Surgical outcome in relation to duct size at the porta hepatis and the use of cholagogues in patients with biliary atresia.

Background : Small ductules communicating with the bile ducts have been described at the porta hepatis in extrahepatic biliary atresia (EHBA) and these form the basis for hepatic portoenterostomy. The use of cholagogues like dehydrocholic acid (DHC) and ursodeoxycholic acid (UDCA) to enhance bile flow postoperatively has been reported. Aims : This communication describes our experience with the use of cholagogues following surgery in EHBA and attempts to correlate the outcomes with the diameter of the ductules. Material and methods : Fifty five EHBA patients treated by the Kasai procedure form the basis of this study; 35 patients treated during 1979-1986 and administered DHC (3-5mg/kg) postoperatively and 20 patients treated during 1999-2002 and administered UDCA (15mg/kg) postoperatively. The diameter of ductules was measured using an optical micrometer on 5μm serial sections; the ducts were classified as type I (no demonstrable ducts, n=14), type II (<50μm, n=22) and type III (>50μm, n=19). The clinical outcome was categorized as 1 (jaundice free survival at 5 years follow-up, n=7), 2 (initial good response but deteriorated after one year, n=27) and 3 (expired within one year following surgery, n=21). The response to surgery was monitored using biochemical liver function tests (LFT), hepatobiliary scintigraphy (HIDA scan) and occurrence of cholangitis. Results : Age did not affect the size of ducts in both DHC and UDCA groups but patients in the DHC group were older than those treated with UDCA (mean age DHC: 105.22+33.53 days, UDCA: 74.68+23.73 days; p=0.009). There was no statistically significant difference between duct size and postoperative LFT in both groups (DHC p=0.1, UDCA p=0.5). Bile excretion on HIDA scan was significantly better with larger ducts (DHC p=0.003, UDCA p=0.025); overall UDCA showed significantly better bile excretion (p=0.003) but this was not reflected in the surgical outcome. There was no significant difference in the surgical outcome of those treated with DHC or UDCA but a significantly higher incidence of cholangitis was seen with smaller ducts in the UDCA group (p=0.02). Conclusions : There was no correlation between duct diameter and postoperative LFT but type III ducts were associated with better bile flow on HIDA scan. Cholangitis was seen more often with type I and II ducts in both DHC and UDCA groups. UDCA administration seemed to be beneficial in patients with type III ducts in increasing bile flow and reducing cholangitis.

Physical growth in children with reflux nephropathy with normal or mildly impaired renal function.

Ten children aged 11 months to 10 years (means 5.7 years) with reflux nephropathy, vesicoureteric reflux (VUR) and normal or mildly impaired renal function having GFR more than 50 ml/min/1.72 m2, were included in the study. The hematological and biochemical parameters were within normal limits. Height standard deviation score (HZ score) was reduced at entry and, decreased further during follow-up (-2.2 and -2.6 at 0 and 12 months, respectively). Weight for height index (WHI) improved significantly (p=0.0004) during follow-up. The basal and stimulated peak growth hormone levels of these patients were found to be elevated, 18.53 ± 11.36 μg/L and 34.20 ± 5.86 μg/L, respectively. The IGF-1 levels were low ranging from 45.00 to 84.40 ng/dl (mean ± SD 61.54 ± 10.21 ng/dl) compared to 51.80 to 247.50 ng/dl (mean ± SD111.20 ± 70.24 ng/dl) in age and sex matched controls, indicating partial insensitivity to growth hormone.

Recent advances in the management of congenital diaphragmatic hernia.

The management of congenital diaphragmatic hernia (CDH) is undergoing continual change and refinement, fuelled by recent advances in this field. Although many studies have documented the benefits of these recent advances but definite recommendations are lacking. Also, injudicious use of some of these strategies may be counterproductive, underscoring the importance of evidence based treatment strategy. This article discusses the utility of the recent advances in the management of CDH.

Peripherally inserted central venous lines versus central lines in surgical newborns - A comparison.

Objective. To compare the insertion characteristics, utilization profile, life span and the complication rates of Central lines (CL) and Peripherally inserted central lines (PICL). Methods. A prospective study of all CL or PICL insertions during January 2007 to September 2007 in the Neonatal Surgical Intensive Care Unit of a tertiary care center was done. The number of attempts, procedure time, duration of catheter stay, number of dressing done, complication during insertion and maintenance and cause of removal were noted and the differences analyzed statistically using Pearson chi square / t test. P value . 0.05 was considered significant. Results. Ninety two neonates were included in the present study of whom 60 were PICL insertions and 32 CL insertions. The two groups were comparable in terms of age, weight and the use of total perental nutrition (TPN) through the catheters. On comparing the PICL and CL groups, the number of attempts for successful insertion (p=0.003), the time taken (p=0.005), the number of dressing changes required during the indwelling period (p=0.005) and the overall complication rates (p=0.002) were significantly less in the PICL group. The PICL could be maintained for longer periods of time (p= 0.005) and only in 11.5% of the patients it had to be removed before completion of therapy as compared to 37.5% early removals for CL (p=0.02) Conclusion. PICL is a safe, effective and reliable method of providing prolonged IV access in newborns. It also has the least incidence of complications during insertion and maintenance over prolonged period of time when compared to CL and should be recommended for routine use in neonatal surgical patients.

Evaluation of ultrastructural changes by electron microscopy in neonatal cholestasis.

Background: Biliary atresia (BA) and idiopathic neonatal hepatitis (NH) account for 50-70% of all cases with neonatal cholestasis. The treatment of the former is early surgical intervention, while the latter requires non-surgical supportive care. Failure to differentiate the two conditions may result in avoidable surgery in NH, which may significantly increase morbidity. The lack of differentiating clinical features, biochemical markers and other specific investigations to distinguish the two is still a major problem. Aim: This study was thus initiated to evaluate electron microscopic changes in the liver in patients with NH and BA, to correlate these with changes on light microscopy and look for specific differentiating features between the two. Methods: Ten patients with neonatal cholestasis whose liver specimens were available for electron microscopic analysis were included in the study. There were 6 patients with BA and 4 patients with NH. Results: Among the biochemical parameters, serum alkaline phosphatase and gamma glutamyl transpeptidase were significantly higher in BA than in patients with NH. On light microscopy, giant cell transformation was seen in 75% patients with NH and 33.3% of patients with BA. Even in BA, intracellular cholestasis was more prominent than ductular cholestasis (100% vs. 50%). Ductular proliferation was seen in 50% of NH patients and all patients of BA. Electron microscopy revealed prominent endoplasmic changes in all patients with NH and to a milder degree in BA. Changes in mitochondria and glycogen content were similar in both groups. Conclusion: Ultrastructural changes in neonatal cholestasis seen through electron microscopy are largely non-specific and do not differentiate BA from NH.

Larvicidal activity of Artemisia annua L. callus culture against Anopheles stephensi larvae.

The emergence of resistance by both Plasmodium falciparum and Anopheles stephensi made the search for an alternative environmentally safe plant based insecticide inevitable. Artemisia annua is a well known antimalarial. Present study is an attempt to induce callus production from young leaves of Artemisia annua plant and study its larvicidal activity against larvae of Anopheles stephensi. Callus was initiated by using different concentrations of auxins and cytokinins. A suitable culture media was standardized for optimal growth of callus. Healthy callus cultures were obtained in the slightly modified Murashige and Skoog’s medium + NAA and BAP (0.03 and 0.2 mg l-1 respectively) + Sucrose 20 gm l-1 + Agar 8 gm l-1 within 28 days of inoculation. Callus was successively extracted in order of increasing polarity of solvents. Larvicidal activity, in terms of lethal concentration (LC50) of the callus extract in chloroform was calculated to be 18.45 ± 0.75 ppm after 72 hr against third instar larvae of A. stephensi.

The development of intrapulmonary arteriovenous shunts as a poor prognostic factor following surgery for biliary atresia.

Background & Aims: Chronic liver disease requiring liver transplantation is a common occurrence following corrective surgery for extrahepatic biliary atresia (EHBA). The formation of intrapulmonary arteriovenous shunts (IPS) is a well-known feature of chronic liver disease. The aim of this study was to investigate the development of IPS and its prognostic significance in postoperative patients with EHBA. Methods: Fourteen patients who underwent Kasai’s portoenterostomy during 1993-2005 were included in the study. The clinical features, hepatobiliary scintigraphy and biochemical liver function tests were recorded. A transthoracic contrast enhanced echocardiogram using a four-chamber view was performed in all patients within a week of the Kasai’s procedure by injecting 5 mL of hand-agitated saline solution into a peripheral vein. The opacification of microbubbles in the left atrium 3-6 minutes after their emergence in the right atrium was considered diagnostic of IPS. The contrast enhanced echocardiogram was repeated 6 months after the Kasai’s procedure in all patients Results: Nine patients were clinically asymptomatic after surgery. HIDA scan was excretory in all 14 patients at the time of the study, although 5 patients were jaundiced. The serum bilirubin increased in 2 patients after surgery; both these patients were jaundiced and developed ascites and 1 expired one year after surgery. Contrast enhanced echocardiogram was negative for IPS in all 14 initially. In the follow-up evaluation the only patient who died was the one who had developed IPS. Conclusions: There is a risk of developing IPS following a failed Kasai’s portoenterostomy in patients of EHBA. Contrast enhanced echocardiography can be used to serially monitor these patients for early detection of this complication. It can be used to predict prognosis after hepatic portoenterostomy and can be extremely useful in selecting patients who will need liver transplant on priority.

Pre-operative manometry of the blind rectal pouch to predict post-operative potential for continence in anorectal malformation.

AIM: Despite technical advances in the surgical repair of anorectal malformation, many children suffer post-operative faecal incontinence. There are many ways to assess postoperative continence in these patients but there is no manometry-based method to assess and make predictions pre-operatively. In this pilot study an attempt was made to correlate the pre- and postoperative manometry and electromyography findings in order to use the pre-operative findings to predict the postoperative potential for continence. METHODS: Ten patients aged 12 to 54 months were subjected to pre-posterior sagittal anorectoplasty manometry by introducing the balloon catheter probe through the distal colostomy into the blind rectal pouch. Electromyography activity in the striated muscle complex was also studied by placing electromyography needles in the midline in the anal dimple. A second study was repeated after posterior sagittal anorectoplasty (PSARP), the probe was introduced into the rectum via the neo-anus and the electromyography needles were placed on either side of the neo-anus. A third study was done, similar to the second study, after colostomy closure along with Kelly's scoring. Results of the three studies were compared. RESULTS: Pre-posterior sagittal anorectoplasty rectal pouch pressures were in the range of 18.3-93.3 cm H2O and electromyographic activity was between 43.6 and 383.0 microv. Post-posterior sagittal anorectoplasty studies showed anal canal pressure in a similar range of 16.0-95.5 cm H2O and electromyographic activity between 57.0-340.7 microv. The post-colostomy closure anal canal pressures ranged from 22.7 to 99.1 cm H2O and electromyographic activity ranged from 65.7 to 335.7 microv. The Kelly's score ranged from 1-6. CONCLUSION: Since, the pre-and postoperative manometry findings are quite similar and they correlate well with the surgical outcome, it may be possible to predict such an outcome before PSARP. Also, the pressure profiles and EMG activity in post-operative assessments suggest intact neural pathways despite blind pouch mobilisation.

Spontaneous perforation of the extrahepatic biliary tract.

Spontaneous perforation of the extra-hepatic biliary tract presenting with pseudocyst is rare. We report the case of a two-month old infant who presented to us with increasing jaundice and progressive loss of weight. Ultrasonography, magnetic resonance cholangiopancreatography and hepatobiliary iminodiacetic acid scan revealed features of obstructed choledochal cyst. Laparotomy revealed a small, walled-offcollection of bile near the confluence of the cystic and common bile ducts. Distal obstruction was excluded and biliary tract drainage was successful in treating the infant.

Peritoneal penetrating pencil injury.

An 8 year old school going boy sustained an accidental peritoneal penetrating injury while playing with a pencil in his trouser pocket. Surgical exploration revealed intact intraperitoneal and retroperitoneal viscera and the pencil could be successfully removed. In addition to the acute injuries there are numerous late sequlae of pencil injuries that cause concern.

Aspergillus niger as a new allergic agent associated with bindis and its efficacy against homeopathic drugs.

Aspergillus was found as a dominant fungi to associate with brands of bindis. Among three potencies of four homeopathic drugs, Lycopodium 1M, Sulphur 1M, and Sepia 30 showed maximum inhibition zone of Aspergillus niger in inhibition zone technique. In poison food technique, Sepia 30M, Tellurium 30M, Sulphur 1M and Lycopodium 200 showed maximum percentage inhibition against A. niger

Effective method for extraction of larvicidal component from leaves of Azadirachta indica and Artemisia annua Linn.

Leaves of Artemisia annua linn. and Azadirachta indica were extracted in petroleum ether and hexane respectively by different methods of extraction i.e. cold extraction, reflux extraction and soxhlet extraction. The crude extract obtained was tested against third instar larvae of Anopheles stephensi. On comparison of larval mortality of crude extract obtained by these three methods, both soxhlet and reflux extraction method showed 100% mortality at 200 ppm after 48 hr in case of A. annua. However LC50 (20 ppm) value of crude extract obtained by soxhlet extraction showed better results than reflux extraction (35 ppm) method after 72 hr. In case of A. indica, crude obtained by soxhlet showed 100% mortality (after 48 hr) at 250 ppm and LC50 of 69 ppm at 72 hr. Reflux extraction does not show any appreciable mortality even at 250 ppm concentration.

Anorectal malformations and their impact on survival.

OBJECTIVE: To evaluate the incidence, types and the effect on outcome of associated anomalies in neonates with anorectal malformations (ARM). METHODS: This retrospective study was carried out on all neonates with ARM admitted to the neonatal surgical intensive care unit (NSICU) from 1998 through 2003. RESULTS: Of the 754 neonates admitted to the NSICU during the study period of 6 years, there were 124 (16.4%) neonates with anorectal malformations. Of these 110 were included in the study. 73 % were male and 27% female. 86% of these were high ARM (HARM) while only 14% were low ARM (LARM). Associated anomalies were seen in 68% of patients. The incidence was 72% for HARM and 50% for LARM. The major associated anomalies consisted of esophageal (13%), gastrointestinal (GIT) (11%), genitourinary (GUT) (32%), skeletal (26%), cardiac (33%) and miscellaneous 26%. The overall survival rate was 84% (82% for HARM and 94% for LARM). The survival among those with associated esophageal anomalies was 43%, GIT 67%, GUT 80%, cardiac 61%, skeletal 76% and miscellaneous 79% respectively. This difference in survival was significant only for those with esophageal (p=0.004) and cardiac anomalies (p=0.0026). The survival rates among those with one, two or more than two organ systems involved with associated anomalies were 88%, 82% and 58% respectively. This difference was significant only for more than two organ systems involvement (p=0.003). CONCLUSION: Associated anomalies are common in neonates with ARM, the incidence being similar for HARM and LARM. The survival depends upon the number and severity of associated anomalies both in patients with LARM and HARM. Neonates with more number of organ systems involved have a poorer survival specially when associated with esophageal and cardiac anomalies. All neonates with ARM merit a meticulous search for associated anomalies so that the management can be tailored for each baby.

Respiratory distress in neonates.

Respiratory distress due to either medical or surgical causes occurs commonly in neonates. It is the most common cause of admission to a neonatal surgical intensive care facility in a tertiary care hospital. The distress can be caused by a variety of clinical conditions; common conditions treated in medical intensive care units are transient tachypnea of the new born, respiratory distress syndrome, pulmonary air leak and pneumothorax. In surgical causes of respiratory distress in neonates the underlying mechanisms include airway obstruction, pulmonary collapse or displacement and parenchymal disease or insufficiency; the common causes are congenital diaphragmatic hernia, congenital cystic adenomatoid malformation, congenital lobar emphysema and esophageal atresia with or without tracheo-esophageal fistula. Obstructive lesions of the new born airway include choanal atresia, macroglossis, Pierre-Robin syndrome, lymphangioma, teratoma or other mediastinal masses, cysts, subglottic stenosis and laryngo tracheomalacia. Imaging plays a very major role in the pre-operative diagnosis of these conditions and proper pre-operative resuscitation helps in improving the results of surgery dramatically.

Manometric evaluation of postoperative patients with anorectal anomalies.

AIM: To evaluate the outcome of surgical treatment in patients with anorectal malformations and to correlate the clinical, manometric and electromyographic studies in assessment of postoperative continence in these patients. METHODS: Forty-one patients operated on for anorectal malformations were evaluated retrospectively. These included 13 patients with low anomalies, 24 with high anomalies, and 4 with congenital pouch colon. Functional results after surgical correction were assessed on clinical basis using the Kelley's scoring system and by anorectal manometry. In addition, the electrical activity of contraction of the external sphincter muscle was studied using electromyography. RESULTS: There was direct correlation between anal canal pressures and Kelley's score in patients with both high and low anomalies; Kelley's score of 6, 5, 4, 3 and less had pressures ranging between 60-75, 45-59, 30-44, 15-29 and less than 15 cm H2O, respectively. However, the electromyographic activity did not correlate well with Kelley's score. CONCLUSIONS: Anorectal manometry correlates well with Kelley's scoring system and may be a more objective method of analyzing the results of surgery. Poor correlation between Kelley's score and electromyography may be a reflection of poor compliance with instructions to voluntarily contract the muscles of continence.

Low anorectal malformation associated with sarococcygeal teratoma.

The association of sacrococcygeal teratoma with anorectal malformation is rare event in teratopathogenesis. One such case is described here. The Sacrococcygeal teratoma was excised at birth and the low anorectal anomaly was also treated at the same time.

Sacrococcygeal teratoma with anorectal malformation.

A 7-month-old child presented with imperforate anus, penoscrotal hypospadias and transposition, and a midline mucosa-lined perineal mass. At surgery the mass was found to be supplied by the median sacral artery. It was excised and the anorectal malformation was repaired by posterior sagittal anorectoplasty. Histologically the mass revealed well-differentiated colonic tissue. The final diagnosis was well-differentiated sacrococcygeal teratoma in association with anorectal malformation.