Surgical biliary tree pathologies in paediatric patients

To find out various pathologies affecting biliary tree in paediatric age group and mode of investigations performed to arrive at diagnosis. Descriptive case series. Department of Paediatric Surgery Unit B, National Institute of Child Health Karachi, from January 2007 to December 2007. All paediatric patients below the age of 12 years who presented with symptoms related to biliary tree were included. A detailed history was taken including presence of jaundice, color of stool, mass an pain in right upper abdomen etc. all wee subjected to ultrasound as a screening test. Laboratory investigations included blood complete picture, liver function tests including bleeding profile, TORCH titre where appropriate, HIDA scan and CT scan as indicated. Laparoscopy was done in cases with persistent jaundice for operative cholangiogram and liver biopsy. Surgical procedure was tailored according to the pathology found. A total of 18 patients were managed. The number of male and female patients was nine each. The ages of the patients ranged from one month to nine years. Most common pathology was biliary atresia [n7]. Eleven patients presented wit persistent jaundice with age range from one month to 18 months. In all them HIDA scan showed failure of visualization of excretion of contrast into duodenum. All underwent laparoscopy and in seven of these biliary atresia found. There were four patients in whom extrahepatic biliary tree was found patent on cholangiogram. They were in older age range [from three months to 18 months]. All had grossly cirrhotic liver. Three patients had choledochal cyst [two males and one female]. The age ranged from 1 1/2 month to 9 year. A female of 2 1/4 year presented with history of fever and failure to thrive. Ultrasound showed presence of gall stones. Cholecystectomy was done in this child. Three patients had common bile duct [CBD] pathology. All had history of fever, recurrent jaundice with dilated CBD on ultrasound. All had CBD stone/ sludge. In two choledochotomy and removal of stone/ sludge was done while other had cholecystectomy in addition because of inflamed gall bladder. No T tube was places. One patient with idiopathic variety of gall stone had cholecystectomy. Ultrasound in expert hands is a good screening test in patients suspected of having surgical biliary tree pathology. HIDA scan can be safely omitted from list of investigations and laparoscopy is recommended in all cases of prolonged neonatal jaundice where surgical pathology is suspected

Video assisted thoracoscopy in children

To determine the outcome of video-assisted thoracoscopic surgery [VATS] in terms of its efficacy, safety and usefulness in children. Case series. Department of Paediatric Surgery Unit B, National Institute of Child Health, Karachi, from May 2006 to December 2006. This study was carried out on patients who were admitted with various intra thoracic pathologies and had video assisted thoracoscopy. Total of 13 patients underwent VATS. There were 6 patients of empyema thoracis who underwent thoracoscopic decortication and done successfully. There were four patients of hydatid disease among which three were converted into open thoracotomy. Two patients were of mediastinal mass and one of bronchopleural fistula. In these patients only biopsy was done which was conclusive in one patient, who was diagnosed as having ganglioneuroma. In other biopsy was inconclusive. Biopsy report was that of tuberculosis in patient with bronchopleural fistula. Video-assisted thoracoscopy is a safe and effective diagnostic and therapeutic procedure in children and this new approach has an important place in pediatric thoracic surgical practice. Thoracoscopic decortication can be treatment of choice for early empyema thoracis. As the learning curve progresses, more and more procedures can be done by VAT

Prenatal counseling and informed consent: ethical dilemma

With advancement in technology, congenital anomalies are increasingly recognized on antenatal ultrasound with great accuracy. This has opened up an entirely new field where all those who care for expectant parents and prospective baby like obstetricians, neonatologists, pediatric surgeons, psychologists, social workers etc are required to prove their expertise to deal with psychological issues and be able to guide expectant couple and their families as to what to expect and approach the baby born with congenital anomaly. If some life threatening condition is recognized at anomaly scan the decision of termination of pregnancy is even more difficult to make. This report describes an experience gained in dealing with one such couple whose baby on antenatal ultrasound, well beyond the age of termination of pregnancy, found to have omphalocele major. Many counseling sessions were held but the desired result was not achieved. How such problems should be dealt with in future, is discussed

Renal hydatid cyst: an isolated involvement

Hydatid cyst can occur in any part of the body. Isolated involvement of viscera other than liver and lung is rare In this report we present a case of seven years old male child who had an isolated involvement of left kidney with hydatid cyst. CT scan showed multiple cysts of left kidney with no renal function. His indirect hemagglutination [IHA] test showed a value of 1:8192. He was initially put on albendazole to which he showed partial response. At surgery multiple hydatid cysts were removed from kidney. Post operative radio isotope renal scan revealed the function of 15%

Management of simultaneously ingested and aspirated foreign bodies in an infant

This report describes the management of a 7-month-old baby who aspirated one and ingested two paper pins at a time. Bronchoscopic removal was done for aspirated pin and ingested pins were observed for spontaneous passage in stool, which occurred in 48 hours without any untoward incidence

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

Non-operative management of intestinal obstruction due to Ascaris lumbricoides

To compare, evaluate and analyze three different non-operative modalities of treatment of intestinal obstruction due to ascaris lumbricoides. Design: A non-randomized, cohort and comparative study. Place and Duration of Study: Department of Pediatric Surgery, National Institute of Child Health, Karachi from March 2001 to October 2002. Patients and A total of 45 patients with the diagnosis of intestinal obstruction due to ascaris lumbricoides were included in the study. They were divided in 3 groups of 15 patients each. Group I patients were given I/V fluids only, group II patients were given hyoscinbutylbromide in infusion and group III patients were given hypertonic saline enema. The outcome of all groups was compared in terms of improvement in obstruction and hospital stay. The data was analyzed by SPSS 11.0 by using ANOVA and HSD Tuckey test for multiple comparisons. The non-operative treatment was successful in all of the patients. In group III improvement of intestinal obstruction occurred in 1.6 +/- 1.11 days [p value=0.001], whereas it was 2.6 +/- 1.11 days in group II and 3.4 +/- 1.35 days in group I. The mean hospital stay in group III was 4 +/- 1.69 days [p value=0.003], whereas it was 6.27 +/- 2.31 days in group II and 5.87 +/- 1.25 days in group I. We recommend that hypertonic saline enema is a better non-operative treatment modality of intestinal obstruction, due to ascaris lumbricoides, in patients who do not have peritonitis. It is associated with early improvement of obstruction coupled with reduced hospital stay