Management of Symptomatic Meckel's Diverticulum in Infants and Children

Objectives The primary objective of the present study was to review the demographics of infants and children operated upon for Meckel's diverticulum. The secondary objectives were to review the clinical characteristics, surgical procedures performed, postoperative complications, and the outcome.

Materials and Methods This study is a single-institutional, retrospective study and descriptive in nature. It consisted of infants and children below 12 years who were operated upon for Meckel's diverticulum. This study was conducted at the author's department of pediatric surgery, and it was performed for 21 years from January 1, 2000 to December 31, 2020.

Results Eighty-four children below 12 years were operated upon for Meckel's diverticulum during the study period of 21 years. The ratio for males to females was 3:1. This study consisted of infants, (n = 22, 26.19%), children of 1 to 5 years of age (n =19, 22.61%), and children of 6 to 12 years of age (n = 43, 51.19%). Clinically, children with Meckel's diverticulum presented in the following order of frequency: (1) intestinal obstruction (n = 59, 70.23%), (2) perforation peritonitis (n = 17, 20.23%), (3) lower gastrointestinal bleeding (n = 4, 4.76%), and (4) incidental finding (n = 4, 4.76%). In 35 (41.66%) children, bowel gangrene was detected. One-fifth (n = 17) of Meckel's diverticulum was responsible for the secondary intussusception. In children (n = 84), for Meckel's diverticulum, surgical procedures were performed in the following order of frequency: (1) resection of Meckel's diverticulum, an adjacent segment of ileum and ileoileal anastomosis (n = 36, 42.85%); (2) Meckel's diverticulectomy (n = 32, 38.09%); (3) resection of Meckel's diverticulum, an adjacent segment of ileum with or without cecum and an ileostomy (n = 12, 14.28%); and (4) resection of Meckel's diverticulum, an adjacent segment of ileum, cecum, part of the colon, and ileocolic anastomosis (n = 4, 4.76%). In 8 (9.52%) children, complications were documented during the postoperative period. The present study observed three (3.57%) deaths during the postoperative period.

Conclusion Meckel's diverticulum was one of the common causes of acute intestinal obstruction in infants and older children. Ninety percent of children with Meckel's diverticulum presented with features of an acute abdomen. Forty percent of children evidenced bowel gangrene during the surgical procedures. In these children, early diagnosis, timely referral, and institution of surgical therapy for acute abdomen/intestinal obstruction may prevent the development of bowel gangrene and the requirement of bowel resections to some extent.

Surgical Management of Intussusception in Children: A Retrospective Review of 212 Cases

Objectives The primary objective of this study was to analyze and review the demographics of children operated upon for intussusception. Secondary objectives were to review the clinical characteristics, surgical procedures performed, postoperative complications, and outcome.

Materials and Methods It is a single-institution, retrospective study and consists of children below the age of 12 years. This study was conducted at the author’s department of pediatric surgery for the past 21 years, from January 1, 2000 to December 31, 2020.

Results During the study period, 212 children were operated upon for intussusceptions and included 146 (68.86%) boys and 66 (31.13%) girls. This review consisted of infants 158 (74.52%), and children of 1 to 5 years of age (30; 14.15%), and 6 to 12 years of age (24; 11.32%). Clinically, 177 (83.49%) children presented with the features of acute intestinal obstruction, and the remaining 35 (16.5%) presented with features of perforation peritonitis. Primary (idiopathic) intussusception was documented in 188 (88.67%) of the cases. Gangrenous bowel was evident in 98 (46.22%) children. Sixty-two percent of the cases required bowel resection. Surgical procedures were executed in children for intussusception in the following order of frequency: (1) operative reduction with or without serosal tear/bowel perforation repair, n = 81 (38.2%); (2) resection of diseased ileum and ileoileal anastomosis, n = 52 (24.52%); (3) resection of diseased ileum ± part of colon and an ileostomy, n = 36 (16.98%); and (4) resection of diseased ileum, cecum, part of colon, and ileocolic (ileo-ascending or ileo-transverse) anastomosis, n = 43 (20.28%). Postoperatively, 9 (4.24%) children required reexploration for the management of their complications. Twenty-one (9.9%) children died during the postoperative period.

Conclusion Intussusception remains the most common cause of acute intestinal obstruction in infants and young children. Delay in the referral, diagnosis, and seeking treatment were significantly associated with bowel gangrene, required bowel resection during the surgical therapy, and also culminated in significantly higher mortalities.

Management of Patent Vitellointestinal Duct in Infants

Objectives This study was undertaken to investigate and review the clinical presentation, surgical procedures executed, and the final outcome of infants managed for the patent vitellointestinal duct.

Materials and Methods This is a single-institution, retrospective study and included infants who were operated for the patent vitellointestinal duct. This study was conducted at author’s Department of Paediatric Surgery during the last 20 years; from January 1, 2000 to December 31, 2019.

Results A total of 24 infants were operated for the patent vitellointestinal duct during the study period and comprised 20 (83.3%) boys and 4 (16.6%) girls. The age of infants ranged from 7 days to 10 months, with a mean of 88.41 ± 64.9 days. Twenty-three (95.8%) infants were operated within 6 months of the age, 17 (70.8%) of them were operated within 3 months of the age. Only one (4.1%) infant was operated at the age of 10 months. Among 24 infants, 13 (54.1%) were presented with features suggestive of acute intestinal obstruction and remaining 11 (45.8%) were presented with fecal discharges through the umbilicus without intestinal obstruction. Among 13 infants who presented with acute intestinal obstruction, 12 had prolapsed bowel and 6 of them also had gangrenous bowel. Operative procedures were executed (n = 24) in the following order of frequency: (1) resection of patent vitellointestinal duct, wide wedge resection of ileum,and ileal repair (n = 13, 54.1%); (2) resection of patent vitellointestinal duct, small segment of ileum, and ileoileal anastomosis (n = 9, 37.5%); and (3) resection of patent vitellointestinal duct, segment of ileum, and an ileostomy (n = 2, 8.33%). Postoperatively, two (8.3%) infants developed anastomotic leak and peritonitis one each, later on, both of them died.

Conclusion Patent vitellointestinal duct not only present with fecal discharges through the umbilicus but half of the infants presented with prolapsed bowel and with features of acute small bowel obstruction. Delay in seeking treatment for such cases was associated with considerable morbidity and mortality and therefore the patent vitellointestinal duct should be excised at the earliest.

Management of Intussusceptions Secondary to Pathological Lead Points in Infants and Children

Objectives This study was undertaken to investigate and review the age, sex, clinical presentation, surgical procedures done, major postoperative complications, and the final outcome of infants and children operated for intussusceptions secondary to pathological lead points (PLPs).

Materials and Methods This is a single-institution, retrospective study and included infants and children below the age of 12 years who were operated for the secondary intussusceptions. This study was conducted at author’s Department of Paediatric Surgery during the last 20 years; from January 1, 2000 to December 31, 2019.

Results During the study period, 200 infants and children were operated for the intussusceptions, and 23 (11.5%) of them were operated for the intussusceptions secondary to PLPs. This review comprised 18 (78.26%) boys and 5 (21.73%) girls, and consisted of infants (n = 9, 39.13%) and children of 1 to 5 years of age (n = 7, 30.43%) and 6 to 12 years of age (n = 7, 30.43%). The age at presentation ranged from 3 months to 10 years, with the mean age of 41.47 ± 40.06 months. Clinically, all the children presented with features of acute intestinal obstruction. Ultrasonography (USG) examination of the abdomen revealed the diagnosis of intussusception in all of them but not able to document the PLPs as a cause for it. During the exploratory laparotomies, gangrenous bowel was detected in 15 (65.21%) cases. PLPs causing intussusceptions were Meckel’s diverticulum (n = 17, 73.91%), begin ileal growth (n = 4, 17.39%), benign ileal polyp (n = 1, 4.34%), and caecal lymphoma (n = 1, 4.34%). Surgical procedures were executed in the following order of frequency: (1) resection of segment of ileum including PLP, and ileoileal anastomosis (n = 13, 56.52%); (2) resection of segment of ileum including PLP, caecum and part of ascending colon, and ileoascending anastomosis (n = 5, 21.73%); (3) Meckel’s diverticulectomy (n = 3, 13.04%); and (4) resection of segment of ileum including PLP and terminal ileostomy (n = 2, 8.69%). This study documented two (8.69%) deaths in postoperative period.

Conclusion Meckel’s’ diverticulum was the commonest pathology for the secondary intussusceptions in infants and children and documented most frequently during infancy. Half of the secondary intussusceptions occurred within 24 months of age. Bowel resection was required in more than 85% of the cases during the surgical procedures.

Management of Ruptured Occult Left Hydronephrotic Kidney in 7-Year - old Boy: A Case Report

Pre-existing, occult, congenital renal anomalies are often discovered during evaluation of children for blunt injury of the kidney and abdomen, presenting with or without haematuria. This is a report of 7-year-old boy; who presented with blunt injury abdomen with haematuria following fall from motorcycle. He had pallor, and features of hypovolumic shock and peritonitis. Skiagram of the abdomen showed haziness of the abdomen, without free gas under diaphragm. Ultrasonography (USG) of the abdomen revealed significant hemoperitoneum and gross hydronephrosis of the left kidney, which was undiagnosed previously. Exploratory laparotomy was done for peritonitis and the findings were hemoperitoneum, hematoma at the left mesocolon and left retroperitoneum. Postoperative computed tomography (CT) scan of the abdomen reported left hydronephrosis due to pelvi-ureteric junction (PUJ) obstruction with rupture of the renal pelvis. The ruptured hydronephrotic kidney was successfully managed by nephrostomy followed by delayed open dismembered Anderson-Hynes pyeloplasty. His postoperative recovery following pyeloplasty was uneventful and he was doing well at follow-up after a month of pyeloplasty.

Chylolymphatic Cyst of Mesentery of Terminal Ileum: A Case Report in 8 Year-old Boy

Mesenteric cysts are rare benign intra peritoneal tumor and more than half of the mesenteric cysts involve the mesentery of the terminal ileum. We present 8 year-old boy, who presented with features of acute intestinal obstruction. Ultrasonography (USG) of the abdomen revealed a cystic mass in the peritoneal cavity with dilated loops of bowel. Exploration of the abdomen revealed a solitary cyst of the mesentery of the terminal ileum measured 10 x 8 cm. There was twisting of the part of the ileum (volvulus) due to the cyst. It also involved the wall and lumen of the adjacent ileum and there were dilated bowel loops proximal to the cyst. Complete cyst excision and resection of the part of the ileum involved with the cyst was done en bloc. An ileostomy was created due to gross disparity in the lumen of the ileum, which was closed two and half month later. Histopathology of the excised cyst was consistent with the chylolymphatic cyst (mesenteric cyst).

Management of giant cystic lymphangioma in an infant

Lymphangiomas are benign lesions with a marked predilection for the head and neck region. Giant lymphangiomas of head and neck may occur and they may present with life threatening complications. The author is presenting here, a three month-old boy who presented with a giant cystic lymphangioma on left side of neck, which extended to the head as well. His clinical diagnosis of a cystic lymphangioma was confirmed on a Ultrasonography (USG) examination. Complete surgical excision of the lesion was achieved, without damaging any vital structures. His post-operative recovery was uneventful. A follow-up at two months after his surgery showed a cosmetically acceptable scar and no recurrence was noted.

Two-staged management for all types of congenital pouch colon

BACKGROUND

The aim of this study was to review our experience with two-staged management for all types of congenital pouch colon (CPC).

PATIENTS AND METHODS

This retrospective study included CPC cases that were managed with two-staged procedures in the Department of Paediatric Surgery, over a period of 12 years from 1 January 2000 to 31 December 2011.

RESULTS

CPC comprised of 13.71% (97 of 707) of all anorectal malformations (ARM) and 28.19% (97 of 344) of high ARM. Eleven CPC cases (all males) were managed with two-staged procedures. Distribution of cases (Narsimha Rao et al.'s classification) into types I, II, III, and IV were 1, 2, 6, and 2, respectively. Initial operative procedures performed were window colostomy (n = 6), colostomy proximal to pouch (n = 4), and ligation of colovesical fistula and end colostomy (n = 1). As definitive procedures, pouch excision with abdomino-perineal pull through (APPT) of colon in eight, and pouch excision with APPT of ileum in three were performed. The mean age at the time of definitive procedures was 15.6 months (ranges from 3 to 53 months) and the mean weight was 7.5 kg (ranges from 4 to 11 kg). Good fecal continence was observed in six and fair in two cases in follow-up periods, while three of our cases lost to follow up. There was no mortality following definitive procedures amongst above 11 cases.

CONCLUSIONS

Two-staged procedures for all types of CPC can also be performed safely with good results. The most important fact that the definitive procedure is being done without protective stoma and therefore, it avoids stoma closure, stoma-related complications, related cost of stoma closure and hospital stay.

Ventriculoperitoneal shunt complications needing shunt revision in children: a review of 5 years of experience with 48 revisions

BACKGROUND

The aim of this study was to review the management of ventriculoperitoneal (VP) shunt complications in children.

PATIENTS AND METHODS

During the last 5 years (January 1, 2006 to December 31, 2010), 236 VP shunt operations were performed in children under 12 years of age; of these, 40 (16.94%) developed shunt complications and those who underwent VP shunt revisions were studied.

RESULTS

This prospective study included 40 (28 boys and 12 girls) children and required 48 shunt revisions. Complications following VP shunts that required shunt revisions were peritoneal catheter/peritoneal end malfunction (18), shunt/shunt tract infections (7), extrusion of peritoneal catheter through anus (5), ventricular catheter malfunction (4), cerebrospinal fluid (CSF) leak from abdominal wound (4), shunt system failure (2), ventricular end/shunt displacement (2), CSF pseudocysts peritoneal cavity (2), extrusion of peritoneal catheter from neck, chest, abdominal scar and through umbilicus, one each. Four-fifth of these shunt complications occurred within 6 months of previous surgery. Surgical procedures done during shunt revisions in order of frequency were revision of peritoneal part of shunt (27, 56.25%), revision of entire shunt system (6, 12.5%), extra ventricular drainage and delayed re-shunt (5, 10.41%), shunt removal and delayed re-shunt (5, 10.41%), opposite side shunting (2, 4.16%), cysts excision and revision of peritoneal catheter (2, 4.16%) and revision of ventricular catheter (1, 2.08%). The mortalities following VP shunt operations were 44 (18.64%) and following shunt revisions were 4 (10%).

CONCLUSIONS

VP shunt done for hydrocephalus in children is not only prone for complications and need for revision surgery but also associated with considerable mortality.

Tube thoracostomy: primary management option for empyema thoracis in children

AIM

The aim of this study was to review our experience with tube thoracostomy in the management of empyema thoracis in children.

PATIENTS AND METHODS

This retrospective study included 46 children (26 boys and 20 girls) who were admitted and managed for empyema thoracis, between January 1, 2010 and December 31, 2010 at the author's department of paediatric surgery.

RESULTS

During the last 12 months, 46 children aged below 12 years were treated for empyema thoracis: Five (10.86%) were infants, 22 (47.82%) were 1 to 5 years and 19 (41.30%) were 6 to 12 years of age. All the patients presented with complaints of cough, fever and breathlessness of variable durations. Twenty three (50%) children had history of pneumonia and treatment prior to development of empyema. Thirty five (76.08%) children had right-sided and 11 (23.91%) had left-sided empyema. Thirty nine (84.78%) children were successfully treated with tube thoracostomy, systemic antibiotics and other supportive measures. Seven (15.21%) children failed to respond with above and needed decortications. Most commonly isolated bacteria were Pseudomonas (n = 12) and Staphylococcus aureus (n = 7). The average length of hospital stay in patients with tube thoracostomy was 15.35 days, and in patients who needed decortications was 16.28 days following thoracotomy. There was no mortality amongst above treated children.

CONCLUSIONS

Majority of children with empyema thoracis are manageable with tube thoracostomy, antibiotics, physiotherapy and other supportive treatment. Few of them who fail to above measures need more aggressive management.

Exploratory laparotomy for acute intestinal conditions in children: a review of 10 years of experience with 334 cases

AIM

The aim of this study was to review 10 years of experience in the management of children with acute intestinal conditions requiring exploratory laparotomy.

PATIENTS AND METHODS

This retrospective study included 334 children (244 boys and 90 girls) who underwent laparotomy for acute intestinal conditions between Jan 1, 2000 to Dec 31, 2009. Patients were grouped into two categories: group A (n = 44) included patients who needed laparotomy with terminal ileostomy and group B (n = 290) included patients who needed laparotomy without terminal ileostomy. We excluded neonates and patients with jejunoileal and colonic atresias, anorectal malformations, congenital pouch colon, neonatal necrotising enterocolitis, Hirschsprung's disease, appendicitis, abdominal trauma and gastrointestinal tumours.

RESULTS

During the last 10 years, 334 laparotomies were performed in children under 12 years: 59.88% for intestinal obstruction and 40.11% for perforation peritonitis. Causes in order of frequency were: ileal perforations 34.13%; intussusceptions 26.34%; Meckel's obstruction 10.17%; congenital bands and malrotation 6.88%; postoperative adhesions 5.98%; miscellaneous peritonitis 5.68%; miscellaneous intestinal obstructions 4.79%; abdominal tuberculosis 4.19% and roundworm intestinal obstruction 1.79%. Ileostomy closures (n = 39) was tolerated well by all except one. The mortalities were 28 (8.38%) in group B and 6 (1.79%) in group A.

CONCLUSIONS

The need for re-exploration not only increases the morbidity but also increases mortality as well. Diverting temporary ileostomy adds little cumulative morbidity to the primary operation and is a safe option for diversion in selected cases. The best way to further reduce the mortality is to create ileostomy at first operation.