Endoscopic Management of Vesicoureteral Reflux and Long-term Follow-up

Objectives: To report our experience with endoscopicmanagement of vesicoureteral reflux (VUR) by injection of atissue bulking substance – Dextranomer/ hyaluronic acid co-polymer at vesicoureteric junction.Design: Retrospective analyses of case records.Setting: Pediatric Surgery department in a tertiary caregovernment Institute.Participants: 500 children (767 renal units) consecutivelyreferred to the out-patient department with vesicoureteral refluxnoted on micturating cysto-urethrogram (MCU) over a period of13 years (2004-2016).Intervention: Preoperative VUR grading and renal scars onradionuclide scans were documented. Dextranomer hyaluronicacid copolymer was injected through a cystoscope at thevesicoureteral junction as a day care procedure under shortanesthesia. Patients were followed (average duration 27.3 mo)with clinical assessment, periodic urine cultures and renal scans.Main outcome measure: Cessation of VUR and symptomaticrelief / clinical success postoperatively at 3 months.Results: Complete symptomatic relief was obtained in 482(96.4%) patients. In 681 units where MCU was available, 614(90%) units showed resolution of VUR.Conclusion: Endoscopic injection of tissue bulking substancesat vesicoureteric junction to stop VUR seems to be an effectiveintervention

Esophageal surgery in newborns, infants and children.

The most common surgery on the esophagus by pediatric surgeons the world over is performed in the newborn period in babies with congenital esophageal atresia with tracheo-esophageal fistula. Post-operative complications like recurrent fistula, anastomotic stricture and some patients with gastroesophageal reflux would also require surgical intervention. Apart from esophageal dilatation, gastrostomy and feeding jejunostomy, children with strictures secondary to caustic ingestion, reflux or previous esophageal anastomosis may require esophageal substitution. This operation may also be required in babies with pure esophageal atresia as well as those with a long gap esophageal atresia with fistula. The entire stomach, stomach tubes, colon or jejunum are often used but techniques preserving as much of the original esophagus as possible are preferable and more physiological. Surgery is also required in children with congenital esophageal stenosis and duplication cyst.

Current status of fetal surgery.

The allure of fetal surgery is the possibility of interrupting in utero progression of an otherwise treatable condition. In spite of advances in prenatal diagnosis and refinements in surgical techniques, this field has not yet got off the ground because the risks to the mother and fetus, during and after the procedure far outweigh the benefits, and the infrastructure required to support such activity is prohibitively expensive. The various surgical conditions in which fetal surgery has been attempted and the present status of this specialty are discussed.

Primary vesicoureteral reflux: progress of disease, somatic growth and renal parameters.

Thirty children (45 units) in the age group 1 day-12 yrs with primary vesicoureteral reflux were studied prospectively and periodically assessed for renal function, scarring, grade of reflux and somatic growth parameters. Four children (6 units) with grade IV reflux underwent ureteric reimplantation. Complete resolution with medical management was seen in all 12 units of grade I-III reflux and in 5 of the remaining 27 units of grade IV-V reflux over 6 months-6 yrs. This group showed highly significant improvement in height . The weight gain of the above 2 groups was statistically significant compared to those with persistent reflux. Focal defects were seen initially in 62 percent refluxing units. None of the patients showed deterioration in renal function or formation of new scars over the next 1-7 years. Three children on conservative management showed persistent growth retardation with associated breakthrough infection, hypertension, multiple renal scars and poor renal functional volume.

Bronchial transection: delayed diagnosis and successful repair.

Traumatic bronchial transection is usually recognized and repaired immediately after injury. Bronchial transection has a variety of clinical presentations due to air leak into the pleural cavity and it is very rare to have total absence of air leak from the transected bronchus at presentation. We present one such case of main right bronchus injury with total absence of initial clinical signs and symptoms, leading to a delay in the diagnosis. However, the surgical repair eight months after injury showed excellent recovery of the chronically collapsed lung.

Preoperative aspiration for anterior mediastinal cyst with respiratory distress.

We report a 5-month-old boy who presented with an anterior mediastinal cystic teratoma. Pre-operative symptoms of respiratory distress secondary to airway obstruction were markedly reduced by percutaneous aspiration. Aspiration was also beneficial in easily ventilating the baby during the surgical procedure.

Hunt-Lawrence pouch after total gastrectomy: 4 years follow up.

A 12-year-old boy had undergone total gastrectomy for gastric volvulus with subsequent severe weight loss and malnutrition. A Hunt-Lawrence pouch was constructed to provide gastric reservoir capacity and the child at 4-years follow-up has regained near normal weight for his age and is attending to school and other activities.