Non-operative management of giant omphalocele with topical povidone-iodine and powdered antibiotic combination: early experience from a tertiary centre

PURPOSE

The aim of the study was to evaluate topical povidone-iodine and topical powdered antibiotic combination (Polymyxin, Bacitracin and Neomycin) in initial non-operative management with delayed closure of the defect of giant omphaloceles.

METHODS

A prospective study was conducted between July 2010 and June 2013 including all neonates with giant omphalocele without signs of intestinal obstruction. All cases were managed by daily application of povidone-iodine (5% solution) followed by spraying topical powdered antibiotic combination to promote eschar formation and eventual epithelialisation. Record was made of sex, associated anomalies, length of stay, and thyroid function tests.

RESULTS

Twenty-four neonates with giant omphaloceles were treated with topical povidone-iodine and topical powdered antibiotic combination. No sac ruptures were observed in our series. All patients had a normal thyroid function test at presentation and after 10 days of initiation of treatment. Six patients have undergone delayed repair.

CONCLUSION

Topical povidone-iodine and powdered antibiotic combination promotes more rapid escharification and epithelialisation of the omphalocele than povidone-iodine alone. We also hypothesise that combination minimises the chances of hypothyroidism associated with use of povidone-iodine alone.

Clinico-immunological response to intratumoral versus intravenous neoadjuvant chemotherapy in advanced pediatric solid malignancies

Background:

There is minimal literature on the use of intralesional chemotherapy in the pediatric age group. We undertook this present study to evaluate the two modalities (intratumoral and intravenous) of giving chemotherapy in terms of toxicity of chemotherapy, hematological parameters, efficacy of chemotherapy in reduction in volume of the tumor as well as resectability of tumor with special emphasis on immunological parameters.

Materials and Methods:

Advanced cases of Wilms’ tumor and Neuroblastoma were included in the study. Intratumoral chemotherapy was given through 25 G spinal needle under aseptic precautions and ultrasound guidance in the same dose as in systemic chemotherapy. Intravenous group was given chemotherapy in the usual way. Reassessment was carried out after every course of chemotherapy.

Results:

Group A included 16 cases of Wilms’ tumor and 6 cases of neuroblastoma. In group B, there were 14 cases of Wilms’ tumor and 8 of neuroblastoma. Vomiting, diarrhea, mucositis, and thrombophlebitis were more common in the intravenous group (P<0.05). The fall in Immunoglobulin A, Immunogloblulin G, Immunoglobulin M, and T-cell rosetting was more common in the intravenous group (P<0.05). Seventy percent of patients had completely resectable tumor at the end of 6 doses of intratumoral chemotherapy as compared to 50% resectability in the intravenous group (P<0.05).

Conclusion:

Intratumoral chemotherapy, besides causing less of the adverse effects and increasing the resecability rate, also causes less suppression of the immune system. This may be offered as an alternative safe and effective modality of treatment for advanced solid tumors.

Hemangioma: review of literature

Hemangiomas are tumors identifed by rapid endothelial cell proliferation in early infancy, followed by involution over time. All other abnormalities are malformations resulting from anomalous development of vascular plexuses. The malformations have a normal endothelial cell growth cycle that affects the veins, the capillaries or the lymphatics and they do not involute. Hemangiomas are the most common tumors of infancy and are characterized by a proliferating and involuting phase. They are seen more commonly in whites than in blacks, more in females than in males in a ratio of 3:1.

Clinical spectrum of neural tube defects with special reference to karyotyping study

BACKGROUND

Neural tube defects are common congenital malformations of the central nervous system. Despite years of intensive epidemiological, clinical, and experimental research, the exact etiology of NTD remains rather complex and poorly understood. The present study attempted to look into the association of occurrence of NTD with reference to folic acid levels, along with karyotyping status.

MATERIALS AND METHODS

Detailed history was taken with emphasis on age of the baby and mother, parity, antenatal folic acid intake. Five milliliters of blood was drawn from all the babies and their mothers and divided equally in preheparinized vials (for karyotyping) and plain vials (for folic acid estimation). The total duration was 2 years.

RESULTS

The total number (n) in the study group was 75. The folic acid level was less in affected babies and their mother when compared to matched controls. Chromosomal defect was observed in nine of the 75 patients. Karyotyping defects were higher in children born to mothers of the age group 31-40 years and when their birth order was second.

CONCLUSION

Folic acid supplementation needs to be continued to prevent the occurrence of NTD, and the perinatal identification of NTD should alert one to the possibility of chromosomal abnormalities and prompt a thorough cytogenetic investigation and genetic counseling.

Stochastic behavior analysis of complex repairable industrial systems utilizing uncertain data

The purpose of this paper is to present a novel technique for analyzing the behavior of an industrial system stochastically by utilizing vague, imprecise, and uncertain data. In the present study two important tools namely Lambda-Tau methodology and particle swarm optimization are combinedly used to present a novel technique named as particle swarm optimization based Lambda-Tau (PSOBLT) for analyzing the behavior of a complex repairable system stochastically up to a desired degree of accuracy. Expressions of reliability indices like failure rate, repair time, mean time between failures (MTBF), expected number of failures (ENOF), reliability and availability for the system are obtained by using Lambda-Tau methodology and particle swarm optimization is used to construct their membership function. The interaction among the working units of the system is modeled with the help of Petri nets. The feeding unit of a paper mill situated in a northern part of India, producing approximately 200ton of paper per day, has been considered to demonstrate the proposed approach. Sensitivity analysis of system's behavior has also been done. The behavior analysis results computed by PSOBLT technique have a reduced region of prediction in comparison of existing technique region, i.e. uncertainties involved in the analysis are reduced. Thus, it may be a more useful analysis tool to assess the current system conditions and involved uncertainties.

Intralesional bleomycin in lymphangioma: an effective and safe non-operative modality of treatment

Introduction:

Lymphangiomas are benign hamartomatous lymphatic tumors. The mainstay of the therapy is surgical excision, but due to its infiltration along the nerves and muscles, total excision is not always possible. In the present study, we have evaluated the clinical profile of all the cases of lymphagiomas coming to our department and evaluated the efficacy of intralesional Bleomycin as a sclerosing agent in its management.

Materials and Methods:

In this prospective study, all patients were evaluated clinically and color Doppler ultrasonography (USG). The required dose was calculated as 0.5 mg/kg body weight, not exceeding 10 units at a time. The response was assessed clinically and on the basis of color Doppler USG.

Results:

Thirty-five patients of lymphangioma were included in the study. The neck region was the most common site of involvement. The response was excellent in 7 (20%), good in 26 (74.29%), and poor in 2 (5.71%) patients. The complications included fever, transient increase in size of swelling, local infection, intraluminal bleed, and skin discoloration in 10 patients.

Conclusion:

This therapy may be used as primary modality instead of surgery in selected group of patients.

Spectrophotometric, Fourier transform infrared spectroscopic and theoretical studies of the charge-transfer complexes between methyldopa [(S)-2 amino-3-(3,4-dihydroxyphenyl)-2-methyl propanoic acid] and the acceptors (chloranilic acid, o-chloranil and dichlorodicyanobenzoquinone) in acetonitrile and their thermodynamic properties

Methyldopa is a much used antihypertensive drug. It is the subject matter of study mostly for the determination and estimation of methyldopa in pharmaceutical properties. These considerations led us to study the charge-transfer interactions between methyldopa, a centrally acting antihypertensive agent of limited use with the known acceptors like o-chloranil (o-ClN), chloranilic acid (ClA) and dichlorodicyanobenzoquinone (DDQ). Methyldopa (MDP) formed beautifully colored complexes (having absorption maxima at 581 nm and 368 nm; 519 nm; 583.5 nm, 547 nm and 346 nm, respectively) with the acceptors mentioned before. The physico-chemical properties of the complexes were studied using UV-visible spectrophotometry and FTIR measurements. The composition, the accurate association constants and thermodynamics of the complexes were determined spectrophotometrically. Attempts were made to interpret the thermodynamics of complexes in terms of I(D)(V), E(A)(V) and hν(CT). Solid CT complexes between MDP+o-ClN, MDP+ClA and MDP+DDQ were prepared and FTIR spectra of the complexes were studied. The energies hν(CT) of the charge-transfer complexes and vertical ionization potential I(D)(V) of methyldopa were compared with the theoretical values of hν(CT) obtained from HOMO and LUMO of the donors and acceptors calculated using Density Function Theory utilizing different basis sets. The agreement between the results can be regarded to be reasonable. Oscillator strengths and dipole strengths of the complexes were determined theoretically and experimentally and the limitations of the calculations were outlined.

Unusual content of omphalocele: a congenital mature cystic teratoma of falciform ligament of the liver

Omphalocele is a congenital midline abdominal wall defect that results in herniation of intraabdominal contents covered by a lining of peritoneum and amnion. The severity of the defect often ranges from a minor herniation of the umbilical cord to a significant protrusion that includes large proportions of intestine and liver. We report unusual content of omphalocele that is congenital mature cystic teratoma of falciform ligament of liver which was confirmed by histopathology. This is a very uncommon entity and not described in world literature.

Surgical considerations in pediatric necrotizing fasciitis

BACKGROUND

Necrotizing fasciitis (NF) is a serious infection of soft tissues. This paper presents experience with pediatric NF and suitability of conservative surgery in its management.

MATERIALS AND METHODS

In this retrospective study, 70 patients of NF were managed during the study period of eight years. The study was divided into two time periods- first period (June 1998 to June 2001- group 1) and second period (June 2001 to June 2006- group 2). The parameters studied were age, sex, site of involvement and treatment. The treatment included intravenous antibiotics, supportive therapy and either aggressive (group 1) or conservative surgery (group 2).

RESULTS

Age of presentation ranged from 10 days to 11 years. Male to female ratio was 1.69:1. Back was the commonest site to be involved. Culture reports were polymicrobial in 70% with predominance of Staphylococcus species. Predisposing factors included malnourishment, boils, scratch injury, intravenous cannulation and injections. Conservative surgery had better outcome in terms of hospital stay, complications and cost of treatment.

CONCLUSION

NF is a serious and disease which requires immediate and all out attention. Early diagnosis, aggressive supportive treatment and conservative surgery improve survival.

Split notochord syndrome associated with dorsal neuroenteric fistula: A rare entity

Split notochord syndrome (SNS) is an extremely rare congenital malformation associated with anomalies of the vertebral column, gastrointestinal tract and central nervous system. Twenty cases of SNS associated with dorsal enteric fistula have been reported in literature till date. The present report describes a unique case of SNS associated with lumbosacral meningomyelocele, dorsal neuroenteric fistula and dorsal herniation of right kidney along with vessels. The neonate was well managed by excision of enteric fistula, closure of duramater of meningomyelocele and repair of posterior wall hernia after placement of kidney in renal fossa. This kind of entity is uncommon and not been reported earlier.

Atresia of ileocecal junction, ileocecal valve: Rare variants of bowel atresia

Atresia of ileocecal junction and isolated atresia of ileocecal valve are rare types of intestinal atresia with very few reports in literature. We report two such cases. Radiology showed dilated ileal segment and distal micro colon in both the cases. At laparotomy there was atresia of ileocecal junction in the first case and isolated ileocaecal valve atresia with normal ileocecal junction in the other case. Both the babies were managed by ileocolic resection with an end to end anastomosis. The prognosis of ileocecal atresias is satisfactory.

Sutureless skin closure with isoamyl 2-cyanoacrylate in pediatric day-care surgery

Importance of day-care surgery in pediatric age group is ever increasing and nowadays bulk of surgery is performed as a day-care procedure. Day-care procedure requires short intra-operative period and less postoperative complications. The introduction of tissue adhesive has been received enthusiastically since they may result in equivalent tensile strength-improved cosmetic appearance of the scar and lower infection rate when compared to sutures, staples and adhesive tape. We have used isoamyl 2-cyanoacrylate as a tissue adhesive for skin closure in day-care surgery. Novocryl is ideal for such procedure as it is a sterile, inert, non-toxic, biocompatible and bacteriostatic liquid topical skin adhesive containing isoamyl 2-cyanoacrylate formulation. We applied isoamyl 2-cyanoacrylate glue in 100 patients over skin cut margin after stitching subcutaneous tissue. Skin margin were held together by means of skin hook for 1-2 min. The cosmesis was better as there were no suture marks or lumpiness. There were no major complications in our study. Thus, isoamyl 2-cyanoacrylate can be considered as an alternative to skin suturing in the pediatric day-care surgery.

Conservative management of ulcerated haemangioma--twenty years experience

Ulceration is the most common complication of haemangioma and occurs in 5-15% of cases. The present study was carried out to evaluate the clinical features of ulcerated haemangioma and efficacy of the management protocol adopted by us over a period of 20 years. All patients with ulcerated haemangioma were evaluated on the basis of age at presentation, sex, rural or urban distribution and site of haemangioma. Treatment included application of topical antibiotic and systemic antibiotic and analgesic for pain. The total number of patients was 608. The male to female ratio was 1: 2.28. The rural:urban distribution was 2.43:1. The most common site of involvement was head and neck. Mean age of patients was 5.60 +/- 2.44 months. Mean size of haemangioma and ulceration was 47.30 +/- 20.67 cm(2) and 7.49 +/- 4.52 cm(2), respectively. The mean time for ulcer healing was 40.06 +/- 19.41 days. Ulcer size of more than 10 cm(2) took more time to heal. Response to treatment was satisfactory. Ulcerated haemangioma usually occurs before completion of 1 year of age; hence, every patient with haemangioma needs careful attention. Adequate treatment and regular follow up brings satisfactory response in the patients.

An unusual presentation of hydatid cyst in anterior abdominal wall

Hydatid disease is a parasitic infestation caused by the larval form of the cestode worm Echinococcus. The most commonly encountered form of the disease is visceral hydatid cyst caused by Echinococcus granulosus or dog tapeworm. Muscular involvement has been reported in only 3-4% cases. We are reporting this case because of its rarity, difficulty to diagnose clinically, dramatic response to medical treatment and to alert the reader of this rare infestation so that open biopsy will be avoided.

Twenty years' experience of steroids in infantile hemangioma--a developing country's perspective

BACKGROUND

Hemangioma is a common vascular tumor. Though it involutes spontaneously, results are unpredictable. Steroid therapy is an effective mode of its regression. We present our experience of largest series and possible recommendations for treatment.

MATERIALS AND METHODS

A total of 2398 patients were treated during the study period of 20 years. They were given oral prednisolone, intralesional triamcinolone, or combination of both as per the protocol and followed for the response. Response to the treatment was graded as excellent, good, poor, or no response.

RESULTS

The male-to-female ratio was 1:2.3. In 81% of patients, hemangioma was noticed within first month of life. The commonest site of involvement was head and neck (57%). The commonest clinical presentation was discoloration and swelling. Mean age and size were 8.43 +/- 7.04 months and 23.64 +/- 20.13 cm(2). Response rate was highest for superficial type using any modality of treatment. Patients younger than 1 year showed better response (90.3%) in comparison with children older than 1 year (80.8%). The specific complications occurring were infections in 249 (12.4%), cushingoid facies and growth delay in 62 (3.1%), and hypertension in 51 (2.5%) patients.

CONCLUSION

Steroid therapy either oral or intralesional as per the requirement is an easy and safe modality. Results are good to satisfactory in most patients. The complications are minimal. If treatment is needed, it should be used as a first-line therapy, especially when cost is an important concern.

Histology of the terminal end of the distal rectal pouch and fistula region in anorectal malformations

OBJECTIVE

Until recently, surgeons have been posed with a dilemma---whether or not they should preserve the terminal end of the distal rectal pouch and the fistula region in anorectal malformations (ARMs). A detailed histological study of this region was conducted to establish a consensus for preserving or excising this region for reconstruction of ARMs.

METHODS

Histopathological examination using haematoxylin and eosin-stained sections of the terminal portion of the distal rectal pouch and proximal portion of the rectourogenital or rectoperineal connection was performed in 60 cases of high, intermediate and low ARMs.

RESULTS

Distorted internal sphincter was present in 93.3% of high, 90% of intermediate and 100% of low ARMs. The proximal fistula region was lined by transitional epithelium in 50% of cases, and anal glands were present in 83.3% and anal crypts in 68.3% of cases. The rectal pouch in the region of the internal sphincter and fistula was aganglionic in all cases.

CONCLUSION

This study shows that the terminal end of the distal rectal pouch and proximal fistula region possess distorted anal features with aganglionosis, and contradicts the recommendation that this region should be reconstructed in patients with malformations.

Anterior intratumoural chemotherapy: a newer modality of treatment in advanced solid tumours in children

OBJECTIVE

Advanced and inoperable solid tumours in children have high mortality despite aggressive multimodal treatment. Intravenous chemotherapy is abandoned at times because of systemic toxicity. This study investigated intratumoural chemotherapy and compared it with intravenous chemotherapy.

METHODS

Forty children with advanced inoperable solid tumours (Wilms' tumour and neuroblastoma) were randomly allocated into two groups of 20. Group A was given intratumoural chemotherapy and group B was given intravenous chemotherapy. Both groups were compared for reduction in tumour size and volume, tumour resectability, histopathological changes and drug side effects.

RESULTS

Intratumoural chemotherapy was superior to intravenous chemotherapy in terms of reducing tumour size and volume (63% in group A vs. 22% in group B). The resectability was 70% in the intratumoural group compared with 40% in the intravenous group. The overall good histopathological response was 71% in group A as opposed to 0% in group B. Moreover, the incidence and severity of drug side effects and morbidity were less with intratumoural chemotherapy. Mortality was also low in group A (5%) compared to group B (20%).

CONCLUSION

Intratumoural chemotherapy can be offered as an effective and safe alternative treatment modality for advanced and inoperable Wilms' tumour and neuroblastoma.

Quantification of groundwater recharge in a hard rock terrain of Orissa: a case study

A study was carried out to select the best method to estimate groundwater recharge in a hard rock terrain. Various standard empirical methods, soil-moisture balance method, water table fluctuation (WTF) method and commonly adopted norms set by Groundwater Estimation Committee (GEC), Govt of India were used to estimate recharge for the Munijhara watershed in the Nayagarh block of Orissa (India). The empirical formulae gave recharge rates ranging from 13 cm to 32 cm/year with average of 22.4 cm and standard deviation of 5.34, independent of other influencing factors like soil, topography and geology. The soil-moisture balance study indicated that recharge is more dependent on the continuous heavy rainfall total annual volume of rainfall. Recharge was limited at up to 10 mm per day, possibly due to presence of hard rock below the soil surface. The rise in water table depth was 3.45 m to 5.35 m with a mean rise of 4.5 m during the year 2006-2007. Annual groundwater recharge based on the WTF approach varied from 10.3 to 16.85 cm with a mean of 13.5 cm, standard deviation of 1.57 cm and coefficient of variation 11.57%. This recharge accounted for 8 to 14% of rainfall received. With a water budget approach based on GEC norms, recharge was calculated as 17 cm per year. The study showed that the magnitudes of annual groundwater recharge as estimated by the WST method and GEC norms are in conformity with other recent findings in India under the same climate conditions. Based on the results recharge structures could be planned in suitable locations to reduce fallow areas under the watershed.

Placement of the peritoneal end of a ventriculoperitoneal shunt in the suprahepatic space: does it improve prognosis?

INTRODUCTION

Hydrocephalus is a common pediatric problem. Ventriculoperitoneal shunts (VPS) are the most frequent operative procedures used to treat hydrocephalic children. The peritoneal end is usually placed in the general peritoneal cavity. We present an alternative site of peritoneal end placement in the suprahepatic space in an attempt to reduce the abdominal complications.

MATERIAL AND METHODS

All patients with a diagnosis of congenital hydrocephalus were included in the study. In group 1, the lower end of the VPS was placed in the suprahepatic space. Patients were evaluated for abdominal complications like pseudocyst formation, intestinal obstruction and blockage of the lower end of the VPS. The data were compared with those patients in whom the peritoneal end was placed in the general peritoneal cavity (group 2).

RESULTS

The total number of patients in groups 1 and 2 was 133 and 175, respectively. Complications in group 1 were dislodgement of the shunt in the general peritoneal cavity in 28 (21.05%), suprahepatic pseudocyst formation in 2 (1.5%) and blocked lower end in 2 patients (1.5%). In group 2, complications noted were pseudocyst formation in 5 (2.8%), blocked lower end in 25 (14.2%), intestinal obstruction in 9 (5.1%), inguinoscrotal migration in 10 (5.7%) and perforation of viscera in 6 patients (3.4%). The overall follow-up period ranged from 1 to 7 years.

CONCLUSIONS

Placement of the lower end of the shunt in the suprahepatic space can be advantageous to placing it in the general peritoneal cavity. The procedure is simple and results can be rewarding.

Neonatal surgery: a ten year audit from a university hospital

Neonatal surgery is the flagship and most challenging component of pediatric surgery, which is the youngest subspeciality of surgery. Neonatal surgery carried a survival rate of only 30% three decades ago. In the last decade there has been a significant change in the scenario. Earlier recognition and referral of these anomalies, availability of neonatal intensive care, better preoperative planning, decision, and techniques have lead to the change in the management. This is an audit into the outcome of neonatal surgery from one of the largest units in India over a ten year period. This audit reveals an across the board survival of 65-70% newborns after surgery on nearly two thousand case over a ten year period. It has an important message that while pediatric surgery units expand, risk stratification of surgical newborns and their treatment in suitable units is mandatory to maintain and improve these figures to match international standards over the next decade.

Juvenile polyposis syndrome

AIM

Report of a series of 12 cases of juvenile polyposis coli.

METHODS

The study period was from 1995 to 2005. All the patients were treated by total colectomy with rectal mucosectomy and endorectal ileoanal pullthrough with or without ileal pouch formation. Covering ileostomy was avoided in all the cases. Time taken for the surgery, postoperative complications and continence were documented.

RESULTS

The mean operating time was 4.2 h (range: 4-5 h). The mean duration of hospital stay was 16.3 days (range: 15-18 days). The most common postoperative complication was pouchitis and perianal excoriation. Initially, all the patients were passing stools at an interval of 2 h, and after 3 weeks, the frequency has reduced to 6-8 stools per day. In the follow-up after 3 months, the frequency was 3-5 per day with minimal soiling.

CONCLUSIONS

Single-stage total colectomy with rectal mucosectomy and endorectal ileoanal pull-through without covering ileostomy and pouch formation is a safe and definitive treatment for juvenile polyposis coli if the patient selection is appropriate.