Megaesophagus in the pediatric age group: a diagnostic dilemma

A 5-year-old boy weighing 8 kg presented with recurrent pulmonary infections, occasional nonbilious vomiting, intermittent cough, and failure to thrive since birth. On physical examination, vital signs were normal, but on auscultation left-sided fine crackles were found. The child was anemic, other blood biochemistry levels were within the normal range. A chest X-ray and computed tomography [CT] revealed bronchiectasis localized to the left hemithorax and a radiolucent air column within a distended esophagus. Other causes of chronic pulmonary diseases, such as cystic fibrosis, congenital immune deficiencies and primary ciliary dyskinesia were excluded. A barium swallow demonstrated a dilated esophagus with an air-fluid level and sudden narrowing at the distal end [Figure 1]. Esophageal manometry showed uncoordinated, low-amplitude peristalsis of the esophageal body and the lower sphincter pressure 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