patients, slow (but unobstructed) drainage was persistent in two units (14%) at 3 years. Group C: Of the 16 patients, only 5 (31.3%) were asymptomatic. Six patients (nine units) had persistent VUR for 6 months to 3 years. Of the 20 units with HUN, 17 (85%) were persistent at 1-4 years (mean 2 years). Eight patients (50%) required a second fulguration while 3 (18.7%) required urethral dilatation for stricture following which all parameters improved.

CONCLUSIONS

Adequacy of fulguration should be assessed by a properly performed MCUG. A postop PU/BU ratio >3 SD (1.92) should alert to an incomplete fulguration or stricture. Patients within normal range ratio have faster recovery of slow draining units, reflux and less voiding dysfunction. There is a strong correlation between incomplete fulguration and persistent slow draining units, uremia, voiding dysfunction and urinary tract infections.

Inflammatory pseudotumor of the omentum

Inflammatory pseudotumor is an unusual quasineoplastic lesion, of uncertain natural history and etiopathogenesis, which consists of inflammatory cells and myofibroblastic spindle cells; and is usually found in children and young adults. Clinical manifestations and radiological feature of this rare entity, can be indistinguishable from a malignant sarcomatous or lymphoproliferative disorders. Here, a case of surgically proven inflammatory pseudotumor of the omentum in a child and its review of literature is presented. Conservative surgery is curative in most cases of inflammatory pseudotumors. Awareness of this lesion is essential for clinicians, radiologists and pathologists, as pre-operative recognition may spare the child from unnecessary radical surgery or harmful chemoradiotherapy.

Rare case of pediatric cecal volvulus

An 11-year-old female child presented with abdominal pain, vomiting and constipation. An exploratory laparotomy revealed a cecal volvulus due to a congenital band and malfixation of the cecum. This was treated by excision of the band, derotation and decompression of cecum though an appendiceal stump suction.