Is single incision pediatric endoscopic surgery more painful than standard laparoscopy in children? Personal experience and review of the literature

AIM

It has been speculated that single incision pediatric endoscopic surgery (SIPES) in children could result in more postoperative pain given the device size for a child umbilicus. Herein, we compare the postoperative pain in children who underwent SIPES or standard laparoscopy (SL).

METHODS

Patients who underwent SIPES via Olympus TriPort™ Access system between 2010 and 2011 were prospectively compared with SL controls (similar age, sex and type of operation). Primary endpoint was analgesic requirement (number of doses and dose/kg). A systematic review of the literature included all articles (2008-2012) comparing postoperative pain following transumbilical SIPES and SL in children. Data were analyzed using non-parametric tests.

RESULTS

Ten patients (8 males, median age 9 years, range 4-15) underwent 11 SIPES procedures: appendicectomy (N.=6), orchidopexy (N.=2), cholecystectomy (N.=2), and total colectomy (N.=1). There was no difference in paracetamol requirement between SIPES (median 74 mg/kg, range 14-149) and SL (median 59 mg/kg, range 13-108, P=0.76) patients. Morphine was required by only two patients per group (no difference in dosage or frequency). Eight studies (2010-2012) comparing 334 SIPES vs. 343 SL patients were analysed. Three studies showed advantage of SIPES, and four no difference between SIPES and SL. One randomized trial reported greater pain in SIPES appendicectomy, but no difference with SL once patients were discharged home.

CONCLUSION

SIPES does not seem to be associated with more postoperative pain than SL in children. In appropriate cases, SIPES is a valid alternative to SL for a good range of pediatric procedures.

Evidence for medium chain triglycerides in the treatment of primary intestinal lymphangiectasia

Primary intestinal lymphangiectasia is an uncommon congenital anomaly. It is an intrinsic abnormality of the intestinal lymphatics system. Over the years, various treatment options such as diuretics, albumin transfusions and a medium chain triglycerides (MCT) diet as well as surgical options such as resection of isolated segments and peritoneal-venous shunts have been used. An MCT diet, which is a low fat, high protein diet, is increasingly used in the management of this anomaly.

AIM

The aim was to review the evidence for medium chain triglycerides as a therapeutic option in patients with primary intestinal lymphangiectasia.

MATERIAL AND METHODS

A literature search was performed and individual case details were extracted. We found 55 cases, of which 3 were from our own institute. The cases were divided in 2 groups: Group A (n=27) consisted of patients treated with MCT, and Group B (n=28) consisted patients not treated with MCT. Cases were analysed for symptomatic response to MCT as well as mortality.

RESULTS

17 of 27 cases (63%) treated with MCT had complete resolution of symptoms while only 10 of 28 (35.7%) patients in group B showed complete resolution. Mortality for Group A was 1 out of 27 (3.7%), while mortality in group B was 5 of 28 (17.85%) patients.

CONCLUSION

We conclude that, although an MCT diet is not completely curative in all cases, it does improve the symptoms of primary intestinal lymphangiectasia and reduces mortality. Hence it is a valid option in the paediatric age group.

Brain biopsy in Creutzfeldt-Jakob disease: evolution of pathological changes by prion protein immunohistochemistry

The formation of protease-resistant prion protein (PrPsc) is considered to be an early event in the pathogenesis of Creutzfeldt-Jakob disease (CJD) and hence its demonstration in brain biopsies by immunohistochemistry is considered diagnostic. We analysed eight brain biopsies from the frontal cortex collected from different parts of India from cases diagnosed as CJD on clinical and pathological grounds for the expression of prion protein (PrP). The duration of illness in these cases varied from 2 months to 1 year. Immunohistochemistry was carried out on paraffin sections using two different clones (KG9 and 3F4) of monoclonal antibodies to PrP. Although all eight cases showed classical features of spongiform encephalopathy of varying severity, only five of the eight cases revealed PrP(sc) in the brain tissue. The immunolabelling was focal and all areas with spongiform change were not labelled. A temporal evolution in the staining pattern was evident - particulate diffuse labelling (synaptic type) in early stages (2 months), perivacuolar deposits in intermediate stages (5-6 months), and dense plaques in late stages (12 months).

Endometrial stromal sarcoma with sex-cord like features

Endometrial stromal sarcomas are rare, low grade, malignant uterine tumours. Sometimes, they manifest an epithelial like or sex-cord like differentiation. This is a report of one such case in a 35 year old female.

Tuberculoma in the Meckel's cave: a case report

A case of an intracranial tuberculoma located within the confines of the Meckel's cave is presented. The patient was young, non-immunocompromised and otherwise in good health. The granuloma mingled with the fibres of the trigeminal nerve. The lesion mimicked a trigeminal neurinoma in its clinical presentation, preoperative investigations and intraoperative consistency and vascularity. The rarity of the location and possible mode of transmission of infection to this site is discussed. The literature on this subject is briefly reviewed.

Malignant melanotic neuroectodermal tumour of infancy affecting the occipital squama

An unusual case of a melanotic neuroectodermal tumour of the occipital squama, which underwent malignant transformation in a nine-month-old infant is reported and pertinent literature reviewed.

Cutaneous blastomycosis. Report of a case with diagnosis by fine needle aspiration cytology

BACKGROUND

Blastomycosis is rare in India. Clinically, cutaneous blastomycosis may be mistaken for keratoacanthoma, squamous cell carcinoma, tuberculosis, tertiary syphilis, leprosy or pyoderma.

CASE

A 19-year-old male presented with a soft, fluctuant swelling at the medial canthus of the eye. Fine needle aspiration biopsy (FNAB) showed many single, spherical structures with thick walls. They had basophilic protoplasm and six nuclei in the center. A few of them showed budding with a broad base.

CONCLUSION

The cytomorphology of Blastomyces dermatitidis is characteristic, and the organism can be differentiated from other yeast forms. The disease is sensitive to antifungal imidazole derivatives and can be cured.

Fallopian tube carcinoma--a report of two cases

Primary adenocarcinoma is a rare tumour involving the fallopian tube. Two such cases are reported; the first case was associated with papillary carcinoma of the paratubal cysts and the second occurred in a young female.

Aspergilloma in the paracavernous region--two case reports

A 30-year-old male and a 40-year-old female presented with Aspergillus fungal granuloma in the cerebral locations involving the gasserian-ganglion and its divisions in one case and was densely adherent to the lateral dural wall of the cavernous sinus in the other. Both patients were otherwise healthy with no evidence of immuno-suppression. The lesions resembled benign tumor on preoperative imaging and intraoperative consistency and vascularity. The lesions were successfully and completely resected. Both patients developed major cerebral arterial territory infarcts in the postoperative phase, remote from the site of operation, leading to crippling neurological deficits in one patient and death in the other. The unusual location and the unusual and similar clinical course suggests that awareness of the possibility of ischemic complications after surgical resection of intracranial aspergillomas is necessary.

Large optic nerve glioma

Twelve cases of optic nerve glioma seen over a 28 year period are analysed herein in this autopsy study.

Extensive extraaxial blastomycosis granuloma at the skull base--case report

A 37-year-old female presented with a rare case of intradural, extraaxial Blastomyces dermatitidis granuloma involving a large part of the skull base. She had the principal complaint of worsening vision, but was otherwise healthy. The lesion mimicked an en-plaque meningioma on radiological examination and in gross appearance during surgery. This is a very unusual presentation for a blasto-mycosis granuloma.

Hemangiopericytoma of the kidney

The diagnosis and management of a thirty year old male with a hemangiopericytoma of the kidney is reported.

Rectal duplication

Duplications of the alimentary tract are of a great rarity, particularly so in the rectum. Because of its rarity, the difficulty of making a correct diagnosis and of selection of proper approach for treatment, this entity bears a special significance. The present case report deals with a female newborn who presented with imperforate anus and a rectovestibular fistula and a mass prolapsing at the introitus. Complete excision of the mass was carried out through the perineal approach and the child then underwent, a PSARP for the correction of the rectal anomaly. Histology confirmed the mass to be a rectal duplication.

Intraparenchymal schwannoma of the frontal lobe

A 45 year old woman with bifrontal headaches and progressive diminution in vision over 6 months was found to have bilateral papilloedema. CT scan showed large right frontal lesion with surrounding oedema. Right basal frontotemporal craniotomy was performed to excise the multinodular, intraparenchymatous tumor. Hispathology confirmed the diagnosis of schwannoma. Post-operative course was uneventful with disappearance of pre-operative signs and symptoms.

Brain abscess caused by Cladosporium trichoides

Brain abscess caused by the fungus Cladosporium trichoides is rare. Only 20 cases of brain abscess caused by this fungus are reported in the literature. We report a case of brain abscess caused by Cladosporium trichoides in a healthy adult male. The relevant literature on this subject is reviewed.

Intracranial haemorrhage and death after iohexol myelography

Images

Peripheral nerve sheath tumours: an ultrastructural study of 30 cases

This report deals with the ultrastructural observations of 30 peripheral nerve sheath tumours [PNST], which include 25 schwannomas of acoustic nerve, one schwannoma of cauda equina, one neurofibroma from a case of Von Recklinghausen's disease, one pigmented neurofibroma of spinal nerve root and a malignant schwannoma of frontal region. Interdigitating slender cytoplasmic processes covered with a continuous layer of basal lamina constitute the single most important ultrastructural attribute of Schwann cells. Myelin formation was encountered in the cell processes of four out of 25 acoustic schwannomas. In four cases Microtubular arrays identical to that in an axon were seen in Schwann cells. These two observations require further support by additional cases of PNST studies by electron microscopy. The neurofibroma consisted only of Schwann cells and no ultrastructurally identifiable perineurial cells or fibroblasts were detected. The cells in the pigmented neurofibroma revealed submicroscopic features of both Schwann cell and melanocyte, indicating their common ancestry. A unique case of malignant schwannoma arising from frontal meninges is illustrated and it is emphasized that electron microscopy is mandatory for a correct histogenetic diagnosis of malignant tumours which occur at unexpected anatomical sites.

Methyl alcohol poisoning: an autopsy study of 28 cases

Twenty eight fatal cases out of the 97 cases of methyl alcohol (MA) poisoning admitted to K. E. M. Hospital in August 1988 during a single outbreak were studied. The latent period between consumption of the drink and development of symptoms was variable (range 7 1/2 hours to 60 hours). CNS symptoms were predominant (75% of cases) and shock either at admission or as a late event was seen in 89% of the cases. Blurring of vision was seen in 42.8% and blindness in 10.7% of cases. Minimum fatal period was 7 1/2 hours and maximum was 12 days. Methanol levels in blood and viscera were variable (average 155.8 mg%, max. 420.4 mg%). In 4 cases, significant amount of MA was detected in stomach contents 5-12 days after consumption of MA, raising the question of resecretion of MA in stomach. Shrinkage and degeneration of neurons in the parietal cortex was seen in 85.7% of cases. Putamental degeneration and necrosis was seen in 7.14%. Haemorrhage (3.5%) and sponginess (7.14%) was observed in the optic chiasma. Severe renal tubular degeneration and patchy necrosis was seen in all cases. Fatty changes (67.8%) and microvesicular fat (42.5%) were seen in the hepatocytes.

Intracranial ectopic pituitary tumour

Pituitary tumours originating primarily from sites other than the sella turcica are rare. A case of an ectopic pituitary tumour in the region of the lesser wing of the sphenoid is reported. The patient presented with signs and symptoms of a progressive increase in intracranial pressure. CT scan appearances resembled those of a sphenoid wing meningioma. The vascular lesion was partially excised. Histology showed it to be a pituitary tumour.

Profile of congenital cholesteatomas of the petrous apex

Congenital cholesteatomas of the petrous apex are now frequently being approached by otologists. Involvement of the cerebello pontine angle by this lesion produces a myriad of signs and symptoms. Otological as well as neurosurgical literature is reviewed to achieve an overall understanding of the nature and behaviour of this uncommon but interesting lesion.

Differences in infant mortality and their implications for policy

"This note tries to identify a few social and environmental factors that explain variation in infant mortality among some of the developing and developed countries of the world. Using the data of the Population Reference Bureau's World's Children Wall Chart, the authors have shown that access to drinking water supply is important as a single factor in reducing infant mortality. But adult female literacy and percentage of the labour force engaged in agriculture are more important. Female literacy has turned out to be the most crucial factor irrespective of the development status of the countries."

Radiation induced sarcoma

A case of radiation induced sarcoma presenting seven years after radiotherapy for a conus cauda equina astrocytoma is reported.

Death following external carotid artery embolization for a functioning glomus jugulare chemodectoma. Case report

A 24-year-old man with left sixth through twelfth cranial nerve palsies and severe, fluctuating, systemic arterial hypertension was found to have a large, vascular, catecholamine-forming glomus jugulare chemodectoma. After his electrolyte imbalance was corrected, left external carotid embolization (using Gelfoam) was carried out. The systemic blood pressure stabilized at around 160/100 mm Hg over the next 12 hours. Ten hours later the hitherto conscious patient developed acute arterial hypotension, lapsed into coma, and died. Autopsy showed tumor infarction, swelling, cerebellar tonsillar herniation, and medullary compression. An unusual complication of glomus tumor embolization is highlighted. The roles of preliminary decompressive surgery and urgent resuscitation by vasopressors are discussed.