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.

Mutational analysis of the betaglycan gene-coding region in susceptibility for ovarian failure

BACKGROUND

Elevation of FSH is frequently a consequence of impaired ovarian follicle growth. Down-regulation of the FSH levels by inhibins is mediated through its receptor betaglycan in the gonadotrophs. Understanding of germline status of the betaglycan gene (TGFBR3) is essential for ovarian failure pathophysiology.

METHODS

Sequence analysis was performed for the coding region of TGFBR3 gene in a cohort of 196 ovarian failure cases that include 133 premature ovarian failure (POF) cases, 63 primary amenorrhoea (PA) cases compared with 200 controls.

RESULTS

Forty-six variants including six novel exonic variants and 16 novel intronic variants were revealed. Two variants were missense: (i) p.Iso184Val in a control and (ii) p.Pro775Ser in a POF case. Genotypic distribution of three variants (c.382-81C>T, c.382-77T>C and c.1200G>A) was significantly different in the patients as compared with the controls. Five variants c.382-81C>T, c.382-77T>C, c.566-216G>A, c.1200G>A and c.2022T>C were chosen for haplotyping. The CCAAT haplotype was significantly higher in the patient population as compared with the controls (P = 0.00007).

CONCLUSION

This study establishes the first mutational report of the TGFBR3 gene in correlation with ovarian failure. Significant diversity of genotype distribution and haplotype analysis suggested susceptibility of the TGFBR3 gene for ovarian failure aetiology.

Management of accessory hepatic ducts in choledochal cysts

This report describes the surgical management of 2 children with fusiform choledochal cysts who had accessory hepatic ducts (AHD) identified during excisional surgery for fusiform choledochal cysts (CC). Two children presenting with a triad of recurrent jaundice, fever, and abdominal pain were investigated and found to have type 1 choledochal cyst. Preoperative imaging and intraoperative cholangiography missed the AHD in both cases. In one of the patients, the main and the accessory ducts were separated by the right hepatic artery. In both the patients the accessory ducts were reconstructed successfully into a Roux loop along with the main common hepatic duct. Follow-up studies showed no evidence of biliary tract obstruction or atrophic changes in the liver. There was satisfactory uptake and drainage on hepatic scintigraphy. During excision of CC, AHD may be encountered. These may be missed on preoperative imaging. AHD may have a close relationship with neighboring vascular structures in the porta. Accessory hepatic ducts should be anticipated, identified, and reimplanted into the Roux loop during excisional surgery.

Transcatheter coil embolization of a traumatic intrahepatic arterioportal fistula

Traumatic arterioportal fistulas are rare lesions in the pediatric age group. This case highlights the safe and effective management of intrahepatic arterioportal fistulas by transcatheter coil embolization.

Outbreak of Pichia anomala infection in the pediatric service of a tertiary-care center in Northern India

An outbreak of nosocomial fungemia due to the unusual yeast, Pichia anomala occurred in the pediatric wards of our hospital over a period of 23 months (April 1996 to February 1998). A total of 379 neonates and children (4.2% admissions) were infected. The probable index case was admitted to the pediatric emergency ward, with subsequent transmission to the premature nursery, pediatric intensive care units, and other children wards. Carriage on the hands of health care personnel was likely to be responsible for dissemination of the fungus. The outbreak could only be controlled after a health education campaign to improve hand-washing practices was instituted and after nystatin-fluconazole prophylaxis to all premature neonates and high-risk infants was introduced. In a case-control study, we identified a lower gestational age, a very low birth weight (<1,500 g), and a longer duration of hospital stay as significant risk factors associated with P. anomala fungemia in premature neonates. We conducted a culture prevalence survey of 50 consecutive premature neonates and found that 28% were colonized with P. anomala at a skin or mucosal site on the date of delivery and that 20% of these neonates subsequently developed P. anomala fungemia. We performed multilocus enzyme electrophoresis on 40 P. anomala outbreak isolates (including patient and health care workers' hand isolates), and the results suggested that these isolates were identical. Our study highlights the importance of P. anomala as an emerging nosocomial fungal pathogen.

Ectopic scrotum and patent urachus

Ectopic scrotum is a rare condition and has been reported in association with other urological abnormalities. We present a case with an associated patent urachus and a brief discussion on the possible mechanism to explain this deformation.

Blunt injury of the abdomen: a plea for CT

A 3-year-old boy was brought to the emergency unit 1 h following a deceleration injury. On clinical examination there were no signs of injury and US showed only free intraperitoneal fluid. The following morning, contrast-enhanced CT showed the right kidney did not enhance and delayed scans showed contrast medium in the renal vein. This is an indirect sign of post-traumatic renal artery occlusion. Failure to recognise this sign may have disastrous consequences in a patient with solitary kidney or bilateral renal artery occlusion. Contrast-enhanced CT scan remains the most widely available investigation for accurate staging of blunt renal trauma.

Enteric duplication cyst associated with melanosis peritonei

Melanosis peritonei is usually associated with benign cystic teratomas of the ovary. We describe a one-and-a-half-year-old girl with melanosis peritonei associated with enteric duplication cyst. Melanophages were seen in aggregates in and around the serosal blood vessels, nerve bundles, and scattered within the muscular wall of the cyst. Presence of hyperplastic nerve bundles associated with melanophages suggests their origin from the neural crest.

Partial nephrectomy in cystic partially differentiated nephroblastoma

Cystic partially differentiated nephroblastoma (CPDN) is an uncommon renal neoplasm in children. It is now recognized as a tumor with low but definite malignant potential. The authors report a patient that was treated with partial nephrectomy and chemotherapy with successful outcome. The literature on CPDN is briefly discussed.

Iatrogenic esophageal perforation during devascularization procedure managed with Thal wrap

We describe the successful use of 270 degrees Thal's partial fundal wrap to close an iatrogenic esophageal perforation in a patient who underwent devascularization and splenectomy after failure of sclerotherapy for bleeding esophageal varices.

Management of anorectal malformation in neonates

Anorectal malformations are one of the commonest anomalies in the new born. Major advances have been made in the last decade in operative techniques to reconstruct this abnormality. The final outcome in these babies is dependent on careful planning and operative intervention in the neonatal period. The purpose of this paper is to discuss the varied presentations of this anomaly, initial assessment and operative management with reference to our own experience.

Interaction between B.7 and CD28 costimulatory molecules is essential for the activation of effector function mediating spontaneous tumour regression

The spontaneous regression of a rat histiocytoma, AK-5, is mediated by activated natural killer cells through antibody-dependent cellular cytotoxicity. In addition to the Fc-FcR interaction between the target and the effector cells demonstrated previously, we show the participation of costimulatory molecules B7 and CD28 in the efficient killing of the tumour cell. Blockade of the costimulatory interaction in vivo using anti-CD28 led to increased tumour growth and a suppressed cytokine response. Anti-CD28 antibody administration in vivo also diminished the cytotoxic potential of NK cells against AK-5 cells in vitro. Our studies also demonstrate the expression of B7.1 and B7.2 antigen on AK-5 tumour cells. The cytotoxic activity of natural killer cells was significantly inhibited when the effector/target cells were cultured in the presence of antibodies raised against B7.1, B7.2 and CD28. Administration of anti-CD28 in vivo also affected the efficiency of the formation of effector/target conjugates in vitro. Similarly, anti-CD28 injections affected expression of the adhesion molecules LFA 1 and ICAM 1 by splenocytes. Administration of anti-B7.1 and B7. 2 antibodies in AK-5 tumour-bearing animals showed a differential response. The cytotoxicity of natural killer cells was significantly inhibited after anti-B7.2 administration, suggesting the preferential participation of B7.2 molecules in vivo. These observations suggest an important role for B7-CD28 interaction in AK-5 tumour regression.

Epispadias repair using the Mitchell technique

PURPOSE

The results of epispadias repair using Mitchell's technique in nine patients is analyzed and the advantages of the procedure discussed.

METHODS

Nine boys aged between 6 weeks and 6 years underwent epispadias repair between November 1996 and March 1998 (Penopubic epispadias, inferior vesical fissure, and midpenile epispadias, one patient each; exstrophy epispadias complex, six patients). Eight patients had first attempt at repair of epispadias. Two patients had closure of exstrophy and epispadias at one stage.

RESULTS

At a mean follow-up of 10 months, all children had a conical glans, eight patients had ventral orthotopic meatus, and one had coronal hypospadiac meatus. Minor penopubic fistula developed in one patient. Six patients had downward angled penis, and three had horizontal penis in a flaccid state. All children were observed to have good erections during sleep.

CONCLUSIONS

Mitchell's technique of epispadias repair allows an anatomic reconstruction of the penis with superior cosmetic and functional results. Long-term follow-up studies are necessary to evaluate the genital functions.

Choledochal cysts in infants and children

OBJECTIVE

To study the clinical spectrum and management of choledochal cyst in children below 12 years of age.

DESIGN

Descriptive study.

SETTING

Tertiary care hospital.

METHODS

Twenty three children with choledochal cysts were managed between January 1991 to September 1997 and their clinical details, investigations and management were recorded. Choledochal cyst was diagnosed by ultrasonography and confirmed by ERCP or peroperative cholangioram (POC) Children were treated with antibiotics and/or percutaneous transhepatic biliary drainage if there was cholangitis and subsequently subjected to surgery (excision of the cyst and jejunal loop interposition hepaticoduodenostomy).

RESULTS

The median age of these children was 3 years with an almost equal sex ratio. Predominant presentation was jaundice in 18, pain abdomen in 15, fever in 12, and lump abdomen in 9 cases. The classical triad of jaundice, pain and lump was present in only 4 cases. ERCP conducted in 7 and POC in 14 cases yielded positive findings in all. Clinically there were two distinct forms of presentation: (i) infantile form (< or = 1 year) comprised 9 infants which presented with jaundice in all, acholic stool in 6, lump abdomen in 4 but only one had classical triad; and (ii) childhood form (> 1 year) presented with pain abdomen in 12 and jaundice and cholangitis in 9 subjects each. Type I cyst was seen in 20 and type IVa in 3. Two children refused surgery, and the rest underwent surgery. Three infants died after surgery, the remaining 18 were alive and well on follow-up (median 25 months). Secondary biliary cirrhosis was seen in 6, extra hepatic biliary artresia in 2 and congenital hepatic fibrosis in 1 on histology.

CONCLUSIONS

Choledochal cysts present in two clinically distinct forms. Infantile form is an important cause of cholestasis of infancy. Early diagnosis and referral is essential to prevent complications and death, and prognosis after surgery is good.

Juvenile polyposis in a tropical country

The clinical profile, malignant potential, and management of 17 children with juvenile polyposis (more than five juvenile polyps) were evaluated clinically and endoscopically. Colonoscopy and polypectomy were done three weekly until colonic clearance was achieved, and thereafter two yearly. All polyps were subjected to histological examination. Mean age was 7.7 years, with a male preponderance (3:1). Presentation was with rectal bleeding (94%), pallor (65%), stunted growth (53%), and oedema (47%), and the mean (SD) duration of symptoms was 33 (27) months. None had a positive family history or any congenital anomaly. Two children had six polyps up to the transverse colon; the rest had numerous polyps all over the colon. All children had juvenile polyps on histology and 10 (59%) had adenomatous changes (dysplasia). Total colectomy was done in six for intractable symptoms. Colon clearance was achieved in eight after an average 3.4 polypectomy sessions, and three were still on the polypectomy programme. In conclusion, juvenile polyposis is commonly associated with low grade dysplasia. Serial colonoscopic polypectomy is effective but colectomy is required for intractable symptoms and when clearance of the colon is not possible.

Administration of anti-IL-12 antibody in vivo inhibits rejection of a rat histiocytoma and suppresses cytokine response in a tumour-bearing host

Activated macrophages are the major producers of heterodimeric cytokine interleukin-12 (IL-12). Earlier evidence suggested that early rejection of AK-5 tumours is mediated by IL-12 through interferon-gamma (IFN-gamma) production, involving activation of natural killer (NK) cells and upregulation of T-helper 1 (Th1)-type cytokine response. Injection of anti-IL-12 antibody into AK-5 tumour-bearing animals resulted in a large number of changes in the host immune response towards the tumour. These animals showed diminished NK-mediated antibody-dependent cell-mediated cellular cytotoxicity (ADCC) activity, down-regulation of Th1-type cytokine response, decreased anti-tumour antibody response ultimately leading to either delay or inhibition of the tumour-regression process. There was also increased production of IL-10 in the animals that had received anti-IL-12 antibody thereby resulting in the down-regulation of IL-2 and IFN-gamma production. IL-12 plays a major role in the activation of the different immune parameters responsible for early rejection of AK-5 tumour. We also studied the activation status of macrophages from tumour-transplanted animals and their ability to produce IL-12. Monocytes/macrophages from antibody-injected animals were less active and produced lower quantities of IL-12, IL-1 beta and tumour necrosis factor-alpha (TNF-alpha) as compared with the macrophages from AK-5 tumour-bearing animals.

Pathology of post meningitic hydrocephalus

Meningitis of bacterial (including tubercular) or non bacterial origin is a common and lethal infection of central nervous system in children. Although, with the use of modern medical facilities including antibiotics, the mortality rates of meningitis have decreased, yet the number of patients surviving with complications such as hydrocephalus have greatly increased. In this article the etiopathogenesis of post meningitis hydrocephalus has been reviewed. Effective use of appropriate antibiotics and shunt procedures have improved the outcome of post meningitic hydrocephalus of bacterial origin but the same is not true with that of fungal origin, which still carries high mortality and morbidity.

Effect of shunt surgery on spleen size, portal pressure and oesophageal varices in patients with non-cirrhotic portal hypertension

Shunt surgery is considered to be the treatment of choice in patients with non-cirrhotic portal hypertension. There is little data on the effect of side-to-side lieno-renal (SSLR) shunt on oesophageal variceal size, splenic size and splenic pulp pressure (SPP) in patents with non-cirrhotic portal hypertension. We evaluated pre- and postoperatively endoscopic grading of varices, splenic size and SPP for predicting shunt patency in 86 patients with non-cirrhotic portal hypertension: 56 with extrahepatic portal venous obstruction (EHPVO) and 30 with non-cirrhotic portal fibrosis (NCPF). The EHPVO patients with patent shunts (n = 47) showed significant reduction in SPP (pre-operative 43.56 +/- 7.9 vs postoperative 29.96 +/- 0.5 vs 0.92 +/- 0.8). Patients with blocked shunt (n = 9) did not show significant reduction in SPP and varices grades. However, there was reduction in spleen size (8.6 +/- 3.0 vs 6.3 +/- 4.3). In the NCPF group, 28 had patent shunts and showed significant reduction in SPP (46.3 +/- 13.5 vs 33.8 +/- 7.6 cm of saline), splenic size (9.1 +/- 3.3 vs 6.8 +/- 4.6 cm below costal margin) and varices grades (2.8 +/- 0.7 vs 1.05 +/- 0.96). As only two patients with NCPF had blocked shunts, no statistical comparison between patients with patent and patients with blocked shunts could be done. In conclusion, following SSLR, there is a significant reduction in SPP and varices grades in patients with patent shunts. Endoscopic grading of varices can be used to predict shunt patency. However, spleen size is not a good criteria for predicting shunt patency.

Renal failure following unilateral nephrectomy in Wilms tumour

A three year old male child with left sided Wilms tumour with vena caval involvement developed acute renal failure following nephrectomy. The likely etiology of acute renal shut down postoperatively and the relevance of differences in venous anatomy of the right and left kidneys in such a situation are discussed.

Aspiration cytology of Wilms' tumor

We reviewed the cytomorphologic features of fine needle aspiration biopsy (FNAB) smears from 15 cases of renal, extrarenal and metastatic Wilms' tumor. The findings were correlated with the histopathologic features. In cytology smears, blastemal cells were recognized in all cases. The following cell types were seen: epithelial cells, 60%; stromal component, 33.3%; tubular differentiation, 26.6%; and glomeruloid differentiation, 33.3%. FNAB smears of the metastatic lesions in the liver and of the primary lesions did not reveal any significant difference in cellular composition. Subcutaneous soft tissue metastasis from an anaplastic Wilms' tumor showed marked anaplasia and pleomorphism of blastemal cells along with frequent mitosis and bizarre tumor giant cells. Extrarenal Wilms' tumor showed only blastemal cells, though histopathology showed the classic triphasic pattern along with skeletal muscle differentiation. There were no complications attributable to the procedure. Recognition of these cellular components in FNAB smears will help in establishing an FNAB diagnosis of Wilms' tumor, particularly when preoperative chemotherapy is needed.

Side-to-side lienorenal shunt without splenectomy in noncirrhotic portal hypertension in children

Noncirrhotic portal hypertension is a common cause of upper gastrointestinal bleeding in infants, children, and adolescents in India. More than one major bleeding episode, severe hypersplenism, presence of fundal varices, rare blood group, remoteness from the hospital, and patient noncompliance to sclerotherapy formed the main indications for shunt surgery. One hundred four cases of noncirrhotic portal hypertension (age range, 18 months to 20 years) underwent side-to-side lienorenal shunt (SSLR) without splenectomy in a period of 15 years. Splenic veins varying in diameter from 4 to 18 mm and in length from 3 to 4 cm were skeletonized through the root of transverse mesocolon and a shunt of at least 1.5 cm in diameter was constructed. At a mean follow-up of 54 months, 87% of shunts were patent, 13% of shunts were blocked, and 2% were inadequate. Ten percent of the children had rebled, all of whom had a blocked shunt. Growth and development was normal and no patients developed encephalopathy. There was a good correlation between shunt patency on splenoportography and endoscopic disappearance of varices, reduction in the size of spleen and splenic pulp pressure, and improvement of hypersplenism.

Fine needle aspiration cytology of mesoblastic nephroma. A case report

A case of congenital mesoblastic nephroma of the left kidney was diagnosed in a 4-month-old child by fine needle aspiration cytology. The smears consisted of clustered and dyshesive spindle cells with minimal nuclear atypia and mitosis. No epithelial, tubular or glomeruloid differentiation was noted. Considering the age and cytomorphology, a diagnosis of mesoblastic nephroma was made. Histopathology of the nephrectomy specimen showed a tumor with features of atypical mesoblastic nephroma. Cytologic diagnosis of mesoblastic nephroma is important because the tumor has an excellent prognosis, and unlike Wilms' tumor, requires only surgery.

Malignant rhabdoid tumour of kidney. A case report

A case of malignant rhabdoid tumour of kidney is reported. Interesting features are bony metastasis at presentation and FNAB diagnosis of metastasis.

A randomized trial of fully intermittent vs. daily followed by intermittent short course chemotherapy for childhood tuberculosis

Fully intermittent short course chemotherapy regimens have been used successfully in adults but not in children. We report the results on 76 children with tuberculosis, excluding central nervous system tuberculosis and primary pulmonary complex. Isoniazid, rifampin and pyrazinamide were used for treatment. They were randomly allocated to Regimen A (52 doses) and Regimen B (94 doses). Overall efficacy of both schedules was greater than 95% in 27 children with lymphatic, 43 with pulmonary and 6 with disseminated tuberculosis. Compliance in 10 children after 2 to 4 months of therapy was poor because rapid improvement was mistaken by parents for cure. Two children died, probably of underlying lung disease. Follow-up for up to 2 years did not reveal any case of relapse or recurrence of the disease. Therapy for 6 months involving administration of only 52 or 94 doses of drugs was found to be economical, effective and safe for treating children with tuberculosis.

Role of fine-needle aspiration cytology in childhood malignancies

During the last 4 yr, fine-needle aspiration cytology (FNAC) has been employed in 1,474 patients in 0-15-yr age group at our institute. Of these, 245 patients were found to have malignant disease, including primitive neuroectodermal tumors, hepatoblastoma, nephroblastoma, sarcoma, and epithelial malignancies. Four metastases from medulloblastoma and two each from astrocytoma and meningioma were confirmed without open biopsy. FNAC interpretation was easy when cytologic findings were correlated with relevant clinical and radiologic data.

The clinical spectrum of anomalous pancreatobiliary junction

Anomalous junction of pancreatobiliary ducts (AJPB) is known to be associated with choledochal cyst and gallbladder cancer. This report describes our experience with eight patients with AJPB, six of whom were diagnosed at endoscopic retrograde cholangiography and two at transhepatic cholangiography. Four of the patients with AJPB had an associated congenital choledochal cyst, two had a normal biliary tree and one each had inspissated bile syndrome and cholangiocarcinoma. The last two associations have not been previously described. It is felt that the clinical spectrum of AJPB may unfold further with the widespread use of the cholangiographic techniques.