Posterior urethral valves: varied presentations and outcome after preliminary surgical treatment

To find out various modes of presentation and outcome after preliminary surgical treatment of posterior urethral valves in pediatric population. Surgical Unit B National Institute of Child Health, Karachi, during the years 2004-2005. All consecutive patients coming in outpatient / emergency departments, diagnosed as having posterior urethral valves and those who had received initial treatment and came for follow up, were included in the study. All the neonates underwent vesicostomy initially, followed by valve ablation at appropriate age with plan for undiversion at later date. In infants valve ablation was performed if urethral size admitted pediatric cystoscope while older children underwent primary valve ablation. There were total of 22 patients managed during the study period. They included 5 neonates [0-1 month], 11 infants [1-12 months] and 6 older children [1year-12 years]. The main presenting complaint in majority of neonates was inability to pass urine and one had urinary ascites. Infants presented mainly with either difficulty in passing urine [n 5] or dribbling and acute urinary retention in 2 patients each. Majority of older children [n 3] presented with poor urinary stream and dribbling while two had diurnal enuresis and one came with straining at micturition. In all the neonates' vesicostomy was performed. Out of these 3 received valve ablation therapy, followed by undiversion. Two of them improved while 1 had bladder dysfunction. Of the remaining 2 patients with vesicostomy 1 is still waiting for definitive procedure while the other is lost to follow up. Of infant group, 8 were subjected to vesicostomy and valves ablated at later stage whereas 2 received primary valve fulguration therapy. One patient of this group died before any intervention performed. In older age group, 3 received valve ablation as initial treatment while 3 were lost to follow up before any intervention. Outcome assessed clinically, biochemically and radiologically. Out of total 22, four had not received any intervention. Of the remaining 18, treatment completed in 12 patients, 8 of these improved and 4 had residual disease. Two patients expired and 4 were lost to follow up. The overall improvement rate observed at the end of our study was 44%. In 22% patients there were still residual ongoing problems that need to be addressed on long term basis

Childhood nephrectomies for benign renal lesions

To conduct an audit of nephrectomies done in children for benign renal pathology. Evidence based study. Place and Duration: National Institute of Child Health, Karachi, during the year 2004-2005. The record of all the paediatric age group patients undergoing unilateral nephrectomy for benign renal diseases over a 2-year period were reviewed for the underlying diagnosis and indication for nephrectomy. Patients of Wilms` tumor subjected to nephrectomy were excluded. In the study nephrectomy was carried out in a total of 12 patients. There were 8 males and 4 females. The age range was 4 to 12 years. Nephrectomy was performed for renal tuberculosis in 5, pelvi-ureteric junction obstruction [PUJO] in 5, congenital hypoplastic kidney in 1 and one for multicystic dysplastic kidney. All the patients following nephrectomy remained well in the immediate post operative period and thereafter. Late presentation and delay in diagnosis of benign lesions of the kidney remained the main culprit in loosing a vital organ in childhood

Surgical management of renal tumors in children

To analyze case records of children with renal tumors. Case series. Surgical Unit B, National Institute of Child Health, Karachi during years 2004-2005. Case records of all patients managed during the study period were reviewed for clinical presentation, investigations and surgical management. National Wilms' Tumor Study. Group [NWTSG] and International Society of Pediatric Oncology [SIOP] protocols were used depending upon stage in cases of Wilms' tumor. Trucut biopsy was done for tissue diagnosis as proposed by UK Children's Cancer Study Group [UKCCSG]. Touch imprints were also made. Surgical procedure was analyzed in terms of ease of dissection, tumor spillage and extent of excision. Twenty-one patients of renal tumors were managed in two years period. Nearly 60% of patients were less than 2 years of age. Majority [n 14] presented with abdominal mass. Few had complaints of abdominal pain. One patient an infant, presented with profuse hematuria. Trucut biopsy was done in 18 cases to have tissue diagnosis. Three patients underwent primary exploration. There were 17 cases of Wilms' tumor and in one case it was suspected on touch imprints. Fourteen patients of Wilms' tumor were given pre operative chemotherapy [SIOP protocol]. Twelve of them were in stage III and IV. Nine out of this have undergone nephrectomy. Marked tumor regression in size of tumor was noted. The tumor also became firm. Only one tumor ruptured during excision. In one tumor with horse-shoe kidney, residual tumor left at margins of dissection. Three patients underwent primary nephrectomy. Two of these were in stage I and one in stage III [NWTSG protocol]. Patient in stage III died in immediate post operative period because of hemorrhage. There was one case each of mesoblastic nephroma, cystic nephroma and rhabdoid tumor. In all these nephrectomy was done following trucut biopsy. Patient with rhabdoid tumor received pre operative chemotherapy. This tumor ruptured during surgery and gross spillage occurred. Wilms' tumor was the most common pediatric renal tumor. Most of the patients were younger than the reported age and presented with advanced stage of disease. SIOP protocol found more appropriate in our group of patients

Neonatal intussusception: a rare entity

Intussusception is a common cause of intestinal obstruction in infancy. It has been reported in pre-matures and during fetal life as well. In full term neonates it is a rare entity. In this case report we describe our experience of management of a six days old male baby. Who turned out to be a case of idiopathic ileoileal intussusception. As the gut was non viable, resection and anastomosis were performed. Post operative recovery were uneventful

Antibiotic sensitivity pattern in burn wound cultures

To find out the pattern of microbial flora and their sensitivity to antibiotics in burn wounds cultures. Design: Descriptive study. Place and Duration During year 2003, at Burns unit, National Institute of Child Health, Karachi. Subject And Twenty five consecutive patients were included in the study and pattern of most common pathogens was studied with special reference to their antibiotic sensitivity. The bacterial cultures were taken at different intervals during the hospital stay, first on the second day of admission and then subsequently, following every 7-10 days. Antibiotic sensitivity pattern was correlated to the antibiotic the patients were receiving. Our results revealed that the most frequent isolate was pseudomonas [80%] followed by staphylococcus aureus [40%], klebsiella [28%], proteus [16%] and streptococcus [8%]. Time related changes showed that the bacterial isolates were predominantly gram negative rods [70%]. in the first culture taken on the 2nd day of admission and remained high throughout the hospital stay and was up to 90% in the final culture. There is a specific pattern of burn wound microbial colonization, with time related changes in dominant flora. Antibiotic sensitivity profile is helpful to make guidelines for dealing with the burn wound at the outset and for which antibiotic to start with. Following this protocol the morbidity and the resistant flora could be avoided

Thymolipoma in a child [a case Report]

A 2 year old male child with history of mild respiratory difficulty and repeated chest infection on CT scan, found to have an anterior mediastinal mass, which pre operatively was suspected as thymolipoma. Through median sternotomy mass was removed in totto. Histopathology confirmed the pre operative diagnosis. Post operative recovery was uneventful. At 6 months follow up there was no recurrence

Congenital midline cervical cleft: a case report

A 4 months old baby girl was brought with the history of mucoid discharge from small midline defect on the ventral aspect of neck since birth. She had no other associated congenital defect. Family history of facial deformity such as cleft lip or palate or of thyroid disease was negative. On examination the lesion consisted of a cephalad skin tag, a mucosal surface and a caudal sinus in the midline of ventral neck between the chin and suprasternal notch. It was approximately 3 cm long and 1 cm wide. Sinogram of the lesion showed a blind tract going behind sternum. The patient was treated surgically and the cleft with its underlying fibrous cord that was attached with sternum excised. The vertical wound was closed with multiple Z plasties. On histological examination the cleft was partly lined by keratinized stratified epithelium with sebaceous gland and partly by non- keratinized stratified squamous epithelium. Underlying the epithelium were small collection of seromucous salivary glands. Surrounding tissue was densely fibrocollagenous and richly supplied with blood vessels. The post- operative course was uneventful. Patient is on follow up

Hypertrophic pyloric stenosis in a premature. A case report

A four day old baby girl weighing 1.3 kg admitted with respiratory distress. She was delivered by Caesarean section prematurely at 30'h week of gestation due to early rupture of membrane without labor pains. There was no birth asphyxia. She was provided incubator care. As baby was vomiting NG tube was placed. She had non bilious vomiting whenever trial feed given. Surgical opinion was the sought. X ray abdomen showed large gastric shadow with paucity of gas in rest of the abdomen [Figure I]. A diagnosis of malrotation was made. Baby was thus explored. At laparotomy gut was found normally placed with normal caliber of the duodenum. Pylorus was found thickened with dilated stomach. Its appearance was not very classical. Pyloromyotomy was attempted. During the procedure perforation occurred at duodenal end that was closed. Post-operative recovery was uneventful. Baby was put on TPN for 4 days. Trial feed started which was tolerated and then beast feed allowed. She was later discharged