Massive diffuse intraperitoneal multicystic mass in an infant

An 18-month-old boy was referred for painless progressively increasing abdominal distension, poor oral intake, and lethargy since 1 year. There was no history of fever, hematurea, or intestinal obstruction. The child was pale and had a pulse rate of 150 beats/min. The child had mild respiratory distress due to huge abdominal distension. The abdomen was tense and nontender. There was no evidence of intraperitoneal free fluid or any definitive lump. The hemogram showed anemia, other blood biochemistry test results were normal. Ultrasonography of the abdomen suggested the possibility of encysted ascites. A 64-slice contrast-enhanced computed tomography of abdomen showed diffuse intraperitoneal multicystic mass, composed of variable sizes and wall thickness cysts [Figure 1]. The definitive organ of origin could not be identified. Bowel loops were displaced upward by the mass. Diagnostic laparoscopy showed a pale, soft, extremely friable mass composed of cysts of variable sizes arising from the dome of the bladder. The cysts were noncommunicating and had no fluid. The mass was loosely adhered to the bowel, liver, and peritoneum. The rest of the abdominal organs were normal. Complementary cystoscopy was performed to rule out intraluminal extension of tumor, which was normal

Modified method of T-tube placement in cases of ruptured choledochal cyst having complete loss of anterior wall

Survival rates for infants and children who have choledochal cyst with or without spontaneous rupture have improved dramatically in the past decades. Despite excellent long-term survival for patients with choledochal cyst who undergo elective surgery, many significant complications can occur in the patients being operated in emergency for rupture of the cyst. Spontaneous rupture of the cyst is one such problem resulting in considerable morbidity and mortality in these patients. Majority of surgeons manage these cases with T-tube external drainage. The conventional methods of T-tube placement for long period has remained simple as described in choledochotomies where there is no deficit of the walls of common bile duct [CBD]. The present technique has been designed specially for the cases of ruptured choledochal cyst, where the wall of the CBD gets necrosed leaving behind a long gap between the two ends. In these cases, placement of T-tube with conventional method is not possible because there is no wall to suture together, and make the CBD water tight again to prevent leakage of bile. We found only two patients of spontaneous rupture of choledochal cyst with a long gap between two ends of CBD because of necrosed anterior wall. In both of these patients, it was not possible to put T-tube with traditional method and one would have to opt for primary definitive repair despite poor general condition of patients