Loss of interest for training in paediatric surgery in India

BACKGROUND Despite the sizeable Indian paediatric population, few students have opted for postdoctoral (Magister Chirurgiae [MCh]/Diplomate of the National Board of Examinations [DNB]) courses in the past decade. We analyse the apparent loss of interest for training in paediatric surgery in India and suggest remedies. METHODS We did a combination of an online questionnaire-based survey and several interviews among students, teachers and practitioners of paediatric surgery. The results were collated and analysed. RESULTS Information from 238 questionnaires, 35 interviews and 75 feedbacks were distilled. About 83% of respondents agreed to a definite loss of interest among students in paediatric surgery, largely because of poor exposure during undergraduate/postgraduate courses and absence of a department in medical colleges. The blanket increase in seats has led to vacancies. The low saleability of paediatric surgery is linked to high personnel and infrastructure investment, modest remunerative potential and poor insurance cover for patients. Besides increasing public awareness, strategic governmental patronage in postdoctoral training (e.g. establishing a department in medical colleges, moderating the number of seats, encouraging performing training centres and rationalizing the bond after the training course) and facilitation of patient care (e.g. insurance cover for congenital conditions and paediatric surgeon in neonatal care units in district hospitals) is suggested. CONCLUSIONS The loss of interest in paediatric surgery among medical trainees is real and urgently requires a multipronged strategy by the medical fraternity, professional organizations and regulatory bodies across government and non-governmental sectors to facilitate a revival and cater to the sick surgical child in the future.

Calretinin immunohistochemistry versus improvised rapid Acetylcholinesterase histochemistry in the evaluation of colorectal biopsies for Hirschsprung disease.

Background: Acetylcholinesterase (AChE) histochemistry on rectal mucosal biopsies accurately diagnoses Hirschsprung disease (HD), but is not widely employed as it requires special tissue handling and pathologist expertise. Calretinin immunohistochemistry (IHC) has been reported to be comparable to AChE staining with the loss of expression correlating with aganglionosis. Aim: The aim was to evaluate calretinin IHC as a primary diagnostic tool in comparison to the improvised rapid AChE technique in the diagnosis of HD. Materials and Methods: A total of 74 rectal biopsies (18 fresh frozen - 18 cases, 56 formalin fixed - 33 cases) from 51 cases of suspect HD were evaluated with hematoxylin and eosin/AChE/Calretinin. Ten biopsies each from ganglionated and aganglionated segments served as positive and negative controls. Ileal (3), appendiceal (3) and ring bowel (2) biopsies were also included. Two pathologists blinded to the clinical details evaluated the histomorphology with AChE and calretinin. Observations were statistically analyzed and Cohen’s κ coefficient employed to assess agreement between two pathologists and calretinin and the AChE. Results: The study confirmed HD in 26 and non-HD in 25 cases. There were 7 neonates, 5 low level biopsies and 14 “inadequate” biopsies. The results of calretinin were comparable with AChE with a statistically significant measure of agreement of κ = 0.973 between the two. One false-positive case of HD was noted with calretinin. The advantages and disadvantages of calretinin versus AChE are discussed. Conclusion: Calretinin is a reliable single immune marker for ruling out HD by its specific positive mucosal staining of formalin fixed rectal biopsy. The improvised AChE staining remains indispensable to confirm HD on fresh biopsies and thus, along with calretinin IHC maximizes the diagnostic accuracy of HD in difficult cases.

Congenital inclusion tumours in spinal dysraphism.

Objective. To review the presentation, diagnosis and management of children with spinal dysraphism and CIT. Methods. It is a retrospective review of 146 children of spina bifida over 9 years (2000-2008) and details the clinical course and outcome of seven with associated congenital inclusion tumors. Results. 7/146 (4.7%) had spina bifida with CIT, 5 dermoid cysts and 2 mature teratoma. The diagnosis was missed by the primary physician even in the presence of a neurocutaneous marker. Spinal imaging with MRI was conclusive. All were managed with multilevel laminectomy, near total/total excision of the CIT and detethering of cord. Intramedullary involvement and established neurological deficits at presentation were associated with persistent deficits. Conclusion. Early detection and comprehensive management of CIT with spinal dysraphism ensures social fecourinary continence, preserves renal function, achieves ambulation and enables patients to lead an acceptable quality of life.

Preputial adhesions – A misunderstood entity.

Objective. To assess the trends and outcomes in referrals of ‘phimosis for circumcision’ to a tertiary care pediatric surgical department. Methods. This is a prospective study of 100 consecutive children of presumed phimosis referred for circumcision. They were assessed and classified by the senior author as having either preputial adhesions or phimosis. The patients in the former group underwent outpatient preputial adhesiolysis while those in the latter group were offered circumcision primarily. All were followed up till resolution. Results. All 100 were referred with a non-retractile prepuce and an additional reason – preputial ballooning at voiding, dysuria or suspect UTI. Eight (mean age -58 months, referred for preputial ballooning at voiding -6/8 and dysuria -2/8) had phimosis and were primarily offered circumcision. The remaining 92 (mean age – 22 months, referred for preputial ballooning at voiding -52/92, dysuria -28/92 and suspect UTI -12/92) had preputial adhesions. In the latter group, none has a documented urinary infection on specific investigations. These 92 underwent outpatient preputial adhesiolysis. Seventy three (79 %) required a single sitting, 11 (12%) required 2 -4 sittings and 4(4.5%) required 5-8 sittings over a follow up period of 1 -24 months (median -3 weeks). 4/92(4.5%) were deemed non-responders to adhesiolysis and were circumcised later. Conclusion. The majority of children referred with ‘phimosis for circumcision’ to this tertiary pediatric surgical centre were actually physiologic preputial adhesions that were managed with outpatient preputial adhesiolysis. This study underscores a lack of awareness amongst referring primary care physicians regarding preputial adhesions and the potential for an erroneous diagnosis of phimosis translating into unnecessary circumcisions in many young boys.

Spontaneous infantile choledochal cyst perforation.

Spontaneous perforation is a rare complication of infantile choledochal cysts. A 23-weeks female with acute biliary peritonitis is described and differentiation from a spontaneous perforation of the extrahepatic bile duct highlighted.

Aspiration of a tracheostomy tube flange.

Foreign body aspiration is a common pediatric emergency. Aspiration of a metallic tracheostomy tube flange into the left main bronchus and the resultant subacute respiratory distress is presented. Being the only case of its kind in reported pediatric literature, a review of the etiology, clinical presentation and prevention of this accident is appended.

Undescended testes.

Undescended testis or cryptorchidism is a common problem encountered in children. Despite the abundant literature on the pathology and management of undescended testis, it is the subject of numerous misgivings and controversies. The article reviews available literature on the entity and their relevance in clinical practice.

A modified technique for the diagnosis of Hirschsprung disease from rectal biopsies.

BACKGROUND: A diagnosis of Hirschsprung disease requires the demonstration of acetylcholinesterase fibres on frozen sections obtained from snap frozen biopsies of the rectum. This histochemical technique is generally not available in laboratories in developing countries. We improvised on the methodology of tissue preservation to make the staining technique more user-friendly, economical and reliable in demonstrating acetylcholinesterase activity in fresh rectal mucosal biopsies for the diagnosis of Hirschsprung disease. METHODS: Between June 1999 and May 2002 fresh rectal biopsies from 40 suspected cases of Hirschsprung disease were processed for routine frozen section (not snap frozen by liquid nitrogen) and stained by the Karnovsky and Roots method. These sections were assessed for the staining pattern of acetylcholinesterase fibres. The thickness of the nerve fibres and muscularis mucosa was assessed morphometrically. These were compared with biopsies obtained from 6 age-matched controls undergoing surgery for unrelated complaints. RESULTS: The sections stained for acetylcholinesterase by this improvised method of tissue fixation were good and crisp. A definite diagnosis of Hirschsprung disease was made in 25 cases and intestinal neuronal dysplasia in 1. The remaining 14 cases showed an equivocal staining pattern with no hypertrophic nerve bundles, thus excluding a diagnosis of Hirschsprung disease. The mean thickness of the submucosal nerve trunks measured in these enzyme-stained sections was found to be inversely proportional to the mean thickness of the muscularis mucosa. CONCLUSION: Our study on cryostat-cut sections suggests an inverse relationship between the thickness of the muscularis mucosa and the calibre of the nerve trunk--thinner the nerve trunk, thicker the muscularis mucosa and vice versa. Also, routine frozen sections, instead of snap frozen ones taken from a fresh rectal biopsy and stained by the Karnovsky and Roots method for acetylcholinesterase activity, are reliable for the diagnosis of Hirschsprung disease and are within the capability of a simple histopathology laboratory in a developing country.

Pyeloplasty in infancy.

OBJECTIVE: The advent of routine maternal ultrasound has increased the number of neonates diagnosed to have ureteropelvic junction obstruction. Though the debate concerning its ideal management continues, recent years have witnessed reports on pyeloplasty in infancy. This study presents the feasibility and outcome of pyeloplasty in neonates and infants from a single centre. METHODS: The authors examined the records of 40 neonates and infants (46 renal units) who underwent pyeloplasty for ureteropelvic junction obstruction since 1988. Patient characteristics, clinical presentation, investigations, associated anomalies, age at surgery, operative technique and outcome were evaluated. RESULT: The mean and median age at surgery was 3.5 and 2.5 months respectively, and mean postoperative hospital stay six days. Associated anomalies were found in 27% of infants and in some they influenced the outcome. In 72%, no stent or nephrostomy was used. However, all had a closed perinephric drain. There was no mortality in this series. Complications (8.7%) comprised anastomotic leak in three and anastomotic stricture in one unit. In 35 of 38 renal units, improved drainage and recovery of differential function was confirmed on postoperative renogram. CONCLUSION: Where indicated, pyeloplasty in the neonate and infant will be readily adopted by specialists for the select few it would benefit. It is hoped that all those involved in the care of these infants will take cognisance of this fact to ensure early optimal management of ureteropelvic junction obstruction.